Workers Compensation 101. TWCARMF Risk Management Seminar October 12, 2016 Janina Flores, Director of Pool Administration

Transcription

1 Workers Compensation 101 TWCARMF Risk Management Seminar October 12, 2016 Janina Flores, Director of Pool Administration

2 What is Workers Compensation? What is workers compensation? Provides medical and some lost time wages; referred to as New Law (Texas WC Act) Do you have to have WC insurance in Texas? Texas employers, except for public entities, can chose whether or not to provide workers compensation insurance coverage for their employees. Unlike private employers, political subdivisions are required to provide workers compensation coverage for their employees, and the Texas Labor Code specifically excludes the employee election or waiver provision for employees of political subdivisions. Under Texas law, injured employees covered by workers compensation may not sue their employers to recover damages for their injuries. This is referred to as the exclusive remedy provision.

3 Form Name Purpose When Notice 6 The Employer is required to notify employees if they are covered for workers compensation Must be available to new and current employees. Post notice in HR or other highly visible location available OIEC Notification Form The Employer is required to notify employees of the Ombudsman Program services offered by the Office of Injured Employee Counsel (OIEC) Must be available to new and current employees. Post notice in HR or other highly visible location available

4 Employee Rights May have the right to receive benefits. May receive benefits regardless of who was at fault for their injury with certain exceptions, such as: o The employee was intoxicated at the time of the injury; o The employee injured themselves on purpose or while trying to injure someone else; o The employee was injured by another person for personal reasons; o The employee was injured by an act of God; o The employee s injury occurred during horseplay; or o The employee s injury occurred while voluntarily participating in an off-duty recreational, social, or athletic activity.

5 What is an injury? Injury time, place and event Compensable injury arises out of course and scope of employment Course and Scope an activity of any kind or character that has to do with and originates in the work, business, trade, or profession of the employer and this is performed by an employee while engaged in or about the furtherance of the affairs or business of the employer. The term includes an activity conducted on the premises of the employer or at other locations.

6 Is it a WC Claim? Back hurts? Traveling.? Heart attack.? Evacuation during a Hurricane? On call? Aggravation of pre-existing injury? Ordinary disease of life? Mental trauma? What else???

7 Report of Injury Is it work related? not for you to determine; report if employee states/thinks it is work related Employee is required to notify (does not have to be in writing) the Employer of his/her injury within 30 days (according to the Act). Authority should have a policy such as within 24 hours; at end of shift; 48 hours, etc Notice may be given to anyone who holds a Supervisory/Management role at Employer Late Reporting can result in an Administrative Violation ($500 a day) if injury not reported within 8 days of a lost time injury

8 Reporting Responsibilities by Employer File a DWC-1, First Report of Injury to the Fund within 8 days of the date: Of a work-related injury that caused an employee to miss more than 1 day of work, OR Of a work-related fatality, OR The employer learns an employee has an occupational illness even if employee hasn t missed work

9 Employer DWC Forms Form Name Purpose When DWC 1 DWC 3 DWC 6 The Employer is required to file the claim with the insurance carrier To provide the employee s wage information to the carrier for calculating the employee s Average Weekly Wage (AWW) to establish benefits due to the employee. Requires the Employer to report all Return to Work and Post-Injury Change of Earnings. The Employer is required to submit within 8 days after the employee s absence from work or receipt of notice of occupational disease. The wage statement must be filed within 30 days of the employees eighth day of disability. Form must be filed within 3 days after the injured worker begins to lose time from work; 3 days after injured worker returned to work; then later has additional days of lost time; 10 days after a change in earnings; 10 days after the injured worker resigns or is terminated.

10 Types of Claims Incident Only Just reporting injury; no medical attention no lost time Medical Only has sought medical attention but has not lost time from work Indemnity Only has lost time. Report ASAP- Clock is ticking The day of injury does not count as a lost day Must report within 8 days of injury Failure to comply (Employer) is considered an Administrative Violation - $500/day

11 What does the adjuster do? Fund s investigation of the claim: Compensability of the injury Disability Accrual of any benefits 3 point investigation on Lost Time Claims: Statement from employee Contact with Employer/Supervisor/Witness Contact medical provider Fund s philosophy is to pay promptly what is owed; however, when facts develop that indicate a claim should not be paid based upon the law, then the Fund will dispute payment

12 Where do I send employee for medical treatment? Alliance Providers ( Exception for Emergency Rooms New Employee Orientation Alliance acknowledgement form Advise of WC coverage by employer; employees do not have the right to refuse (political subdivision) coverage Medical Treatment DWC 73/Work Status Report form Attending medical/physical appointment Pre-authorization required on some procedures (The WC Act)

13 WC Medical Provider Forms Form Name Purpose When DWC 73 The doctor is required to indicate the employee s current work status. The Report must be filed after initial visit, where there is a change in work status or substantial change in activity restrictions and when requested by the carrier.

14 Full Duty Release Return To Work DWC 73 Light duty / modified duty release with restrictions Bonafide offer must have the following: Location Schedule Wages A description of the physical and time requirements will entail; and A statement that the employer will only assign tasks consistent with the employee s physical abilities, knowledge and skills FMLA/ADA (Americans with Disability Act)

15 What to do on a Lost Time Claim Employee injured - File DWC-1, First Report of Injury Employee is off work need a doctor s note/dwc 73 Injured employee may use his/her own leave for the first 7 days of lost time* Day 8 15, Injured worker accrues benefits Day 15 benefit (payment) due to injured worker File DWC-3, Wage Statement within 30 days of lost time injury FMLA (Family Medical Leave Act) applies with Employers who have 50 employees or greater Any questions, call your adjuster *Notify Fund if you pay any portion of their salary while out on wc

16 Needing Special Attention Encourage medical attention, if appropriate Encourage attendance to medical appointments and physical therapy appointments Encourage communication with adjuster Pre-Authorization may be required for certain treatments Pharmacy card mailed to injured worker Injured worker may be eligible for mileage reimbursement Disputes on claims (ex. Ordinary Disease of Life)

17 Q&A Does an injured worker (IW) have to go to the doctor? No, cannot force IW to go to the doctor However, encourage IW to seek medical attention if necessary Can the IW go to any doctor for treatment? NO. Injured worker must go to a provider in the Alliance Injured worker can ALWAYS go to the ER Website = (Political Subdivision Workers Compensation Alliance) Toll Free Access: PSWCA ( )

18 Q&A What if the IW cannot find a treating doctor? IW needs to contact the adjuster for assistance or possible authorization to got outside the Alliance. When the adjuster gets a claim, what do they do? Investigates the claim to determine if it is compensable Determine if there is a disability Determine if there has been accrual of any benefits ALL according to the Texas Workers Compensation Act

19 What is a lost time claim? Q&A When an IW loses time (medically documented) at least 8 days of work. What does an IW need to do when off on workers compensation? Provide medical documentation for time off Keep in contact with Employer/Follow policy/procedure Keep in contact with Adjuster Go to medical appointments, follow treatment guidelines Stay within restrictions

20 Q&A If a claim is disputed, what can the IW do? The IW can appeal the decision through an Administrative Hearing process. The IW can contact the Office of Injured Employee Counsel for free assistance. How long can an IW be off work for workers compensation? What is the district s policy FMLA may apply Consider a Neutral Absence Termination policy

21 Q&A What kind of benefits does IW receive? Reasonable and necessary medical care for life Temporary Income Benefits Impairment Income Benefits Supplemental Income Benefits Lifetime Income Benefits Death Benefits

22 Questions??? Thank You!