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A WORKERS’ COMP DISCUSSION. A DAY IN THE LIFE OF A CLAIM. By Brad Scofield & Sandi Kuritzky National Interstate Insurance December 14, 2005. TYPE OF W.C. CLAIMS. Medical only Lost time- TTD or TPD Permanent Partial Disability (PPD). Communication Is Key. MEDICAL ONLY. Facts :
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A WORKERS’ COMP DISCUSSION A DAY IN THE LIFE OF A CLAIM By Brad Scofield & Sandi Kuritzky National Interstate Insurance December 14, 2005
TYPE OF W.C. CLAIMS • Medical only • Lost time- TTD or TPD • Permanent Partial Disability (PPD) Communication Is Key
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
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
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
LOST TIME CLAIM • Facts: • Mechanic slipped on ice on ER premises • Severe ankle sprain • EMS to Em Rm, referred to ortho • No RTW
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
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
RTW - modified duty • Confirm w/ ER the RTW date & wages • Pay TPD • Update regulatory forms • Nurse pushes for full duty release
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 Modified Duty
4 wks - released to full duty • Communicate to ER • Pay remaining TPD due • Suspend TPD • Issue regulatory forms • Finalize bills • Close
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
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
4 wks- EE filed Claim Petition • Refer to defense counsel • Schedule Independent Medcial Exam (IME) • Causation • Medical tx • Determine ER’s witnesses • Reserve worksheet- evaluate exposure • Medical ● Vocational Rehab • Wage loss ● Expenses • PPD rating
6 wks- status • IMEopined etiology unknown. Surgery needed. • Surgery done • Receive health insurance lien • No RTW
10 wks - EE able to RTW modified duty • ER has no modified duty • EE won’t return ER’s calls • TTD exposure continues • Medical bills denied • Consider surveillance • Prepare for litigation • EE & ER testimony • Expert witnesses (doctors) • Decision • Appeal
13 wks- released full duty • ER doesn’t want EE back • Doctor opines 10% impairment rating • Surveillance was not helpful • EE remains off work
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 won’t offer RTW Defense will be costly Analysis of facts- How strong is our case?
VALUATION FOR SETTLEMENT • Medical costs & liens • 13 weeks TTD • 10% Permanent Partial disability impairment rating • Voc Rehab • Future medical • Letter of resignation
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
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!
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.
QUESTIONS?? Thank you and Happy Holidays!