Directive. Staff Rule 6.11, Workers' Compensation. Bank Access to Information Policy Designation Public. Catalogue Number. Issued

Transcription

1 Directive Staff Rule 6.11, Workers' Compensation Bank Access to Information Policy Designation Public Catalogue Number Issued Effective October 1, 2011 Retired March 12, 2017 Content Applicable to Issuer HRD Sponsor

2 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 1 of 8 Staff Connections - World Bank Intranet 06 Compensation Workers' Compensation Program 01. Subject, Applicability and Definitions 02. Administration 03. Claims 04. Payment of Disability Benefits 05. Payment of Medical Expenses 06. Payment of Vocational Rehabilitation Expenses 07. Payment of Death Benefits 08. Supplemental Allowance 09. Recovery of Benefits Paid 10. Coordination of Benefits 11. Exclusive Remedy 12. Appeals Annex A: Claims Procedure Annex B: Appeals Procedure 01. Subject, Applicability and Definitions Subject and Policy Rationale 1.01 This Rule sets forth a workers' compensation program which provides staff members with compensation and other benefits in the event of illness, injury or death arising out of and in the course of employment with the Bank Group (sometimes called "work-related" below). This Rule is effective October 1, Applicability 1.02 Except where otherwise specified, this Rule applies to all staff members. Definitions 1.03 In addition to the definitions in Rule 1.01, "General Provisions," for purposes of this Rule, the following definitions apply: Chil The term "child" means the natural son or daughter of the staff member, or the staff member's spouse or registered domestic partner. Child also means a legally adopted son or daughter for whom the Bank Group has determined that a "bona fide" parental relationship exists. e. Claims Administrator. The term "claims administrator" refers to the third party administrator contracted by the World Bank Group to administer workers compensation claims in accordance with Annex A of this Rule. D.C. Act. The term "D.C. Act" means the District of Columbia Workers' Compensation Act of 1998 as amended from time to time. Social Security. The term "social security" means any national social security system. Wages. The term "wages"means: i. for staff paid a net salary, the net salary plus any tax allowance paid by the Bank Group in accordance with Rule 6.04, "Tax Allowance"; and

3 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 2 of 8 ii. for staff paid a gross salary, the gross salary. f. Except for the definitions of "employer", "employee" and "wages", the definitions set forth in Section of the D.C. Act will apply. 02. Administration 2.01 The Claims Administrator will determine whether an injury, illness or death arises out of and in the course of employment and otherwise administer the workers' compensation program in accordance with the provisions of the D.C. Act specified in this Rule, except that where the provisions of this Rule differ from the provisions of the D.C. Act specified, the provisions of this Rule will govern. Provisions of the D.C. Act not specified in this Rule will not apply. Except for par (d) in Section and par (a) in Section , where provisions of the D.C. Act specified in this Rule refer to the Mayor, this will be taken to mean the Claims Administrator A copy of the D.C. Act is available for inspection in the office of the Bank Group's Manager, Human Resources Service Center. 03. Claims 3.01 If a staff member's injury, illness or death is believed by a claimant to arise out of and in the course of employment, a claim for applicable workers' compensation benefits may be filed with the Claims Administrator by the staff member, a surviving spouse or domestic partner, a child, or an appointed guardian. A claim must be filed with the Claims Administrator within the timeline provided in Annex A, Claims Procedure, Paragraph No claim will be deemed compensable where the injury, illness or death was occasioned in a significant part by the staff member s intoxication or willful intention to injure or kill him/her or another. 04. Payment of Disability Benefits 4.01 Staff covered by Rule 6.22, "Disability Program" are eligible for dismemberment and permanent loss of use benefits payable under Section of the D.C. Act, but are not eligible for income replacement benefits under that Act Staff holding an Extended Term Consultant, Extended Term Temporary, Short Term Consultant, Short Term Temporary or Special Assignment (SPAS) appointment, who are unable to work by reason of a work-related injury or illness as determined by the Claims Administrator will be eligible for disability payments. Disability payments will be calculated in accordance with Sections and of the D.C. Act and paid to a claimant in accordance with Section of that Act, except that the wages of a staff member will be wages as defined in paragraph 1.03 (5). 05. Payment of Medical Expenses 5.01 When a claim has been determined to be compensable, the Claims Administrator will approve the appropriate course of medical treatment. The Bank Group will pay all reasonable medical, hospital, and medical rehabilitation costs causally related to the injury, illness, or death as approved by the Claims Administrator A staff member must seek the authorization of the Claims Administrator prior to an anticipated change in the course of treatment by the treating physician to ensure such treatment is eligible for continued payment. A staff member must seek the prior approval of the Claims Administrator for any change of treating physician, either at his/her own initiative or by referral from the original treating physician. Failure to seek such prior authorizations may result in the denial of a subsequent claim if the Claims Administrator determines that the treatment is unnecessary or unrelated to the covered condition.

4 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 3 of Payment of Vocational Rehabilitation Expenses 6.01 In the event a staff member is not able to resume his/her previous job, but is determined by the Claims Administrator to be qualified for vocational rehabilitation, the Bank Group will bear the cost of and the Claims Administrator will arrange for, where available, appropriate vocational rehabilitation services During the period of rehabilitation, the injured person will continue to receive any compensation and medical benefits to which he/she is entitled under this Rule If an injured person declines to participate in an identified vocational rehabilitation program, the Claims Administrator may discontinue any and all benefits provided for under this Rule. 07. Payment of Death Benefits 7.01 In the event a compensable injury causes the death of a staff member, death benefits will be paid to the staff member's survivors and in amounts as specified in Section of the D.C. Act. Survivors are the staff member's spouse or registered domestic partner, and the children of the staff member and his/her spouse or registered domestic partner. 08. Supplemental Allowance 8.01 When the maximum amount of compensation payable for death or disability specified in the D.C. Act is adjusted upwards pursuant to Section of the D.C. Act, a supplemental allowance (also known as "cost-of-living adjustment") will automatically be paid in accordance with Section of that Act to claimants adjudged to be permanently and totally disabled who are already receiving disability benefits or to the claimants' survivors who are already receiving death benefits. 09. Recovery of Benefits Paid 9.01 A claimant receiving payment from a third party for the illness or injury or death for which a claim has been made under this Rule must reimburse the Bank Group to the full extent of benefits he/she has been paid or which have been paid by the Bank Group on his/her behalf under this Rule. In addition, the Bank Group will not be liable for additional benefits payable pursuant to the Workers' Compensation Program until the amount of the workers' compensation benefit due to the claimant exceeds the amount the claimant received from third party. 10. Coordination of Benefits Disability Pension Where a staff member is granted a disability pension under the Staff Retirement Plan by reason of a work-related illness or injury, the staff member will receive the workers' compensation disability benefits to which he/she is entitled under the D.C. Act plus a disability pension, provided that the total of the disability pension and the workers' compensation disability benefit does not exceed 66 2/3 percent of the staff member's pensionable gross salary, adjusted by the same percentage that the maximum amount of compensation has been adjusted in Section 8 of this Rule. Funeral Expenses Funeral expenses that would otherwise be payable to survivors under Section of the D.C. Act will be reduced to the extent that a death benefit is paid pursuant to Rule 6.08, "Benefit on

5 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 4 of 8 Death of a Staff Member in Active Service." Social Security Benefits payable under Section 4 of this Rule will be coordinated with and reduced by 50% of the benefits payable under social security. 11. Exclusive Remedy The claim for compensation which a claimant may file under this Rule constitutes an exclusive remedy against the Bank Group for any illness, injury or death arising out of and in the course of the staff member's employment, except to the extent that the other benefits specified in Section 10 of the Rule may also be pai 12. Appeals A claimant who wishes to appeal the denial of a claim for workers' compensation benefits or a decision taken in connection with the administration of a compensable claim may, within 90 days of receiving notice of the final decision from the Claims Administrator, request administrative review of the decision from an Administrative Review Panel in accordance with Annex B, Appeals Procedure If a claimant, after receiving the final decision of the Administrative Review Panel, who wishes to pursue his/her complaint further, the claimant may then file an appeal with the World Bank Administrative Tribunal in accordance with the provisions of Rule 9.05, "The World Bank Administrative Tribunal." Annex A: Claims Procedure 1.0 Introduction 1.1 The purpose of this document is to detail the claims procedure for accessing workers compensation benefits under the Bank Group Workers Compensation Program. When an illness, injury, or death of a staff member is believed to arise out of and in the course of the staff member s work with the Bank Group, a claim for applicable workers compensation benefits may be submitted by the staff member, or his/her legal representative or guardian, or if the staff member is deceased by the surviving spouse, domestic partner, child, or estate. 1.2 The Bank Group authorizes a Claims Administrator to independently evaluate workers compensation claims and determine whether they are compensable. All benefits payable under this program are funded exclusively by the Bank Group upon approval by the Claims Administrator. The authorized Claims Administrator is currently the Reed Group. Claimants can contact the Reed Group directly as follows. Dedicated toll-free number: Dedicated fax number: address: worldbank@rgl.net Physical address: 19 British American BLVD, Latham, NY 12110, USA 2.0 Submission / Receipt of Initial Claim 2.1 Upon the claimant s initial contact with the Claims Administrator, the Claims Administrator will open a case file for the claimant and mail him/her a workers compensation information packet that includes and introductory letter as well as the following which also can be obtained from the Bank Group via the links provide Workers Compensation Claim Form Attending Physician s Statement Release to Work Form Staff Rule 6.11, Workers Compensation 2.2 Claims must be submitted to the Bank Group s Claims Administrator within 12 months after the illness is

6 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 5 of 8 diagnosed or the injury or death occurs, or if later, 12 months after the date when the claimant became aware, or by the exercise of reasonable diligence should have become aware, of the relationship between the staff member s employment and his/her illness, injury or death. 2.3 The claimant must ensure that the Workers Compensation Claim Form and the Attending Physician s Statement are substantially completed prior to consideration of the claim by the Claims Administrator; The claimant must also ensure that all relevant test results, office notes and/or discharge summaries completed by the attending physician are attached to the Attending Physician s Statement. The claimant must also ensure that any additional information requested pursuant to Paragraph 3.4 of this Annex has been provided to the Claims Administrator including the Release to Work Form, when appropriate Claims submitted on behalf of an impaired staff member by a guardian or other representative must be accompanied by a power of attorney, order establishing legal guardianship or other documentation evidencing the necessary authority to act on the staff member s behalf and to perform the duties required under the workers compensation claims procedure. 3.0 Determination of Compensability 3.1 Once the initial, completed claim is received, the Claims Administrator assigns a Claims Adjuster and a Case Manager to independently review each claim. The Claims Administrator will also notify the Bank Group s Insurance Unit and Health Services Department of the receipt of the claim. 3.2 The Claims Adjuster will: contact the claimant to provide an overview of the claim review process; review and clarify with the claimant all information relating to diagnosis and treatment; treatment providers; insurance claims previously submitted; relation of the condition to the staff member s work; events giving rise to claim; witnesses, observers, et; and obtain information, clarification and testimony directly from other relevant sources regarding how the illness, injury, or death occurred and how it related to the staff member s work. 3.3 The Case Manager will: contact the claimant for an Initial Clinical Interview during which he/she will review with the claimant information relating to diagnosis, treatment, or history of the injury, illness or death, as well as information relating to the attending physician, other medical treatment providers, or insurance claims previously submitted; and contact all medical provider(s) directly to obtain/confirm medical information; review prognosis for recovery and anticipated duration of condition; clarify relation of the condition to the staff member s work. 3.4 During the course of the reviews, the Claims Administrator may request additional information or documentation from the claimant. The claimant must provide additional information and documentation as needed on a timely basis in order to ensure a timely response to the claim by the Claims Administrator. Additionally, the Claims Administrator may require the claimant to undergo an Independent Medical Examination (IME) by an independent medical examiner, at the Bank Group s expense. The claimant will receive copy of the Independent Medical Examiner s finall report. The claimant must submit to the Independent Medical Examination, if so require 3.5 When the Claims Administrator is in receipt of the completed and documented claim, along with any additional information and documentation that the Claims Administrator may request during the course of the review, the Claims Administrator shall promptly notify the claimant that his or her claim is deemed complete Once the Claims Adjuster and the Case Manager have completed their independent reviews of the claim, they will agree on a determination to approve or deny the claim. The Claims Administrator will have 30 calendar days from the notification to the claimant of the receipt of the completed and documented claim to inform the claimant, the Bank Group s Insurance Unit, and Health Services Department of the decision to approve or deny the claim. 3.6 If the claim is approved, the Claims Administrator will define applicable benefits in accordance with Staff Rule 6.11and determine the compensability of the recommended course of treatment. The Claims Administrator may establish with the claimant a schedule of periodic, on-going reviews. At any time during the course of approved treatment and evaluation, the Claims Administrator may request additional medical examinations or documentation. 3.7 The Claim Administrator may request reinvestigation of the events giving rise to the workers compensation claim. 4.0 On-Going Treatment, Administration, and Review of Approved Claims Payment of Medical Expenses

7 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 6 of The staff member has the right to select an attending physician, as well as other medical services providers to carry out the appropriate medical treatment, subject to the approval of the Claims Administrator. 4.2 When an appropriate course of medical treatment has been approved by the Claims Administrator, the Bank Group will cover all reasonable medical, hospital, laboratory, and therapy expenses associated with the approved treatment. To that end, the claimant must complete and submit a Workers Compensation Medical Claim Form, which may be obtained from the Claims Administrator or from the Bank Group via the link provide 4.3 When submitting claims for medical expenses, the claimant must complete a separate Workers Compensation Medical Claim for each medical treatment provider and list all services received from that provider as of the claim date, purpose of services, dates of services, charges, and amounts to be reimburse Proof of payment for all requested reimbursements must be attached to the completed Workers Compensation Medical Claim Form for submission. All claims for medical expenses must be submitted to the Claims Administrator within 30 calendar days of receipt of medical service. 4.4 The staff member must seek prior authorization from the Claims Administrator to change any element of the approved course of treatment, even when the changes are recommended by an attending physician. The staff member must seek prior authorization from the Claims Administrator to change the attending physician or add a treatment provider, even when the changes are recommended by the attending physician or another treatment provider. Only treatments and expenses authorized by the Claims Administrator will be covered for reimbursement. Failure to seek such prior authorizations may result in the denial of a claim if the claims administrator determines that the treatment is unnecessary or unrelated to the compensable condition. 4.5 Medical treatment approved under the Workers Compensation Program will not be covered by the Bank Group s Medical Insurance Plan (MIP) or Medical Benefits Program (MBP). 4.6 The Claims Administrator will review all claims for medical expenses and will have the authority to reject any expenses that do not comply with the approved treatment plan or are not deemed to be necessary and related to the compensable condition. The Claims Administrator may also authorize reimbursement on a provisional basis subject to further review. Claimants may appeal rejection of a medical expense claim in accordance with Annex B of Staff Rule Medical expense claims in full compliance with the approved medical treatment plan will be paid to claimant within 30 calendar days of receipt by the Claims Administrator. 4.8 The Claims Administrator may require the claimant to undergo an Independent Medical Examination (IME) at any time deemed necessary during the treatment perio In determining convenience of place of examination, the Claims Administrator shall consider the following with reasonable notice to the claimant. If the claimant unreasonably refuses such an examination, the benefits may be suspended by the Claims Administrator. the distance to be traveled the physical condition of the staff member; the various modes of transportation available to the staff member; and the location of the qualified physicians who are available to conduct the examination 4.9 Fees and other charges for treatment or medical services shall be limited to those that are reasonable and customary charges prevailing in the local medical community as determined by the Claims Administrator. Examples include physician s charges, diagnostic and lab tests, and hospitalization expenses Reasonable transportation costs incurred to access treatment or to undergo examinations will be covered by the Bank Group. Mileage reimbursement will be assessed in accordance with the rates defined in the Workers Compensation Act of the District of Columbi Vocational Rehabilitation 4.11 In the event a staff member is not able to resume his/her previous job, the Claims Administrator may prescribe a vocational rehabilitation program designed to return the staff member to work in a capacity that will provide a level of income that is as close as possible to the level of income earned by the staff at the time of injury. The Bank Group will bear the cost of and the Claims Administrator will arrange for, where available, appropriate vocational rehabilitation services. During the period of rehabilitation, the injured staff member will continue to receive any compensation and medical benefits to which he/she is entitled under this Rule. If an injured staff member declines to participate in an identified vocational rehabilitation program, the Claims Administrator may discontinue any and all benefits provided for under this Rule.

8 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 7 of 8 Request for Reconsideration by the Claims Administrator 4.12 A claimant who wishes to contest the denial of a claim for workers' compensation benefits or a decision taken in connection with the administration of a compensable claim must request reconsideration of the decision by the Claims Administrator within 90 days of receiving notice of the decision The request for reconsideration shall include any new information not previously furnished with the initial application. If a claimant needs more than 90 days to prepare the request for reconsideration, the claimant may request, in writing, an extension of time from the Claims Administrator. The Claims Administrator will provide up to 30 additional days to file the request for reconsideration The Claims Administrator will render its decision within 60 days of receipt of the request for reconsideration. If the Claims Administrator requires more time to make a decision, the claimant will be provided notice in writing which will include an explanation of why more time is require The additional time will not exceed 30 days, assuming the Claims Administrator has complete information to render its decision If upon reconsideration, the Claims Administrator upholds the denial of the claim; the claimant may appeal to the Administrative Review Panel at the Bank Group. Disability Benefits / Income Replacement 4.16 The Claims Administrator will conduct on-going reviews of a staff member s general condition and response to treatment and will authorize continuation of eligibility for disability benefits or income replacement as necessary. Annex B: Appeals Procedure 1.0 Introduction The purpose of this document is to detail the process by which a staff member, the staff member s surviving spouse, domestic partner, or child, or the staff member s legally appointed guardian can appeal to the Bank Group s Administrative Review Panel for further review a final decision rendered by the Bank Group s Claims Administrator. 2.0 Administrative Review Panel 2.1 The Bank Group s Administrative Review Panel is composed of the following. The head of the Bank Group s Benefit unit responsible for the workers compensation program (Chair) A representative from the Bank Group s Health Services Department; and A representative of the Staff association appointed by the executive committee of the Bank Group s Staff Association 2.2 The Panel will review the decision under appeal on the basis of the written record as provided by the claimant, as well as the response provided by Claims Administrator. The Panel may request from the Worker s Compensation Administrator, the claimant or any other party additional information it deems necessary to reach a conclusion. 3.0 Request of Administrative Review 3.1 A claimant who wishes to appeal the the Claims Administrator's denial of a claim for workers' compensation benefits or a decision taken in connection with the administration of a compensable claim may, within 90 days of receiving notice of final the decision on reconsideration from the Claims Administrator, request administrative review of the decision from the Administrative Review Panel by completing and submitting a Request for Administrative Review form. The form may be accessed via the links provided or from the Claims Administrator. 3.2 The appeal should be submitted to the Chair of the Administrative Review Panel. 3.3 The claimant s must ensure that the Request for Administrative Review form contains the following competed information. e. f. Claimant s full name, address, and telephone number Staff member s name and UPI number Written notification of the decision against which the request is being made and the date on which the notification was received Grounds upon which the Appeal is made Statement of the relevant facts, together with supporting documentation and evidence The conclusion the appellant wishes the Panel to make; and

9 Staff Manual - Table of Contents - Staff Rules Workers' Compensation Program Page 8 of 8 g. Date of the Appeal and claimant s signature 3.4 In preparing an appeal, a claimant may request, and the Claims Administrator will furnish, copies of any medical reports, bills for medical treatment, vocational rehabilitation reports or official forms not already in the claimant's possession. When making his/her request to the Administrative Review Panel, the claimant must provide all necessary documentation, including relevant medical information. The claimant shall not include any new information not previously considered by the Claims Administrator in his/her appeal to the Administrative Review Panel. 3.5 Upon receipt of the appeal request, the Administrative Review Panel will provide a copy of the appeals request to the Claims Administrator who will prepare a written response within 60 days of receipt. The claimant will be provided a copy of the Claims Administrators written response and he/she will have 30 days to provide comments to the Administrative Review Panel on the response given by the Claims Administrator. 3.6 The Administrative Review Panel will review the decision being appealed based on the written record as supplied by the claimant and the response from the Claims Administrator. The Administrative Review Panel may request from the Claims Administrator, the claimant or any other party, additional information it deems necessary to reach a conclusion. 3.7 Within 90 days of receiving all requested documentation, the Panel will transmit a memorandum to the claimant and the Workers Compensation Administrator detailing its decision and the reasons for the decision on the Appeal. In the absence of receipt of requested documentation within a reasonable period of time as determined by the Panel, the Panel may proceed to issue its decision. 3.8 If a claimant, after receiving the final decision of the Administrative Review Panel wishes to pursue his/her complaint further, the claimant may then file an appeal with the World Bank Administrative Tribunal in accordance with the provisions of Staff Rule Search Help/Feedback Site Index IFC MIGA ICSID WBG Home