Provided By Touchstone Consulting Group Workers Compensation Employee Benefits

Transcription

1 Prvided By Tuchstne Cnsulting Grup Wrkers Cmpensatin Emplyee The Wrkers Cmpensatin Act f Clrad (WCAC) determines the benefits available t emplyees wh are injured in the curse and scpe f emplyment. In general, an injury is cmpensable if the damage r harm an emplyee suffers is the direct result f an accident r expsure t a hazardus envirnment in the nrmal curse f his r her emplyment. When the WCAC applies, benefits include cverage fr medical expenses, death benefits, burial csts and wage replacement. The Divisin f Wrkers Cmpensatin (DWC), part f the Clrad Department f Labr and Emplyment, investigates and handles wrkers cmpensatin claims in the state. Waivers fr cmpensatin r medical benefits are nt allwed fr the aggravatin f any pre-existing cnditin r disease. Hwever, the WCAC des nt invalidate any waivers that were filed and apprved befre March 1, MEDICAL BENEFITS Emplyers must prvide prmpt and adequate medical care t their emplyees fr wrk-related injuries r illnesses. Medical benefits include: This guide is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. It is prvided fr general infrmatinal purpses nly. It bradly summarizes state statutes and regulatins generally applicable t private emplyers, but des nt include references t ther legal resurces unless specifically nted. Readers shuld cntact legal cunsel fr legal advice. Medical, surgical, dental, hspital and nursing treatment; Medical, hspital and surgical supplies; and Crutches r any apparatus reasnably needed t cure and relieve the emplyee frm the effects f the injury. Medical benefits must als include the purchase, repair r replacement f artificial members, glasses, hearing aids, braces, dentures and ther external prsthetic devices. Emplyees may request a replacement if: They have undergne an anatmical change since the previus device was furnished (r fr ther gd cause shwn); The anatmical change (r gd cause) is directly related t and caused by the injury; and The replacement is necessary t imprve the functin f each member r part f the bdy affected by the injury. Imprving the functin als includes relieving pain and discmfrt. The DWC regulates the prcedures available fr medical care and the fees that health care prviders can charge fr the treatment f wrk-related injuries. Designated Medical Care Prviders Medical benefits cver the csts f the treatment an emplyee receives fr his r her wrk-related injury. Emplyers are required t cver these csts nly if the emplyee receives treatment frm an authrized medical care prvider. Hwever, if an authrized prvider des nt prvide its services at the time f injury, emplyers must cver the csts an emplyee incurs fr treatment with a physician f the emplyee s chice Zywave, Inc. All rights reserved. 06/15 JPA

2 As f April 1, 2015, emplyers must authrize, and prvide their injured emplyees with a chice between fur designated medical care prviders. At least ne f the fur authrized medical care prviders must be withut cmmn wnership and at a distinct lcatin frm the ther authrized prviders. Upn request, emplyers must prvide a list f wnership interests and emplyment relatinships regarding their designated medical care prviders within five days. An emplyer may allw an emplyee t change his r her designated treating physician if the emplyee prvides written ntice within 90 days f injury. The ntice must be submitted befre the emplyee reaches maximum medical imprvement (MMI). The new medical care prvider must als be n the emplyer s authrized list f prviders. An injured emplyee may als request authrizatin t receive treatment frm his r her persnal physician. An emplyer that bjects t having the emplyee s persnal physician prvide treatment must prvide a written explanatin t the requesting emplyee within 20 days. An emplyer that des nt grant r refuse a request t receive treatment frm a persnal physician within 20 days waives its right t bject t the request. Emplyees als have the right t request that the DWC authrize a change f physicians. Exceptins An emplyer that cannt find at least fur qualifying prviders may qualify fr an exceptin if it can demnstrate that it cannt find designated prviders willing t treat the emplyer s injured emplyees that are at distinct lcatin withut cmmn wnership within 30 miles f its place f business. In additin, gvernmental entities and health care prviders that currently have their wn ccupatinal health care prvider systems may designate health care prviders frm within their wn systems and are nt required t prvide alternative physicians r crprate medical care prviders frm utside f their systems. Similarly, emplyers that wn n-site health care facilities may designate thse facilities as the authrized designated prviders. An n-site health care facility is an entity that meets all applicable state requirements t prvide health care services n an emplyer s premises. Mandatry Medical Examinatins Emplyers may require emplyees receiving wrkers cmpensatin benefits t submit t mandatry medical examinatins r vcatinal evaluatins. Medical examinatins must be perfrmed by a licensed physician. Emplyers must cver the csts f mandatry medical examinatins. An emplyer that pays estimated examinatin expenses may recver these csts if the emplyee fails t attend a required examinatin. Mandatry medical examinatin csts include any expense the emplyee incurs fr attending the examinatin, including: Transprtatin; Mileage; Fd; Accmmdatins; and Wages lst as a result f attending the examinatin (wage lss must be verified and wage reimbursement rate is $75 per day). Wrkers cmpensatin benefits may be suspended fr any emplyee wh refuses t submit t r wh bstructs a medical examinatin r vcatinal evaluatin. The DWC may als reduce r suspend the cmpensatin f any individual wh persists in any unsanitary r injurius practice that jepardizes r delays recvery. The same is true fr an individual wh refuses t submit t a treatment that is reasnably required t prmte recvery. 2

3 Emplyees have the right t request, at their wn expense, t have their physicians present at any mandatry examinatins. DEATH AND BURIAL BENEFITS The WCAC requires emplyers in Clrad t pay burial benefits fr any emplyees wh die because f wrk-related injuries. In additin, the WCAC requires emplyers t prvide death benefits t the deceased emplyees surviving dependents. In situatins when an emplyee leaves n dependents, the benefits are limited t burial csts and the medical, surgical and hspital expenses related t the deceased emplyee s treatment. Burial Under the WCAC, burial csts may cver up t $7,000 in reasnable funeral and burial expenses. This sum must be paid t the emplyee s dependents, the undertaker, the cemetery r any ther persn wh has paid fr the deceased emplyee s funeral and burial csts. Death Death benefits are intended t cmpensate an emplyee s surviving dependents fr his r her lss f incme. Under the WCAC, death benefits are available at a rate f 66 and tw-thirds percent f the emplyee s average weekly wage (AWW). The minimum death benefit payment is 25 percent f the state average weekly wage (SAWW) and the maximum is 91 percent f the SAWW. Death benefits may be reduced in cases where the dependents receive ld age, survivr r disability benefits frm the state r federal gvernments. The reductin may be up t 50 percent f the value f the gvernment benefits received by the dependents. Hwever, the WCAC prhibits any adjustment t reduce dependent benefits belw zer. Death benefits will terminate fr an underage dependent wh reaches the age f 18 r with a tw-year lump sum fr a spuse wh remarries. Dependents wh were supprted nly in part by the deceased emplyee receive death benefits in prprtin t the supprt they received frm the deceased emplyee. WAGE REPLACEMENT BENEFITS If an emplyee cannt return t wrk because f a wrk-related injury r illness, he r she is entitled t receive wage replacement benefits (als called disability, indemnity r cash benefits) while he r she recvers. In general, these benefits are immune t wage assignments, creditr claims, levies, executins, attachments and ther remedies fr the cllectin f debt. Hwever, wage replacement benefits may be adjusted t accunt fr Scial Security, retirement, pensin, disability r unemplyment cmpensatin benefits. Temprary Ttal Disability (TTD) An injured emplyee has a temprary disability when the emplyee sustains an injury that prevents him r her frm perfrming sme r all f his r her wrk duties, but the emplyee is expected t recver. Temprary disability can be ttal r partial. Temprary disability benefits may be terminated r mdified: T ffset the injured emplyee s Scial Security, disability pensin r ther similar benefits; During perids f imprisnment; r T accunt fr damages received frm a third-party claim. Temprary ttal disability exists when an injured wrker is cnsidered ttally disabled and unable t wrk. Weekly TTD benefits are 66 and tw-thirds percent f the emplyee s AWW. The maximum amunt f TTD benefits is 91 percent f the SAWW. A new TTD rate becmes available n July 1 f each year. The maximum TTD rate fr the perid is $ TTD benefits are generally paid every tw weeks, unless the DWC has rdered a different payment frequency. The first payment is due n the date when the emplyer admits liability fr the claim. TTD benefits may be terminated when: 3

4 The injured emplyee reaches maximum medical imprvement (MMI); The injured emplyee returns t regular r mdified emplyment; The treating physician issues a written release allwing the injured emplyee t return t regular emplyment; r The emplyee fails t begin emplyment after he r she receives: A written release t return t mdified emplyment frm his r her treating physician; and A written ffer fr mdified emplyment frm his r her emplyer. TTD benefits cannt be terminated when the emplyee has accepted an ffer fr vcatinal rehabilitatin. Hwever, any party may terminate vcatinal rehabilitatin at any time, after prviding 14 days ntice t the ther parties and the DWC. In additin, an emplyer is nt bligated t pay TTD benefits during a perid where it cannt verify an injured emplyee s ability t wrk. Usually, the emplyer can verify inability t wrk with the emplyee s treating physician. An exceptin exists fr emplyees wh have been unable t receive treatment fr reasns beynd their cntrl, including circumstances where treating physicians fail t submit verificatin (thrugh n fault f the emplyees). Temprary Partial Disability (TPD) Emplyees wh suffer a temprary partial disability are thse wh cannt return t full emplyment because f a wrk-related injury, but they retain sme ability t wrk. Hwever, during their recvery, these individuals may experience a reductin f incme due t the restrictins f their disabilities. The WCAC requires emplyers t prvide TPD benefits t assist emplyees wh suffer wage decreases because f their TPDs. TPD benefits are 66 and tw-thirds percent f the difference between the emplyee s pre- and pstinjury wages. TPD benefits are als subject t a maximum f 91 percent f the SAWW. Emplyers must pay TPD benefits at least nce every tw weeks and the TPD benefits must cntinue until: The emplyee reaches MMI; r The emplyee fails t begin emplyment after he r she receives: A written release t return t mdified emplyment frm his r her treating physician; and A written ffer fr mdified emplyment frm his r her emplyer. Permanent Ttal Disability (PTD) An injured emplyee has a permanent disability when he r she is nt expected t fully recver frm his r her injuries. Permanent disability can be ttal r partial. An injured emplyee has PTD when he r she is unable t earn any wages in the same r ther emplyment. PTD is presumed in cases where the injured emplyee has ttal lss f, r ttal lss f use f: Bth hands; Bth arms; Bth feet; Bth legs; PTD benefits are 66 and tw-thirds percent f the emplyee s AWW, up t 91 percent f the SAWW. A new PTD rate becmes available n July 1 f each year. The maximum PTD rate fr the perid is $ These benefits must cntinue until the injured emplyee s death. Hwever, permanently disabled emplyees wh refuse t participate in vcatinal rehabilitatin may lse their PTD benefits if they: Are capable f rehabilitatin; Bth eyes; r Any tw f the bdy parts previusly mentined. 4

5 Refuse an ffer f emplyment by the same emplyer; r Refuse an ffer fr vcatinal rehabilitatin paid fr by the emplyer. Permanent Partial Disability (PPD) An emplyee has PPD when he r she is unable t recver frm the injury, but maintains sme ability t earn wages. The benefits available t PPD emplyees depend n the severity and the extent f the disability. The WCAC classifies PPD as either scheduled r unscheduled. The table belw ffers a summary f PPD benefits. Type f Impairment Scheduled Impairments Unscheduled Impairments Descriptin Lss f functin affecting the tes, feet, legs, fingers, hands, arms, eyes, visin r hearing Cmpensatin based n a schedule f values related t each bdy part Lss f functin affecting bdy parts nt listed n the schedule abve, such as the spine, lungs and mental functin Cmpensatin cnsiders the impairment rating assigned by a physician, the emplyee s age factr, a fixed perid f 400 weeks and the current TTD rate A PPD is scheduled if it appears in a pre-determined schedule that is part f the WCAC. Scheduled PPD benefits are determined by multiplying the scheduled PPD rate by the number f weeks allwed by the schedule. Fr example, cmpensatin fr the lss f an arm at the shulder is determined by multiplying the scheduled PPD rate by 208 weeks, while cmpensatin fr the lss f a middle finger at the distal jint is determined by multiplying the scheduled PPD rate by five weeks. The scheduled PPD rate fr the perid is $ A PPD is unscheduled if the injury is permanent, allws the emplyee t retain sme ability t earn wages, and des nt appear in the PPD schedule. Because cmpensatin fr unscheduled PPD benefits depends n the permanency f the injury, PPD benefits are available nly after a qualified physician has determined that the injured emplyee has reached MMI. MMI is the pint in time when any medically determinable physical r mental impairment has becme stable and n further treatment is reasnably expected t imprve the cnditin. After the physician determines the injured emplyee has reached MMI, the physician will use the revised third editin f the American Medical Assciatin Guides t the Evaluatin f Permanent Impairment t determine the emplyee's medical impairment rating. The impairment rating is a percentage that represents hw much functinality the emplyee has lst due t the injury. Fr example, an impairment rating f 15 percent indicates that the PPD has decreased the injured emplyee s functinality by 15 percent. An emplyee s unscheduled PPD benefit is determined by multiplying the impairment rating by the emplyee s age factr, a fixed cmpensatin perid f 400 weeks and the temprary ttal disability rate. 5

6 The first $10,000 f the ttal PPD benefit amunt must be paid autmatically in a lump sum (sme cnditins and exceptins may apply). The remaining peridic payments must be paid at the TTD rate, subject t a minimum f $150 per week and a maximum f 50 percent f the SAWW, beginning n the date f MMI. The maximum peridic payment fr the perid is $ Disfigurement The WCAC als requires emplyers t cmpensate injured emplyees wh are seriusly and permanently disfigured abut the head, face r parts f the bdy that are nrmally expsed t public view. Disfigurement cmpensatin must be paid in additin t any ther benefits r cmpensatin due t the injured emplyee. The maximum amunt fr disfigurement cmpensatin is generally $4, but may be increased t $9, fr: Extensive facial scars r facial burn scars; Extensive bdy scars r burn scars; r Stumps due t lss r partial lss f limbs. Waiting Perid An injured emplyee is nt eligible t receive wage replacement benefits fr the first three days f his r her disability. Hwever, if the injury results in mre than tw weeks f disability, the injured emplyee must receive indemnity benefits fr the entire disability perid. Limits n Temprary Disability and Permanent Partial Disability Payments An emplyee s cmbined temprary disability and PPD benefits are limited by a maximum that depends n the emplyee s impairment rating. Fr purpses f this cmbined benefit limit, an emplyee s mental impairment rating must be cmbined with his r her physical impairment rating. Updated limits becme effective n July 1 f each year. The table belw presents the limits fr the perid. Reductin f Impairment Rating Limit n cmbined temprary and PPD benefits 25 percent r lwer $81, Mre than 25 percent $162, Wrkers cmpensatin benefits may be reduced by up t 50 percent fr an emplyee wh is injured because he r she willfully: Fails t use safety devices prvided by the emplyer; Fails t bey any reasnable rule adpted by the emplyer; r Misleads the emplyer regarding his r her physical ability t perfrm the jb, and the emplyee is injured n the jb as a result f the physical ability the emplyee misrepresented. MORE INFORMATION Fr mre infrmatin n wrkers cmpensatin laws in Clrad, visit the DWC website r cntact Tuchstne Cnsulting Grup. 6