Municipal Clerks and City Administrators Institute August 28, April 2008 Alabama Department of Industrial Relations

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1 Municipal Clerks and City Administrators Institute August 28, 2014 April 2008 Alabama Department of Industrial Relations

2 Alabama Department of Labor (205) April 2008 Alabama Department of Industrial Relations

3 Examiners Compliance Self-Insurance Medical Claims Ombudsman PEO

4 Must Secure Coverage if regularly employ five (5) or more Employees Cities with populations greater than 2,000 and less than 250,000 must have coverage.

5 Voluntary Insurance Market Group Self-Insurance Fund (J&S Liability) Individual Self-Insurance Must have significant resources and pass auditing tests and actuarial standards.

6 All Employers Must Provide WC Confuse WC with UC I ll Just Terminate Injured Worker I Can t Afford WC Must file First Reporter of Injury only required for lost time claims.

7 Getting Coverage in Place / Maintaining Joint/Several Liability Groups (No Notice)

8 Must Prove Accident arises out of and in the course of employment (Legal Causation) Must be in place where employee is expected to be Must arise out of duties employee is expected to be performing Proof that accident caused the injury (Medical Causation) If proven, employer cannot refuse payment Exclusive Remedy unless Willful (gross) Negligent WC is liberally construed in favor of injured worker.

9 Indemnity/Compensation Money benefits to be paid on account of injury or death AWW Average Weekly Wage (Wages/52) AWW Doesn t include fringe benefits (health, life, disability) - as long as employer continues them during period where compensation is paid.

10 Indemnity Limits: 66 2/3% of AWW TTD/PTD: Max. $794, Min. $218 PPD: Max. $220 3 Day Waiting Period Unless > 21days How long? TTD/PTD - Length of Disability PPD (Body) 300 Weeks PPD (Schedule under ) Death 500 Weeks

11 Medical Benefits All Reasonable & Necessary Medical Treatment Controlled by Authorized Treating Physician Employer Chooses Physician

12 Claimant Responsible if they see Personal Physician Can t Pay through Health Insurance Panel of Four (Add l treatment/1 Panel) Certain Medical Supplies Not Reimbursable (Tylenol, etc.) Mileage Reimbursement (1/12/09) Mileage Subject to Verification B/T Work and Home Not Reimbursable 1 Roundtrip to Pharmacy 1 Year Time Limit

13 Vocational Rehabilitation Retraining Injured Employees for New Job If Employer Chooses Employee Must Participate If Employee Refuses No Compensation If Employee Chooses Treating Physician Must Agree of the Necessity

14 Death Benefits Maximum 500 Wks to Dependents 0 Dependents - $7,500 Lump Sum 1 Dependent 50% of AWW 2 > Dependents 66 2/3% AWW Up to $6,500 for Burial Expenses

15 When/Where/What Happened? Proper Notice (5/90 days) (Oral Notice is generally sufficient. Pre-Existing Conditions Drugs/Alcohol Misconduct/Fraud Light Duty Availability (Return to Work) Employee Attending Doctor Appts Employee Maintaining Contact with Adj. Filing 1 st Report of Injury (Loss-Time Only 15 days

16 Uncooperative Disgruntled Presses for Quick Settlement Calloused Hands/Greasy Fingernails Odd Times (lunch, late Friday/early Monday) No Witnesses Claimant Home when Called Unusually Familiar w/ WC Claims

17 Pay Legitimate Claims Defend When you Can Deviation Intoxication (Comp) Failure to Give Required Notice Willful Misconduct Statute of Limitations Refusal to Accept Suitable Employment (Comp) Refusal to Accept Reasonable Medical Treatment (Comp) Create Atmosphere of Trust Maintain Contact w/ Injured Workers If you don t Lawyer will

18 Proper Notice (5/90) 2 year Statute of Limitations Are you at MMI (Can t settle until) Correct Calculations for AWW & Benefits Can I Close Meds? Can I Receive Lump-Sum Settlement?

19 Light Duty Jobs? Reasonable Accommodation? (No) Jury Trial? (No) Refusal of Reasonable Med. Treatment (No Comp) Refusal of Suitable Offer of Employment (No Comp)

20 Top Questions: Who is my Carrier? How do I File a Claim? What is MMI? My Adjuster is Rude My Adjuster Won t Return Phone Calls Settlement Offers Are they Fair? Getting Approval for Medical Treatment after Settlement.

21 Male, Age 54, $436 AWW Avg. Wkly Wage $436 x.6667 = $ Compensation Rate Age of Claimant, 54 $ (Max.$794 / Min.$218) Yrs (Actuarial Tables) x 52 Wks/Yr Weeks (See Present Value Table) = x (Comp Rate) $185,213.57

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23 Mediation vs. Arbitration Compromise to ALJ s Biggest Problems: Attorneys with No Authorization to Settle Claimant s with Unreasonable Expectations Adjustor s Insisting on Closing Future Meds Attorney s that Try to Intimidate Parties Creates Conflict Claimant s that Bring Supporting Case to a Mediation

24 Past 12 Months 2,314 Mediations 2,190 Voluntary / 124 Court Ordered Resolved 1,960 (84.7%) Total 1,561 (86.0%) Voluntary 61.3% Court Ordered

25 Pain & Suffering Should be Compensated Case is not Limited by Statute Why Can t I Get $50,000 like my Brother did. It s my Back I Should say Whether I Want Surgery

26 Illegal Aliens Mental Disorders Must have Physical Injury which Proximately Causes Disorder Deviation from Employment Retaliatory Discharge In ,455 FROI $722,857,298 Total Losses Meds = 59%; Compensation = 25%

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