Table Of Contents Introduction...2 Procedures For Reporting A Work-Related Injury Or Occupational Disease...3 Workers Compensation Benefits...5 Prescription Processing Services...6 Payroll Procedures...6 Health Insurance And Other Benefits While On LWOP... 7 The Role Of PMA...7 Light Duty Or Alternative Duty...8 1
Introduction Through the workers compensation program, Gallaudet provides for continued income and payment of medical expenses for work-related injuries and illnesses. Gallaudet s workers compensation program is insured by the PMA Insurance Group. Claims are processed by PMA and are adjudicated by the District of Columbia Government, Office of Workers Compensation (OWC). PMA reviews each claim and the medical documentation carefully, provides ongoing monitoring, and may ask that additional information be provided or that a second medical opinion be obtained. Investigations of potentially fraudulent claims are conducted by a special investigations unit of PMA. In order to receive workers compensation, the injury or illness must be verified as work related. If an employee is injured on the job, it is imperative that he or she notify the supervisor and the Personnel Office immediately. Immediate notification will ensure that the correct forms are completed and that the employee receives prompt and appropriate medical attention, if needed. The cause of each injury is carefully investigated to prevent future accidents. If the University has any reason to believe that the incident was not work related, or was caused by willful misconduct, or is in any other way invalid, it will inform the insurance company. This is not to discourage employees from filing a workers compensation claim; it is to ensure that workers compensation privileges are not abused. While the University recognizes that employees may need time to recover, it also expects employees to return to work as soon as possible. PMA will work closely with employees and their physicians to determine what, if any, accommodations may need to be made, and the University will make available lightduty, part-time, or alternative work arrangements whenever possible. 2
The following guidelines should assist both employees and supervisors in processing a workers compensation claim. This brochure and the procedures are not intended to be all-inclusive. PMA, the Personnel Office, or the Office of Risk Management and Insurance will provide additional information and assistance, if needed. PMA Insurance Group P.O. Box 25249 Lehigh Valley, Pennsylvania 18002-5249 Claim Forms: Personnel Office College Hall Room 106 Ext. 5352 Questions/Concerns: Office of Risk Management and Insurance College Hall Room 310 Ext. 5695 Please remember that claims may be denied, or compensation delayed, if forms are not submitted in a timely manner. Procedures For Reporting A Work- Related Injury Or Occupational Disease Employees should report all injuries, even if they do not need medical attention and will not be absent from work, so that a file can be established with PMA in case there are future problems related to the injury. If an employee is injured on the job the employee must: Inform the supervisor of the injury or illness and how it occurred. Complete claim forms 7 DCWC and 7A DCWC and return them to the Personnel Office as soon as possible but no later than three working days from the date of the incident. The forms will be forwarded to the Office of Risk Management and Insurance for review and then submitted to PMA so that a file can be established and a case manager assigned. The employee will be given a copy of the forms. 3
Keep the supervisor informed on a weekly basis, unless instructed otherwise, of the need to remain off work. Provide regular medical documentation to the Office of Risk Mangement and Insurance and to the supervisor. Inform attending medical personnel to forward medical bills and documents to PMA. Medical bills should not be submitted to the employee s health insurance carrier. The supervisor must: Contact the Personnel Office as soon as possible but no later than twenty-four hours from the date of the incident. The form will be forwarded to the Office of Risk Management and Insurance for review and then submitted to PMA. Workers compensation benefits cannot be processed until the supervisor has completed this form. If appropriate, prepare a detailed statement describing all knowledge of what occurred or caused the illness or injury and forward it to the Office of Risk Management and Insurance within 24 hours from the date of the incident. This is particularly important if there is any reason to believe that the illness or injury is not work related. Supervisors should consult with others who may have witnessed the incident in completing the record. If the claim is for an occupational disease, the statement should include: A detailed description of the work performed by the employee. The identification of any fumes, chemicals, or other irritants or situations that the employee was exposed to that allegedly caused the condition. The nature, extent, and duration of the exposure, including hours per day and days per week. A description of the safety precautions taken to ensure that the employee is not exposed to harmful fumes, chemicals, or other irritants. An opinion of the accuracy of the employee s statements. 4
If an employee needs immediate medical attention, he or she should report to Student Health Service. If an employee is severely injured and cannot report to Student Health Service, the employee should be transported to the hospital, or an ambulance should be called. It is essential that the supervisor contact the Personnel Office immediately so that PMA can be informed of the illness or injury. At the hospital, the employee should inform emergency room personnel that he or she has been injured at work and that all medical reports and bills should be submitted to PMA or to the Office of Risk Management and Insurance. Hospital and medical bills should not be submitted to the employee s health insurance carrier. Form 8 DCWC must be completed by the supervisor and returned to the Personnel Office within twenty four hours. Forms 7 DCWC and 7A DCWC should be completed by the employee s representative to ensure that the necessary forms are completed promptly so that there will be as little delay as possible in processing the claim. Workers Compensation Benefits The District of Columbia Workers Compensation program provides for a temporary total benefit, if needed, of 66 2/3% of the employee s average weekly wage up to a defined weekly maximum established by OWC. Benefits begin on the fourth day of the disability. The first three days may be taken as sick leave, annual leave (staff), or leave without pay. Workers compensation payments are made directly by PMA. Payments are usually made within 14 days of the incident. Hospital and medical bills are paid by PMA. Bills should not be submitted to the employee s health insurance carrier. If the absence extends beyond 15 days, the first three days of the disability will be paid retroactively. 5
Prescription Processing Services Injured works are provided a prescription card that enables them to obtain prescriptions with no out-of-pocket costs. PMA is billed directly. All prescriptions dispensed are put through a quality check to assure they are related and not refilled before needed. Payroll Procedures When an employee must be absent because of a work-related injury, the first three days of the absence are recorded as sick leave, annual leave (if sick leave is not available), or leave without pay. Thereafter, the employee may elect one of the following: Continued to use sick leave (and annual leave if necessary) in order to receive full pay; or Be placed on leave without pay status and collect workers compensation benefits (66 2/3% of pay). THE EMPLOYEE IS NOT ENTITLED TO BOTH If an employee elects to use accrued sick leave or annual leave in order to receive full pay, PMA will forward the workers compensation benefits check directly to the Personnel Office. The Personnel Office will work with the employee and the employee s department to repurchased some of the leave used. If the employee does not want to use paid leave or has no paid leave, the employee must be placed on leave without pay status. Workers compensation benefits will be paid by PMA. The Personnel Office must be notified as soon as the employee goes on leave without pay status. A Personnel Action Form (PAF) for leave without pay must be completed and submitted to the Personnel Office. At the box marked Other on the PAF, the notation WC (for workers compensation) must be recorded. When the employee returns, a PAF to remove the employee from leave without pay status must be completed by the employee s department and 6
submitted to the Personnel Office. Health Insurance And Other Benefits While On LWOP When an employee is on paid leave, all benefits deductions continue. When an employee is on leave without pay status or when his or her salary is insufficient to cover the required withholdings, the employee is responsible for the employee s share of all payroll deducted obligations, including health insurance premiums, if coverage is to continue. Payment may be made by direct payment to the Payroll Office, or the deductions will be made when the employee returns to a pay status. The employee may elect to terminate benefits coverage while on leave without pay status. The Role Of PMA PMA does not simply provide compensation and pay medical bills. PMA integrates an aggressive claims investigation with comprehensive managed care and disability management programs. PMA is in contact with the injured worker within twenty four hours after being notified of the injury. The case manager obtains additional information from the employee to assess the level and nature of the injury, helps direct the employee to the most appropriate medical provider if needed, makes arrangements for special equipment if necessary, and establishes a regular communication routine which helps set the pace for an early return to work. If necessary, a nurse may be in contact with the employee s health care provider to begin developing the appropriate rehabilitation plan for the employee. For more serious injuries or occupational diseases, a PMA rehabilitation nurse may be assigned to the case, and a medical advisor may be consulted for advice or injury evaluation. Employees who fail to cooperate with rehabilitation 7
efforts forfeit their rights to workers compensation. Light Duty Or Alternative Duty The workers compensation program emphasizes the importance of returning to work as soon as the employee is able. If an employee is not able to return to his or her regular position within a short period of time, the physician may release the employee for light duty or for a part-time schedule depending on the extent of the injury or illness. The employee s department should try to make the accommodation. If the department cannot, they will be responsible for the employee s salary. Unless the leave has been specifically designed by the University as FMLA leave, refusal to accept a light-duty or part-time arrangement which accommodates the employee s limitations or restrictions will result in the immediate termination of workers compensation benefits. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation, or who knowingly accepts compensation to which he or she is not entitled, is subject to felony criminal prosecution and may, under appropriate 8
Gallaudet University is an equal opportunity employer/educational institution and does not discriminate on the basis of race, color, sex, national origin, religion, age, hearing status, disability, covered veteran status, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, political affiliation, source of income, place of business or residence, pregnancy, childbirth, or any other unlawful basis. 01-42