A WORKERS COMP DISCUSSION

1
A WORKERS COMP DISCUSSION
A DAY IN THE LIFE OF A CLAIM

• By Brad Scofield Sandi Kuritzky
• National Interstate Insurance
• December 14, 2005

2
TYPE OF W.C. CLAIMS

• Medical only
• Lost time- TTD or TPD
• Permanent Partial Disability (PPD)

Communication Is Key
3
MEDICAL ONLY

• Facts
• School bus rear ended by a truck
• Driver had neck injury
• Emergency Room and 1 follow up with doctor
• Missed 2 days of work

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Actions

• 3 point contact
• ER- details, RTW date, direct medical tx
• EE- details of MVA, injury claimed, tx, prior
  injuries
• Dr- Diagnosis, tx plan, disability, reports/bills
• Subro investigation
• Police report witness
• Determine liability
• Notify third party carrier

5
Actions

• Wages due? Waiting period?
• Determine compensability
• Bill review- fee schedule PPO discounts
• Pay bills
• Contact ER/EE- verify no further tx
• Close file
• Pursue recovery via subrogation

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LOST TIME CLAIM

• Facts
• Mechanic slipped on ice on ER premises
• Severe ankle sprain
• EMS to Em Rm, referred to ortho
• No RTW

7
Actions

• Repeat prior steps
• Calculate AWW- pay TTD
• Issue state regulatory forms
• Hire nurse case manager
• Reserves- evaluate exposure
• Encourage ER to maintain contact with EE

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2 wks later- released to modified duty

• Consult with ER- modified duty is available
• Obtain job description
• ER offers modified duty to EE
• Specifics - verbal written
• Date/time, tasks, pay rate, report to whom,
  doctor approved

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RTW - modified duty

• Confirm w/ ER the RTW date wages
• Pay TPD
• Update regulatory forms
• Nurse pushes for full duty release

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Modified Duty

• PROS
• Cost savings
• Avoid long disability
• Fulfill a function
• Establish protocol for others

• CONS
• Re-injury
• Morale issues
• Disgruntled employee
• EE likes modified duty too much

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4 wks - released to full duty

• Communicate to ER
• Pay remaining TPD due
• Suspend TPD
• Issue regulatory forms
• Finalize bills
• Close

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LOST TIME WITH COMPLICATIONS

• Facts
• Motor coach operator claimed a right knee injury
  while unloading luggage
• No report to ER for 2 weeks
• Stopped working when report was filed
• No treatment for 1 wk with family doctor
• Family doctor opines injury is work related
• MRI found meniscus tear
• Surgery recommended

13
Actions

• Repeat prior steps
• Investigate
• R/S EE, witnesses, grapevine info
• Obtain personnel file, DOT physical
• Obtain current past medical records
• Research prior injuries claims
• Refer for Peer Review/ UR
• Issue delay or denial
• Refuse treatment requests

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4 wks- EE filed Claim Petition

• Refer to defense counsel
• Schedule Independent Medcial Exam (IME)
• Causation
• Medical tx
• Determine ERs witnesses
• Reserve worksheet- evaluate exposure
• Medical ? Vocational Rehab
• Wage loss ? Expenses
• PPD rating

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6 wks- status

• IME opined etiology unknown. Surgery needed.
• Surgery done
• Receive health insurance lien
• No RTW

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10 wks - EE able to RTW modified duty

• ER has no modified duty
• EE wont return ERs calls
• TTD exposure continues
• Medical bills denied
• Consider surveillance
• Prepare for litigation
• EE ER testimony
• Expert witnesses (doctors)
• Decision
• Appeal

17
13 wks- released full duty

• ER doesnt want EE back
• Doctor opines 10 impairment rating
• Surveillance was not helpful
• EE remains off work

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Analysis of facts- How strong is our case?

• PROS
• Reported late to ER
• Continued to work
• No witnesses
• Prior history
• Delayed tx
• IME doctor has good rep

• CONS
• Family doctor opines work related
• IME inconclusive
• Undesirable venue
• EE appears credible
• ER wont offer RTW
• Defense will be costly

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VALUATION FOR SETTLEMENT

• Medical costs liens
• 13 weeks TTD
• 10 Permanent Partial disability impairment
  rating
• Voc Rehab
• Future medical
• Letter of resignation

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WHAT CAN ER DO TO ASSIST?

• Good hiring practices
• Direct med tx when permitted
• Develop a process to report claim
• Use internal forms
• Communicate process person to file report
• Use posters
• Train supervisors to ask questions ID witnesses
• Refer EE for med treatment

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WHAT CAN ER DO TO ASSIST?

• Report claims promptly to insurer
• Offer modified duty
• Adhere to modified duty restrictions
• Have job descriptions for full modified duty
  jobs
• Maintain contact w/ EE insurer
• Document! Document! Document!

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FACT OR FICTION?

• If a third party is responsible for injury, no
  W.C. claim needs to be filed.
• Iowa has the highest TTD rate in the nation.
• The lowest max TTD rate in the nation is 351.
• ER has no right to select the medical provider EE
  must see.
• Average cost of a lost time claim that exceeds 30
  days in CA is 30,000.
• EE cannot sue ER or co-worker for negligence.

23
QUESTIONS??

• Thank you and
• Happy Holidays!