Workers Compensation 101

Transcription

1 Workers Compensation 101 Terminology, Concepts and Principles Melissa LeRoy VP Sales Specialty Risk Services

2 Definition Workers Compensation State-mandated, employer-provided provided coverage in all 50 states. Most are compulsory compliance. Covers employee s s economic losses due to work related injury or disease Provides employer with liability protection from being sued for work- related conditions

3 Terminology Exclusive Remedy Employer gives benefits in return for protection from being sued by the employee Similar to a no-fault approach to workplace injuries and accidents Does not apply if employer is fraudulent, negligent, assaults the employee, or is not acting as an employer

4 Terminology Compensability - Determining if benefits are owed based on state statutes, case law and facts of the case Course and Scope Horseplay Personal errand Deviation Traveling employees Arising out of the Employment Accident and defined occurrence Idiopathic injuries But for doctrines

5 Terminology Compensability Occupational Disease Illness due to prolonged exposure to chemicals or other environmental factors Cumulative Trauma No clear or defined accidental occurrence Gradual onset of symptoms Injury sustained over time due to repetitive activity such as pushing and pulling, lifting or bending Pervasive in many industries from manufacturing to office environments

6 Terminology Statute of Limitations Legally specified timeframe during which an action must be taken to be subject to regulatory requirements Notify the employer Seek medical care Submit a claim File suit

7 Terminology Apportionment and Second Injury Funds Allows the employer to take credit or seek reimbursement of claim costs where the employee had prior injury or disability. Pre-existing existing injury or condition impairs recovery Must be documented through medical records and in some cases recorded at the time of hire

8 Terminology Subrogation A third party may be deemed responsible for the accident or injury Auto accidents Slips and falls on property maintained by others Assault by co-workers or others Injury due to defective machinery or equipment WC payor may pursue reimbursement of some or all costs related to that claim

9 Who is covered? All employees or contractors Receiving pay for services Where employment is expressed (orally or written) or implied (by actions) Where contractors activities, methods and equipment are controlled by employer Full and Part Time

10 What is Covered? Bodily injury, disease, or death manifesting itself from covered on-the-job occurrences Bodily injury may be construed to include stress or psychiatric conditions in some states

11 WC Benefit Types Temporary Disability (TD) Total (TTD) Partial (TPD) Wage calculations based on average earnings State defined minimum and maximum Total typically paid at 66 2/3% Partial paid at loss of earnings Tax Exempt

12 WC Benefit Types Permanent Disability Total (PTD) Lifetime benefits May offset with Social Security or other disability benefits Partial (PPD) Scheduled Amputation, loss of limb Percentage of Impairment Doctor s s ratings Death Burial Payments to spouse and/or dependents

13 What is Covered? Medical Directed Care and Choice of Physician Medical Fee Schedules Utilization and Pre-Certification rules Treatment limitations

14 What is Covered? Vocational Rehabilitation May be state funded or employer funded Generally specifies how long or to what dollar amount will be paid

15 How claims are resolved Each State has rules related to when an employee is considered stable, cured or at Maximum Medical Improvement Some states allow for full and final settlements Some states require lifetime medical Employee may be permitted to re-open a claim if they aggravate the injury or experience a worsening of their condition