Louisiana State and Legislature and Revised Statutes
Louisiana State and Legislature and Revised Statutes document sample
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Workers’ Compensation For State Agencies Office of Risk Management Karen C. Jackson, Facilitator Expected Workshop Goals Develop a better understanding of the workers’ comp process Expected Workshop Goals SAVE TIME MONEY Expected Workshop Goals Reduce some of the stress associated with workers’ compensation ORM Workers’ Comp Statistics 6100 active workers’ compensation claims Approximately 1000 of these paid compensation benefits on regular basis ORM Workers’ Comp Statistics $48 million spent on workers’ compensation Money comes directly from agency budgets WORKERS’ COMPENSATION IS THE LAW! • Title 23 Louisiana Revised Statutes • Employers MUST provide workers’ compensation coverage for all employees • IW’s have the RIGHT to file a claim Workers’ Compensation is a penalty-driven statute Anything required by the statute is subject to a penalty if • It is not done • It is not done correctly • It is not done timely Office of Workers’ Compensation Administration (OWCA) • Governing body that ensures the workers’ compensation statute is properly administered. • State agency housed under the Department of Labor • Judicial Authority – Issue Mediation Notices and Citations Who should respond to OWCA Mediations and Citations? IW’s can file a disputed claim with Office of Workers’ Compensation ORM will respond to these on agency behalf Notify ORM adjuster when receive mediation notices and citations Who Can Receive Workers’ Compensation? Anyone employed in the State of Louisiana who is injured on the job Coverage begins the moment employment begins Covered accidents must – arise out of employment – occur during course and scope of employment What benefits are provided under Workers’ Compensation? IW may be entitled to medical benefits at the expense of his employer What benefits are provided under Workers’ Compensation? What doctor can an IW seek treatment from? • Choice of physician in each field of specialty • Approval needed to exceed $750.00 of non-emergency medical treatment • Failure to obtain approval may result in non-payment of bills in excess of $750.00 Can an employer have an IW examined by doctor of its choosing? • Employer or insurer has right to have IW examined from time to time during the course claim • Failure to comply with exam may result in suspension of benefits until exam takes place • Suspended period not recoverable Who’s going to pay for this? • Employer can give verification of initial medical treatment up to $750.00 of non- emergency treatment • Notify the adjuster of what’s been approved Who’s going to pay for this? • IW should NEVER pay out-of-pocket for medical services or use personal insurance to pay for medical expenses that result from a work related accident. How long does IW have to file a claim for medical benefits? Claims for medical benefits must be filed within 1 year from date of accident Period for medical benefits is 3 years from date of last payment What benefits are provided under Workers’ Compensation? IW may be entitled to income benefits at the expense of employer What benefits are provided under Workers’ Compensation? Provisions for – Surviving spouse – Dependent children or – Surviving parents in the event of work - related death. What benefits are provided under Workers’ Compensation? Surviving spouse and dependant children – Entitled to weekly benefits Surviving parents – Lump sum • $75,000 each if – No surviving spouse – No dependent children $7500 burial expense How long does IW have to file a claim for indemnity benefits? • Claims for weekly benefits must be filed within 1 year from date of accident • Weekly benefits open 1 year from date of last payment • 3 years from date of last payment for SEB CIVIL SERVICE RULE 11.21 11.21 Workers’ Compensation Payments When an employee is absent from work due to disabilities for which he is entitled to workers’ compensation he (a) shall, to the extent of the amount accrued to his credit, be granted sick leave not to exceed the amount necessary to receive total payments for leave and workers’ compensation equal to his regular salary. (b) may, to the extent of the amount accrued to his credit, be granted annual leave or a combination of annual and sick leave not to exceed the amount necessary to receive total payments for leave and workers’ compensation equal to his regular salary. (c) may be granted leave without pay. CIVIL SERVICE RULE 11.21 Questions about leave with respect to workers’ compensation should be directed to Civil Service Exclusive Remedy • An IW cannot sue his employer in tort or for negligence, unless • Employer intentionally tried to harm the IW When should IW report an accident? Injured workers must notify immediate supervisor – as soon as an accident occurs What should the supervisor do when an accident is reported? Supervisor immediately initiates paperwork for E-1 to be sent to ORM – Paper – Electronically When should ORM be notified of an accident? Please notify ORM immediately of all accidents – Even if IW has enough sick leave to cover accident – Do not require IW to exhaust all of sick leave before ORM is notified Benefits due 14 days from date employer notified of accident DON’T DROP THE BALL! DO NOT deny employees the right to file a claim – Increased litigation exposure – A filed claim does not mean a paid claim Incidents Not Covered Incidents Not Covered IW intentionally injures himself or another employee Incidents Not Covered IW deliberately failed to use adequate protection provided Incidents Not Covered IW intoxicated at the time of the accident -alcoholic beverages -Rx -OTC -illegal narcotics Burden of proof on employer Incidents Not Covered IW who is proven to be the aggressor unprovoked altercation Incidents Not Covered Injuries resulting from Horseplay Incidents Not Covered Incidents which arise out of purely personal matters Items Not Covered Personal items damaged in work-related accidents “Gray” Coverage Areas “Gray” Coverage Areas Mental stress “Gray” Coverage Areas Heart attacks Strokes Gray” Coverage Areas Clear and convincing evidence that these are – Sudden – Unexpected – Extraordinary – Related to the employment Cannot be related to – Any other health condition – Personal situation Are volunteers and community service workers covered for Workers’ Compensation? • Covered for medical payments only • Community service must be ordered by State court When is IW entitled to receive WC Benefits? Eligibility to receive WC lost time benefits begins when injury prevents IW from RTW for more than 7 calendar days 7 day waiting period Benefits payable on 8th day 1st 7 days not recoverable • unless IW loses more than 42 calendar days When is the first indemnity check due? Comp checks are due 14 days after employer notified of accident How are weekly benefits calculated? Based on 66 2/3 % – average weekly wage (AWW) – up to maximum (Maximum is $454.00) How are weekly benefits calculated? If a worker earns less than the minimum – actual wage is comp rate Maximum and minimum – change every September 1st Wages locked according to date of accident – in most cases How are indemnity benefits initiated? To initiate benefits – Adjuster enters benefit record when claim setup OR – When lost time begins WHEN ARE CHECKS PRINTED? INDEMNITY BENEFIT RECORD – Updated every other Monday – Checks generated every other Monday night or – Nearest date to regular pay day if holiday WHEN ARE CHECKS MAILED? EVERY OTHER TUESDAY Where is the indemnity benefits check mailed? Usually mailed to agency or region of employment Must be mailed directly to injured worker if requested RS 23:1201.1 WORKERS’ COMPENSATION PAYMENTS, AT THE OPTION OF THE EMPLOYEE, SHALL BE MAILED TO THE EMPLOYEE AT THE ADDRESS DESIGNATED BY HIM. HOW LONG IS THE CHECK GOOD? CHECKS EXPIRE 180 DAYS FROM ISSUE DATE TELL US! COMP CHECK INCORRECT – TOO MUCH – TOO LITTLE – WRONG DATES TELL US! EMPLOYEE OUT OF LEAVE – We don’t know until you tell us TELL US! RETIRE QUIT BACK AT WORK TELL US! WHEN AGENCY PERSONNEL CHANGES How to get a check voided, reissued or payment stopped - Notify the adjuster of record – Supplemental – Phone – Email Name and phone number on check stub. Can IW be on WC and FMLA? Employee can be on workers’ compensation and Family Medical Leave at the same time. • Run concurrently Can Workers’ Compensation injuries qualify for ADA protection? Some workers’ compensation injuries may qualify for accommodations under the Americans with Disabilities Act. What if IW can RTW in a lesser capacity? If IW worker can earn wages but – Unable to earn wages equal to 90% or greater of pre- injury wage ENTITLED TO SEB – SEB based on 66 2/3 of difference between • pre-injury wage and • what employee is now capable of earning When do workers’ compensation benefits stop? Once WC benefits are started – They continue until IW returns to work OR Is released to RTW, regular duties by treating physician What can be done to stop WC benefits? Only way to stop payments altogether Transitional Duty Employment What is Transitional Duty Employment? TDE is that employment which enables an IW to go from here Transitional Duty Employment To here Stop and think about it! Would you like for your employee to sit here? Stop and think about it! Or here? When is Transitional Duty Employment done? Transitional Duty Employment is feasible – IW released to some form of employment TP decides RTW – Can’t RTW before doctor says so When is Transitional Duty Employment done? When IW unable to return to his previous work OR Unable to earn wages equal to his pre-injury wage What should an employer do when IW is released to restricted duties? Make every effort to –return IW back to work •same employer –even if IW cannot return to work full duties What if there is no Transitional Duty Employment? R. S. 23:1226 – Rehabilitative services • Job placement • Retraining Transitional Duty Employment When an employee is sitting home collecting a comp check - Who’s going to do that work? The work piles up!!! It doesn’t matter what you call it! • Job modification • Light duty • Restricted duty • Transitional Duty Employment – Cuts cost of workers’ compensation claims Successful Transitional Duty • Open mind of employer required • Employer must make accommodations when IW has been released to some form of restricted duty Successful Transitional Duty Agency involvement is required – Committed to TDE – Communicate with the injured worker Successful Transitional Duty Employers should exercise discretion and caution in determining the transitional duties to be assigned. Successful Transitional Duty Transitional duty employment must not lower the performance standards and expectations of the job as a whole Successful Transitional Duty Transitional duty employment should not establish a precedent for a lower level of duties and performance that other employees might then expect to be applied to them Successful Transitional Duty Transitional duty employment should not have the effect of permanently lowering the employee’s Civil Service job title. Transitional Duty Works • Effective in both public and private sector • 20% decrease in disability costs • Keep productivity and employee moral up • Get employee back into work environment as soon as medically possible Transitional Duty Works • Economical • IW benefits • Employer benefits • RTW makes good business sense • IT’S A WIN – WIN SITUATION Successful Transitional Duty Department of Civil Service, Program Assistance Division can give guidance in evaluating transitional duty employment. Can IW receive both retirement and Workers’ Compensation? Disability Retirement – benefits may be reduced Regular Retirement – benefits payable for 2 years • gainfully employable ORM must be notified immediately Can IW receive unemployment and Workers’ Compensation? CAN’T GET BOTH – Workers’ Compensation – Unemployment Benefits Notify the handling adjuster immediately Attorneys • IW not required to have an attorney • Cannot discourage anyone from retaining an attorney • Drive up the cost and settlement value of claims Are Independent Contractors covered under State workers’ compensation? • Ensure contractor has WC coverage for its employees • If coverage lapses – State can be deemed the statutory employer of their employee - Must provide WC to their employees • Check solvency of contractor periodically What form is used to file a WC claim? • Employers’ First Report (E-1) • Five page form – Original ORM – OWCA • > 7 days disability • Death • Amputation / Disfigurement – Employer – Injured Worker – Treating Physician Completing the E-1 • Social Security Number • Location Code • Purpose of the report is important – More than seven (7) days lost time – Death / amputation / disfigurement – Medical only – Possible dispute Completing the E-1 • Complete MM/DD/YY • Time of day • Date IW RTW • Date disability began – if not back at work • Complete – Name – Current residential address including city, state, zip – Current phone number • Occupation Completing the E-1 Place of accident is important – On the premises – On someone else’s premises These effect coverage Completing the E-1 What was IW doing when accident occurred – Defenses • Horseplay • Intoxication • Personal conflicts – Course and scope of employment – Arising out of the employment Completing the E-1 Complete details on how injury occurred Is the accident due to mechanical defect – or An unsafe act? Completing the E-1 If incident is result of MVA: – who’s at fault • (who hit whom)? Subrogation rights Completing the E-1 Retain damaged property – Product Liability Completing the E-1 • Part of body / nature of injury important What’s wrong with IW? • If leg, arm, eye, ear, fingers or toes are hurt: – which one? • Treating physician / hospital – – address and phone number Completing the E-1 Name of Employer – Identify • region • district Completing the E-1 Always give wage even if IW does not lose time Report wage on WEEKLY basis – overtime earned in the four (4) weeks prior to date of accident – Report any premium or differential pay – Report income that is taxable to employee – Report any part-time employment or second jobs Communication Share information with adjuster that will be helpful in making a determination on the claim. – This can be done at any time during the claims process. DID YOU KNOW? Report workers’ compensation claims on-line using a web-based application Claims Reporting: the “OLD” Way Type claim form Write out E-1 Claims Reporting: the “OLD” Way Send claims through the mail or by fax Claims Reporting: the “OLD” Way Wait for mail to be delivered to ORM Claims Reporting: the “OLD” Way Your Claim At ORM!!! ONLINE CLAIMS REPORTING ELIMATES: – Typewritten claims – Handwritten forms – Faxing Reduces time to receive claim Instant claim set-up Easier to authorize medical treatment ONLINE CLAIMS REPORTING Once trained, no paper claims will be accepted Supplemental Report Of Injury Notify ORM of changes in claim status – Beginning disability – Return to work – Corrected wage reporting – Corrected dates of loss – Retirement status Drug Screening • Post-accident drug screen WC accidents • WC Statute: deny if IW is intoxicated at the time of the accident • Intoxication can be due to alcohol, Rx, OTC medication or illegal narcotics • Employer MUST have a written policy Drug Screening • RS 23:1081(1)(b) has guidelines on what constitutes policy • ALL employees must be made aware of the policy • Post-accident screening paid in conjunction with the WC claim • 0.08 % or greater of alcohol = intoxication • Screen pre-RTW (R.S. 23:1221.3.g) Records Retention • ORM maintains all closed files for two (2) years on-site • Files are archived for three (3) years then destroyed What forms should be sent to ORM? • E-1 • Supplemental Report of Injury • Employer’s Certificate of Compliance POST-OFFER OF EMPLOYMENT MEDICAL INQUIRY (E-2) • Used to secure second injury fund approval only • Must be kept confidential • Will be housed at agency of employment • Must be updated every 2 years POST-OFFER OF EMPLOYMENT MEDICAL INQUIRY (E-2) • Compliant with HIPPA ADA FMLA What is the Second Injury Fund? • SIF established by the legislature to encourage employers to hire / retain persons with pre-existing disabilities • Insurance companies pay a percentage of their workers’ compensation premiums into the fund • Claims are filed with SIF on all qualified claims Second Injury Fund • Employer knowledge of pre-existing disability key to SIF approval • Written statement needed from the employer about knowledge of pre-existing condition before the accident occurred • Knowledge can be: disclosures on insurance and/or retirement forms / prior workers comp claims / E-2 Second Injury Fund • Over $2.0 million received in recoveries last year • Reimbursements credited against the qualifying claim • Reduce the cost of the claims and premiums Second Injury Fund - Vendor • ORM utilizes a contract vendor to help identify and secure SIF approval • Please work with vendor to provide needed information to get approvals HANDOUT Workers’ Compensation For State Agencies ?????? Questions ?????? • Are there any questions?