Workers Compensation Claim State Environmental Guide - Tennessee

Transcription

1 Workers Compensation Claim State Environmental Guide - Tennessee TENNESSEE Indemnity issues Temporary Total Benefits Temporary Partial Benefits Permanent Partial Benefits Average Weekly Wage calculated by averaging the 52 weeks of wages prior to date of injury. Compensation rate equals 2/3 of Average Weekly Wage Minimum: $ Maximum: $ Waiting period: 7 days Retro period: 14 days Temporary Total cap 400 weeks times state AWW (currently $918.50) Filing of wage statement must be done within 30 days of notice of injury or risk of being ordered to pay at max comp rate. If employee returns to work with medical restrictions and earns less than wages earned pre-injury, the employee is entitled to 2/3 of the difference between preinjury and post-injury wages. No minimum. Maximum: $ Shall not exceed 400 weeks. PPD rate is same as compensation rate except the maximum PPD rate is $ Medical impairment ratings are given by authorized physician and settlements are based on both the medical impairment and the vocational disability of the injured worker due to the injury. There are no caps on scheduled members worth less than 200 weeks and therefore they can be settled up to 100% to that body part. Arms, legs, and body as a whole injury settlements are capped at 1½ times the medical impairment if the injured worker returns to work for the same employer making the same or greater wages. If they do not return to the same employer making the same or greater wages, they may receive up to 6 times the medical impairment rating, not to exceed 400 weeks. travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT This material is for informational purposes only. All statements herein are subject to the provisions, exclusions and conditions of the applicable policy. For an actual description of all coverages, terms and conditions, refer to the insurance policy. Coverages are subject to individual insureds meeting our underwriting qualifications and to state availability The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE TN-EXT, Rev

2 Indemnity issues Tennessee Workers Compensation Claim State Environmental Guide If an injured worker with a body as a whole injury settles his claim for the 1 ½ cap or less and they are laid off for any reason other than for cause within 400 weeks of settlement, they may petition the court to re-open their claim for additional indemnity benefits. If an injured worker with upper or lower extremity injury settles claim for the 1 ½ cap or less and they are laid off for any reason other than cause, they may petition the court to re-open their claim for additional indemnity benefits. A cap of 1 ½ times the medical impairment rating will be applied to settlements to the body as whole or scheduled members worth 200 weeks or more if the employee is not eligible or authorized to work in the United States. This is effective for injuries sustained on or after July 1, For injuries occurring after July 1, 2009, the definition of maximum total benefit is equal to 400 times 100% of the state s average weekly wage (currently $835.00) as set annually by the Division. TTD is not included in the calculation of maximum total benefits. Permanent Partial based on AMA Guidelines - Yes The 6 th Edition of the AMA Guide is used for injuries that occur on or after January 1, 2008, to calculate impairment ratings. For injuries that occurred prior to January 1, 2008, physicians use the 5 th Edition of AMA Guide to calculate impairment ratings. Permanent Total Benefits Weekly benefits at PPD rate subject to max rate, which is currently $ until they reach the age of social security eligibility. This can be awarded in lump sum. A worker over the age of 60 at the time of the injury who sustains an injury to the body as a whole can receive no more than 260 weeks in benefits or 65% BAW. Fatality Benefits If the injured worker leaves a surviving spouse and no dependent children, the surviving spouse shall receive 50% of the average weekly wage of the deceased employee. If the injured worker leaves a surviving spouse and child or children, the spouse and children shall receive 66 2/3% of the average weekly wage of the deceased employee. Upon re-marriage of surviving spouse, if there is no child of the deceased employee, the compensation shall terminate. But if there is a child or children under 18 or over 18 and physically or mentally incapacitated from earning, the child or children shall receive 66 2/3% of the average weekly wage. If the deceased employee leaves no dependents, then a lump sum of $20,000 shall be paid to the estate of the deceased employee. Compensation to any dependent shall cease upon the death or marriage of the dependent. Minimum weekly benefit: $ Maximum weekly benefit: $ Burial expenses are covered up to maximum of $7500. Vocational Rehabilitation Not required. Settlement Allowed Yes, but must be approved by Department of Labor or by court. Cap on benefits, exceptions For injuries that occur on or after July 1, 2009, the maximum total benefit is equal to 400 times 100% of the state s average weekly wage as set annually by the Division. Temporary total benefits are not included in this calculation. For injuries prior to July 1, 2009, indemnity benefits are capped at 400 weeks unless the injured worker is found to be permanently and totally disabled. WC Reference 2 Rev. 4/14

3 Tennessee Workers Compensation Claim State Environmental Guide Medical issues Initial Choice of Provider Change of Provider Medical Fee Schedule Managed Care Utilization Review Treatment Guidelines Generic Drug Substitution Employer must give injured worker panel of 3 physicians not associated in the same practice. If the injury is to the neck or back they must also add a chiropractor to the list, but they are limited to 12 visits. A choice of physicians form must be presented in writing to injured worker and must be signed by injured worker. An appropriate panel must be provided for each attending physician and each operating surgeon. There is no statutory right for injured worker to change physicians. However, we do often allow a 2 nd opinion with another physician from the original panel and the Employer has the right to have an IME by a physician of its choice at any reasonable time. Yes The percentage over Medicare varies by procedure. Optional For more information, please refer to the WC Managed Care Quick Reference Chart by State Guide. UR is required when: Cumulative medical costs exceed $5,000 There is any type of inpatient stay There is a non-emergency transfer between facilities PT or OT exceeds 6 visits (12 visits if post-operative) o This applies to CM and CB level claims but not ICU Chiropractic treatment exceeds 12 sessions Psychological treatment exceeds 15 visits. UR is allowed when: Schedule II, III, IV drugs are prescribed greater than 90 days. Employer requests utilization review of above medications. New UR regulations effective 11/12/09 include: UR must be completed by an RN. UR cannot be performed by the same nurse that is assigned for medical case management. A Physician Advisor, also known as the Advisory Medical Practitioner, must have an active TN license, must be board certified, and must be the same or similar general specialty as the recommending authorized treating physician. UR decision is required to be in writing. The state appeal form must accompany all denials. UR forms are required to be completed and penalties are assessed for non-compliance o C-35, UR Notification o C36-37, UR Closure Annual UR Report Does the state mandate the use of evidence based guidelines? No. The state mandates generic substitution. The treating provider can provide a statement of medical necessity to dispense brand as written. WC Reference 3 Rev. 4/14

4 Medical issues Tennessee Workers Compensation Claim State Environmental Guide Medical Mileage Reimbursement Rate If requested by injured worker and if the trip is greater than 15 miles from home or work to medical provider. Paid at state employee rate per mile, currently 47 per mile. Network Information First Health (primary) and CorVel (secondary). Ability to Terminate Medical Treatment We can dispute treatment that is not reasonable and necessary. Settlement Allowed We can settle the medical benefits on all claims with a date of injury after 6/6/11 unless the injured worker has been adjudged permanently and totally disabled. For dates of injury prior to 6/6/11, and if the body part is worth less than 200 weeks, you may settle future medicals. For dates of injury prior to 6/6/11 and for those injuries to body parts that are worth greater than 200 weeks (arms, legs and body as a whole), you cannot settle future medicals until 3 years after the date of the indemnity settlement. Medical can be settled Full and Final Yes depending on body part and date of injury. Please see above Cap on benefits, exceptions Per fee schedule Other Issues WC Hearing Docket Speed Court system. Docket speed varies by county. Staff Counsel David J. Sneed and Associates ( ) 6640 Carothers Parkway, Suite 200 Franklin TN Scott Campbell and Associates ( ) 6750 Poplar Avenue, Suite 412 Germantown TN Hearings require attorney or Require attorney representation claim handler participation Occupational Diseases Six criteria: Must have followed as a natural incident of the work exposure. Is not from a hazard to which employees are equally exposed outside of employment. Can be fairly traced to the employment as a proximate cause. Is incidental to character of employment and not independent of relation of employer and employee. Originated from a risk connected to employment and flowed as a natural consequent there from. There is a direct causal connection between the conditions under which the work is performed and the disease. Diseases of the heart, lung and hypertension arising out of and in the course of employment are considered occupational diseases. Second Injury Fund availability Available only if the employer had knowledge of the prior work-related injury or injuries prior to the subsequent injury and only if he injured worker is permanently and totally disabled through the subsequent injury. WC Reference 4 Rev. 4/14

5 Tennessee Workers Compensation Claim State Environmental Guide Other Issues Other Offset Opportunities EDI In-State Adjusting Required License or Certification Required If a worker injured at age 60 with an injury to the body as a whole is receiving social security old-age benefits at the time of the settlement or trial, ER/carrier is entitled to an offset against that benefit. The offset is calculated by subtracting 50% of the weekly old-age benefit from the weekly permanent partial disability rate, and the resulting figure is then used as the permanent partial disability rate in settlement calculation. FROI as well as several supplemental reports required including initial payment, suspension of benefits, change of benefits, denial of claim, etc. No No WC Reference 5 Rev. 4/14