workers’ compensation for state agencies office of risk management karen c. jackson, facilitator
TRANSCRIPT
ORM Workers’ Comp Statistics
5500 active workers’ compensation claims.
Approximately 1200 of these paid lost time benefits on regular basis.
Overview of Workers’ Compensation
Title 23 Louisiana Revised Statutes requires all employers to provide workers’ compensation
coverage for their employees.
Overview of Workers’ Compensation
R. S. 23:1031.A
Anyone employed in the Stateof Louisiana who is injured on the job.
Coverage begins immediately.
Covered accidents must arise out of employment and occur during course and scope of
employment.
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.
Overview of Workers’ Compensation R. S. 23:1203 / R. S. 23:1221
IW may be entitled to medical and/or indemnity benefits at the expense of his employer.
Overview of Workers’ Compensation
R. S. 23:1231
Provisions for– surviving spouse – dependent children or
surviving parents in the event of work - related death.
Notice of AccidentR. S. 23:1302
Injured workers must notify supervisor as soon as an accident occurs.
Notice of Accident
Supervisor immediately initiates paperwork for
the Employers’ First Report of Injury (E-1) claim to be sent to ORM electronically via STARS.
Notice of Accident
Report all incidents and near-misses in STARS even if the incident does not result in lost time
or incur medical expenses.
Online Access
To request access to STARS online reporting:
www.doa.Louisiana.gov/orm
Quick Links sectionORM Data Liaison Application/change form
Notice of Accident
Please notify ORM immediately
– 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 fromthe date employer aware of accident.
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.
Independent ContractorsR. S. 23: 1021.6
Insure contractor carries
WC coverage for its
employees.
If coverage lapses the
State pays WC benefits
–check solvency of
contractor periodically.
Records Retention
ORM maintains all closed files for two (2) years on-site.
Files are archived for three (3) years then destroyed.
Drug ScreeningR. S. 23:1081(1)(b)
Employers can deny WC claims that result from intoxication if
-have a written policy -notify employees of intent to perform post accident drug screening.
Intoxication can be due to alcohol, Rx, OTC medication orillegal narcotics.
Drug Screening
Post-accident drug screening paid in conjunction with the workers’ compensation
claim.
Incidents Not Covered R. S. 23:1081.1c
IW who is proven to be the aggressor in an
unprovoked altercation.
Incarceration and WC R. S. 23:1201.4
Benefits are not payable when an IW is incarcerated unless the IW can prove he has family who is dependant on the comp check
for support.
“Gray” Coverage Areas R. S. 23:1021(7)
Clear and convincingevidence that these are
– sudden – unexpected– extraordinary– related to the employment.
Cannot be related to– any other health condition– personal situation.
Social Activities Questions to Ask
1) Did employer sponsor the event?
2) Did employer require employee attendance or participation?
3) Was employee paid for attending?
4) Did the employer finance the event?
5) Did the employer benefit through improved morale and/or good will?
Standing By
Accidents which occur when the employee is
waiting until a new task is given or unfavorable conditions change before the work can be
resumed; i.e. rain.
On Call
Accidents that occur while responding to an
on call incident as well as traveling to and
from the call are usually covered under workers’ compensation.
At Lunch or On Break
Injuries that occur at the employer’s place of business during lunch or rest are usually covered under workers’ compensation.
Before and After Work
Employees who arrive early or remain at the
place of work after hours are covered under
workers’ compensation if the period of time is reasonable.
To and From Work
Accidents to and from work are not covered unless:
1) Employer asks employee to perform a task on the way to or from work.
2) If the employer furnishes the transportation.
Special Mission for Employer
Employees on a special mission are within the course ofemployment from “portal-to-portal” or from home to the
location of the mission or from the location of the mission to home.
While Traveling
Accidents which occur while an employee is
traveling on behalf of the employer are
covered under workers’ compensation.
Out of town
Overnight
At the hotel
At the restaurant
… if there is no deviation.
Threshold Doctrine
There are special circumstances in which the
employer’s premises is immediately
adjacent to an unusually hazardous area of
travel. The unusual risk is at the threshold
of the employer’s premises.
--railroad tracks
--designated parking areas
Aggravation of Pre-Existing Condition
Pre-existing disabilities or degenerative conditions (whether known or not) that
are aggravated or accelerated by physical exertion or extraordinary mental stress may be eligible for workers’ compensation benefits.
Choice of Physician R. S. 23:1121(B)(1); R. S. 23:1142(B)
By specialty.
$750 of non-emergencytreatment.
Failure to obtain approval may result in non-payment of bills in excess of $750.
Examination of Injured Workers R. S. 23:1123-1124
Employer or insurer has right to have IW
examined from time to time during the course
of the claim.
Who’s going to pay for this?
Employer can give verification of initial medical
treatment up to $750 of non-emergency care.
Who’s going to pay for this?
IW should NEVER pay out-of-pocket for medical services or use personal insurance to pay for covered medical expenses that result
from a work related accident.
Weekly Indemnity Benefits R. S. 23:1224
Injury prevents IW from RTW for more than 7 days.
7 day waiting period – 1st 7 days not recoverable
unless IW loses more than 41 calendar days.
Benefits payable on 8th day.
Calculation of Weekly Benefits R. S. 23:1221
Based on 66 2/3 % of average weekly wage up
to maximum.
(maximum is $522)
Calculation of Weekly Benefits
If a worker earns less thanthe minimum his actual wage is his comp rate.
Wages locked accordingto date of accident-in most cases.
Maximum and minimumchange September 1st.
Compensation Checks
To initiate benefits adjuster enters benefit record upon claim setup or when lost time
begins.
Compensation Checks
Usually mailed to agency of employment to buy back leave.
Must be mailed directly to injured worker ifrequested.
R. S. 23:1201.1
Workers’ compensation payments, at the option of
the employee, shall be mailed to the employee at the
address designated by him.
Leave Buy Back Report
The Office of Risk Management has established a leave buy back report which agencies can run to aid
in re-crediting leave.
The report identifies:name of injured workeragency of employmentamount of comp check
average weekly waged used to determine comp ratepayment period for the check
Stop payment, Void orReissue check
Notify the adjuster ofrecord
– supplemental– phone– email
Name and phone number on check stub.
Information we need from you
Copy of pay stubs for four weeks prior to dateof accident.
This does not include the week of injury.
Information we need from you Supplemental Report of Injury
Notify ORM of changes
in claim status – beginning disability– return to work – corrected wage– corrected dates of loss– retirement status.
Information we need from you
Employer’s Certificate of Compliance
Certifies employer provides WC insurance.
Certifies employer will not intentionally
defeat IW WC claim.
OWCA Mediations and Citations
DO NOT RESPOND TO
EITHER OF THESE!
ORM will securerepresentation from theattorney general’s office
to respond on you behalf.
OWCA Mediations and CitationsR. S. 39:1533b
The representation of the state and state agencies
in all claims covered by the Self-Insurance Fund,
and in all tort claims whether or not covered by the Self-Insurance Fund, shall be provided by
the attorney general or by private legal counsel
appointed by the attorney general…,
WC and FMLA
Employee can be on
workers’ compensation
and family medical
leave at the same time.
These run concurrently.
WC and ADA
Some workers’ compensation injuries may qualify for accommodations under the
Americans with Disabilities Act.
Supplemental Earnings BenefitsR. S. 23:1221(3)(a)
Entitlement to SEB begins when an IW is unable to earn wages = 90% or > of pre-injury
wage.
SEB based on 66 2/3 of difference between pre-injury wage and what employee is
now capable of earning.
Discontinuance of Benefits
Once WC benefits are started they continue until
IW returns to work or is released to RTW, regular
duties by treating physician.
Transitional Duty Employment
Should be done when IW unable to return to his previous work
or
unable to earn wagesequal to his pre-injury wage.
Transitional Duty Employment
Make every effort to return IW back to work
even if IW cannot return to work full duties.
Transitional Duty Employment
Job modification
Light duty
Restricted duty
Transitional Duty– cuts cost of workers’
compensation claims.
Successful Transitional Duty
Transitional Duty is
feasible when the IW
released to some form
of employment by
treating physician.
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 must not lower the performance
standards and expectations of the job as a whole.
Successful Transitional Duty
Transitional duty 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 should not have the effect of
permanently lowering the employee’s civil service job title.
Successful Transitional Duty
Department of Civil
Service, Program
Assistance Division
can give guidance in
evaluating transitional duty
employment.
(225-342-8274)
Retirement and Workers’ Comp R. S. 23:1223; 1225
Disability Retirement– benefits may be reduced
Regular Retirement– benefits payable
for 2 years • gainfully employable
ORM must be notified
immediately.
Unemployment and Workers’ Compensation
Can’t get both workers’
compensation benefits
and unemployment
benefits.
Notify the handling
adjuster immediately.
Purpose of Report
More than seven (7) days lost time
Death
Amputation / Disfigurement
Medical Only
Possible Dispute
Body of the Report
1) Date of the report - The date the report is completed.
2) Date of injury – date the accident occurred.
3) Normal starting time – time employee normally scheduled to begin work.
4) Employee back to work – date IW returned to work.
5) At same wage.
Body of the Report
6) If fatal injury, date of death.
7) Date employer knew of injury - when injury or illness was brought to the employer's attention.
8) Date disability began - the first date that the employee lost time from work as a result of the injury or illness.
9) Last full day paid date – last day the employee was paid in full.
Injured Worker Information
10) Employee Name - injured worker's first, middle, last name.
11) Male, female - gender of the injured worker.
12) Employee telephone number – IW home telephone number.
Injured Worker Information
13) Employee’s most current residential address - Street address, city, parish, state, zip code. 14) Parish of injury - Name of the parish where injury / illness occurred.
Injured Worker Information
15) Date of hire - date injured worker began working with agency.
16) Date of birth - injured worker's date of birth.
17) Occupation - Employee's occupation. Example: Gardner.
18) Department or division regularly employed .
Place of Injury
19) Employer’s premises: YES or NO – If the injury did not occur on
the employer's premises, coverage may be affected.
20) If "NO"- give the location of the injury including city and state.
What Work Activity was the Employee Doing?
21) What was the IW doing when the accident occurred?
Example - Employee injured while lifting numerous 30 lb. boxes into truck at loading dock. Dollies are provided for this task but employee refused to use them.
What was IW Doing When Accident Occurred?
Defenseshorseplayintoxicationpersonal conflicts
Course and scope of employment
Arising out of the employment
What Caused Incident to Happen?
22) The events which resulted in injury or disease. What happened and how it happened. Full details on all factors which led or contributed to injury or illness. Example: Employee complained of back pain after lifting boxes for 1 week (approximately 50 boxes per day).
What Caused Incident to Happen?
Accidents due to mechanical defects or
unsafe acts should have a safety review.
What Caused Incident to Happen?
If incident is result of MVA, who’s at fault
(who hit whom)?
Subrogation rights
Part of Body and Nature of Injury / Illness
23) Identify part(s) of body involved and the nature of the injury and illness to that body part(s). May include more than one part of body.
Example: Sprain to upper and lower back.
24) If occupational disease – Date doctor diagnosed disease / illness as occupational.
Part of Body and Nature of Injury / Illness
If leg, arm, eye, ear, fingers or toes are hurt: – which one?
Medical Information
25) Physician and address - Doctor
who treated the employee for injury.
26) Hospital name and address.
Employer Information
29) Employer address - Include street address, city, state and zip.
30) Employer’s telephone - Phone number of person completing the form.
Employer Information
31) Employer’s mailing address – if different
from address in Item 29.
32) Nature of business - Nature of employer’s
business. Be specific.
Wage Information
Overtime earned in the four (4) weeks prior to date of accident
Premium or differential pay
Income that is taxable to employee
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.
Website information
• ORM websites: http://www.doa.la.gov/orm/forms.htm
http://www.doa.louisiana.gov/orm/pdf/tranduty.pdf_DOA-ORM-Help
• LDOL / OWCA website: http://www.ldol.louisiana.gov/qm_formsindexdetail.asp?LookupValue=OWCA
• ISIS website:http://www.doa.state.la.us/osis
Contact Information
Contact me:
Karen C. Jackson
State Risk Claims Manager
P. O. Box 91106
Baton Rouge, LA 70821-9106
225-342-7390 (p)
225-342-4470 (f)
REFERENCES
LOUISIANA R. S. TITLE 23
LABI WORKERS’ COMPENSATION DESK
BOOK
MALONE AND JOHNSON TREATISE ON
WORKERS’ COMPENSATION