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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?
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