A WORKERS’ COMP DISCUSSION

By Brad Scofield & Sandi KuritzkyNational 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

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

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

IME opined 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

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 won’t offer RTW Defense will be

costly

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

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!

WHAT CAN ER DO TO ASSIST?

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 andHappy Holidays!