Connecticut Workers' Compensation Act
Workers’ Compensation
Presentation for DOL
October 31, 2017
John A. Mastropietro
Chairman
Connecticut Workers’
Compensation Commission
10/24/2017
1
Workers’ Compensation- An Overview
Simple Definition
•
Provides medical and monetary benefits to
workers who sustain an injury in the course of
their employment
10/24/2017
2
Workers’ Compensation
•
Who’s entitled to Workers’ Compensation benefits?
•
What kinds of benefits are available under the
Workers’ Compensation Act?
10/24/2017
3
Entitlement
•
Any employee who sustains a personal injury
which arises out of and in the course of his
employment.
•
The Act does not require proof of negligence
•
Changing work force and types of injuries
10/24/2017
4
Workers’ Compensation System
•
2013 Marked the 100
th
anniversary of
Connecticut’s Workers’ Compensation Act
•
Before Workers' Compensation Act
–
Injured workers could bring a claim for damages in
civil court for injuries sustained at work
•
Workers had to show negligence on the part of
the employer produced the claimed injury
5
10/24/2017
Triangle Shirtwaist Fire
•
On March 25, 1911 fire broke out on
the 8
th
, 9
th
and 10
th
floors of the
building where the Triangle Shirtwaist
Factory operated
•
Within minutes 146 employees were
killed
•
People were trapped, an exit door was
locked to prevent employee theft
•
Impetus for adoption of Workers’
Compensation legislation
•
Connecticut adopted its Act in 1913
10/24/2017
6
Connecticut’s
Workers’ Compensation Act
•
Connecticut adopted its Workers’
Compensation Act in 1913
•
System has been tweaked over the years but
the essence of the remedy remains the same
Medical Care
Wage Replacement
10/24/2017
7
Remedy
•
Medical Care
•
Monetary Benefits
–
Wage Replacement
–
Specific indemnity (payment for the loss of use or
function of a body part)
10/24/2017
8
Remedy-Wage Replacement
•
Permanent Total
–
Must meet specific statutory criteria
§ 31-307(c)
•
Temporary Total
–
Provides a wage replacement for the period
claimant is healing
§ 31-307(a)
10/24/2017
9
Temporary Total Disability
•
Amount and rate depends on what the statute
allowed at the time of the injury
•
Consists of claimant’s compensation rate with
a COLA if applicable.
•
Claimant’s compensation rate paid during the
period the claimant is unable to perform any
work
•
Compensation rate computed on a percentage
basis of the claimant’s average weekly wage
10/24/2017
10
Temporary Total Disability
•
Current Computation of Compensation Rate
–
Average Weekly Wage computed for 52 weeks
prior to the injury
–
Total earnings for the 52 weeks divided by the
number of weeks of employment
–
Claimant is entitled to 75% of his average weekly
wage once state income tax, federal income tax
and social security deductions are made
10/24/2017
11
Temporary Total
10/24/2017
12
Temporary Partial
•
Paid for the period between the date of
injury and the time that the claimant is able
to return to some work even if unable to
return to his regular employment (Light
Duty)
§ 31-308(a)
•
Employer is obligated to provide light duty if
available
§ 31-313
10/24/2017
13
Permanent Partial Disability
•
Also referred to as specific provides
compensation for the loss of use of the body
part or its function
•
Compensation for loss enumerated in §31-
308(b)
•
Paid in accordance with schedule set out in §
31-308(b)
10/24/2017
14
Wage Loss Differential
•
Additional benefits provided in § 31-308a.
•
Such benefits are within the discretion of the
Commissioner
•
Capped by the number of weeks awarded
pursuant to § 31-308(b) [Specific]
•
Must be available to work in Connecticut.
10/24/2017
15
Medical Benefits (generally)
•
Claimant is entitled to reasonable or
necessary medical care
•
Must be curative not palliative
•
However palliative acceptable if it increases
functionality, e.g., improves ability to work
10/24/2017
16
Workers’ Compensation – The Process
•
90-95% of all claims are
resolved without
resorting to the
Workers’ Compensation
dispute resolution
process
•
Last year the
Commission held
____hearings
10/24/2017
17
Workers’ Compensation – The Process
•
Begins with an injury
•
Filing of a Claim
–
Written notice of claim
•
Identification of a dispute
•
Request for a hearing
10/24/2017
18
Hearing Process
•
Dispute Resolution Process
–
Begins at the District Level
•
Informal Hearing
•
Pre-Formal Hearing
•
Formal Hearing
10/24/2017
19
Hearing Process-Informal Hearing
(Continued)
•
Informal Hearing
–
Short informal meeting between the parties in a
workers' compensation case
–
Presided over by a Workers' Compensation
Commissioner
–
First level of dispute resolution
–
Purpose to narrow issues
10/24/2017
20
Hearing Process-Informal Hearing
(Continued)
•
How do you get an
informal hearing?
–
File a hearing request
–
The hearing request
form requires that the
parties attempt to
resolve issues before
requesting the hearing
10/24/2017
21
Hearing Process-Pre-formal
•
Pre-formal Hearing -analogous to a Superior
Court's pretrial proceeding
–
Generally allows one last chance to try to resolve
issues before proceeding to a formal hearing
–
May include a discovery schedule order
10/24/2017
22
Hearing Process –Pre-Formal
(Continued)
•
Discussion of formal hearing logistics;
•
witnesses to be called
•
time to be allotted
•
particular accommodations (e.g., need for
interpreter)
•
firm identification of issues
10/24/2017
23
Hearing Process – Formal Hearing
•
Formal hearing
–
Analogous to a bench trial in Superior Court
–
Parties put on evidence
•
Live Testimony - Witnesses
•
Deposition
•
Medical Reports
–
Claimant has the burden of proof
10/24/2017
24
Hearing Process – Formal Hearing
(Continued)
•
The burden of proof standard in the Workers’
Compensation forum is the same as it is in
civil court proceedings; the party who carries
the burden must establish the existence or
non-existence of a fact by a preponderance of
the evidence
10/24/2017
25
Hearing Process – Formal Hearing
(Continued)
•
Commissioner – acts as an ALJ
–
Makes factual findings based on evidence
presented
–
Considers and applies appropriate law to
findings
–
Draws legal conclusions
–
Renders decision in the form of a Finding
and Award/Finding and Dismissal
10/24/2017
26
Hearing Process – Appellate Hearings
•
Appellate Hearing
–
If a party is of the opinion that the trial
commissioner committed legal error then they can
appeal to the Compensation Review Board [CRB]
–
CRB is the first tier in the appellate process
–
CRB opinion can be appealed to Appellate Court
and Supreme Court
10/24/2017
27
Hearing Process – Appellate Hearings
(Continued)
•
The CRB forms the basic body of case law, i.e.,
interpretation of statutes.
–
Courts often refer and defer to the agency’s
interpretation and view on statutes and policy .
–
Principals of “Stare Decisis”
–
Decisions of CRB available on the agency’s web
page
10/24/2017
28
Hearing Process – Appellate Hearings
(Continued)
•
What is the principal of Stare Decisis?
“To abide by, or adhere to, decided cases. Policy of
courts to stand by precedent and not to disturb
settled point. Doctrine that, when court has once
laid down a principle of law as applicable to a
certain state of facts, it will adhere to that
principle, and apply it to all future cases, where
facts are substantially the same; regardless of
whether the parties and property are the same.”
10/24/2017
29
Workers’ Compensation – Up Close
•
What can the employer do to assure
compliance in a cost-effective manner?
10/24/2017
30
Employer’s Perspective -Medical Care
•
As soon as an employee tells you he has
sustained a work-related injury you must
provide him with immediate medical care.
•
One of the goals of Workers’ Compensation is
to restore the injured worker to health and a
return to work
10/24/2017
31
Employer’s Perspective –Medical Care
(Continued)
•
If you belong to a Workers’ Compensation approved
Managed Care Plan you must provide the employee
with the list of physicians from which they may choose
their treater.
•
If you do not belong to a Managed Care Plan the
employee may choose any physician licensed to
practice medicine in the State of Conn.
•
Under NO circumstances may you direct you
employee’s medical treatment.
10/24/2017
32
Employer’s Perspective - Medical Care
(Continued)
•
Medical provider fees subject to the Workers'
Compensation medical provider fee schedule
•
Hospital, Ambulatory Surgical Center fees
subject to the hospital/ambulatory surgical
center fee schedule
10/24/2017
33
Employer’s Perspective - Medical Care
(Continued)
•
Medical provider fees subject to the Workers'
Compensation medical provider fee schedule
•
Hospital, Ambulatory Surgical Center fees
subject to the hospital/ambulatory surgical
center fee schedule
10/24/2017
34
Employer’s Perspective-
Wage Loss Benefits
•
You
must
pay the employee the
full day’s wages
the day of
injury. Thereafter, the insurance company will mail any checks
directly to the employee, or his attorney.
•
You
must
submit a wage statement to the insurance company
listing all income earned by the employee for the last
52 weeks
prior to injury
, including OT, shift differential and bonus pay.
•
You
must
allow the employee to receive treatment on company
time with
no loss of wages.
10/24/2017
35
•
Unless you are a state or municipal employer,
you do not
have to
maintain your employee’s medical coverage while they are out on
comp. You must, however, offer them
COBRA
benefits for up to 18
months.
•
If your business requires you to replace your injured employee
you
may do so
, as there is no job protection mandated under the
Workers’ Compensation Act.
•
If your employee’s claim is denied you
must
file for any other
available medical or disability benefits to which the employee would
be entitled.
Employer’s Perspective-
Wage Loss Benefits (Continued)
10/24/2017
36
Employer’s Perspective-
Wage Loss Benefits (Continued)
•
A few caveats
–
Maintenance of health benefits through COBRA
should occur only after the claimant is separated
from employment.
–
During period Claimant is on temporary total with
an expectation to return to work for the same
employer, claimant is liable for any premium
contribution
10/24/2017
37
Employer’s Perspective-
Wage Loss Benefits (Continued)
•
Caveats - Continued
•
Employer must be aware that they cannot terminate
an injured worker or treat them disparately because
they filed a Workers' Compensation claim.
•
Claims for wrongful discharge may be pursued in the
Workers' Compensation forum or Superior Court
•
Costs and damages relating to wrongful discharge are
not covered by a Workers Compensation insurance
policy
10/24/2017
38
Employer’s Perspective-
Wage Loss Benefits (Continued)
•
Caveats – continued
–
Courts have held discharge permissible if part of a
mutually applied absence control policy
–
Reminder – claimant's absence may be subject to
FMLA
–
Courts have held discharge permissible if part of a
mutually applied absence control policy
10/24/2017
39
Workers’ Compensation -Medical
Care Plans
•
An employer can choose to participate in a
Workers' Compensation approved medical
care plan
•
The objective of such plans is to provide a
network of providers to treat injured workers
thereby assuring quality of care at lower costs
•
Providers are generally paid at a discounted
rate off the provider fee schedule
10/24/2017
40
Workers’ Compensation -Medical Care
Plans (Continued)
•
Network providers are generally
providers with experience in treating
injured workers
•
They are educated in all the obligations
assumed by physicians in rendering
treatment under the Act
10/24/2017
41
Workers’ Compensation -Medical Care
Plans (Continued)
•
Allows employees to continue to exercise their
right to select a treating provider
•
Allows the Workers’ Compensation
Commission greater control over the
provider’s participation
•
Allows employers to provide quality medical
care at a reduced cost
10/24/2017
42
Workers’ Compensation
Administration of Medical Care
•
The Workers’
Compensation Tool Box
10/24/2017
43
To Avoid Litigation
•
Guidelines for
Cooperation Between
Providers and Payors
•
Medical protocols
When in Litigation
•
Guidelines for
Cooperation between
Attorneys and Medical
Providers
Workers’ Compensation
Administration of Medical Care (Continued)
•
Purpose of Guidelines for Cooperation
Between Payors and Providers
-
–
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m
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l
y
m
a
n
n
e
r
.
–
Assure productive use of hearing docket
10/24/2017
44
Workers’ Compensation
Administration of Medical Care (Continued)
–
Give each side to the dispute a framework for
how they are to conduct themselves and what
they may reasonably expect from the other
side
–
May serve as framework for determining if a
respondent has engaged in undue delay or
violated other sanctions under th
e Act
10/24/2017
45
46
–
The Guidelines provide examples of
medical treatment/diagnostics where
payor’s pre-approval not required
–
The Guidelines provide deadlines by
which telephone call and inquiries must
be responded to
Workers’ Compensation
Administration of Medical Care (Continued)
10/24/2017
Workers’ Compensation
Administration of Medical Care (Continued)
•
Why do the Guidelines work?
•
Because if we, the stakeholders, don’t
regulate conduct a remedy will be imposed by
the legislature
•
Generally such statutory remedies carry
unintended consequences that disserve both
payors and providers
10/24/2017
47
Workers' Compensation
Medical Protocols
•
Medical Protocols
–
Opioid guidelines
–
Cervical Spine
–
Lumbar Spine
–
Hand, Wrist, And Elbow
–
Shoulder
–
Knee
–
Psychological Pain Assessment and Management
–
Foot and Ankle (in development)
10/24/2017
48
Workers' Compensation
Medical Protocols (cont’d)
The Medical Protocols
–
Serve as Guidelines
–
Foster Communication as it provides a basis
for treatment expectations
–
Serve as a de-facto governor
–
Indicates what is acceptable treatment and
therefore narrows the field of reasonable
contests to treatment disputes
1/6/2014
49
UCONN Health Center
Workers’ Compensation
Administration of Wage Replacement
Benefits
•
Another toolbox
•
Light Duty
•
Self Insurance
•
Health and Safety
Committees
10/24/2017
50
Workers’ Compensation
Administration of Wage Replacement Benefits
(Continued)
•
Light duty
–
If an employer participates in a Workers’
Compensation medical care plan, or self insurance
must have a light duty plan in place
–
Employers are obligated to provide light duty if
available
–
Light duty must be suitable
10/24/2017
51
Workers’ Compensation
Administration of Wage Replacement Benefits
(Continued)
•
Self Insurance
–
Pledging of assets to fund Workers’ Compensation
liability
–
Employer must meet threshold financial solvency
requirements
10/24/2017
52
Workers’ Compensation
Administration of Wage Replacement Benefits
(Continued)
•
Health & Safety Committees
–
The #1 way to minimize Workers’
Compensation costs is to prevent accidents
–
Make the Committee a true Committee both
in terms of membership and commitment
Listen to rank and file’s concerns and
suggestions for accident prevention
Correct situations which were the source
of an injury so as not to repeat
10/24/2017
53
Workers’ Compensation- Filing a Claim
•
Each employer
must
post a
notice
, in a conspicuous
place, naming their workers’ compensation
insurance carrier as well as the name, address, and
phone number of the appropriate district office.
10/24/2017
54
Workers’ Compensation- Filing a Claim
(Continued)
•
Effective October 1, 2017 PA 17-141 an
employer may designate an address to which
Workers’ Compensation claims must be filed.
•
The address must appear on the notice posted
in a conspicuous place declaring employer’s
insurance information
•
Employer may provide the designated address
to the Workers’ Compensation Commission
which will post on its website
10/24/2017
55
Workers’ Compensation- Filing a Claim
(Continued)
Section 31-294c
allows the employee up to
1 year
from the
date of injury in which to file a claim and
3 years
from the 1st
diagnosis of an occupational illness.
It is
not
up to you to determine the compensability of a claim.
You
must
fill out a
1st Report of Accident
for all injuries
resulting in one or more lost workdays. Besides notifying the
insurance company, 2 copies must go to the Chairman’s Office.
10/24/2017
56
Workers’ Compensation- Filing a Claim
(Continued)
•
If you receive a
Form 30C
from the employee, forward it
immediately to your insurance company so they may make a
determination of compensability and if appropriate file a
Form 43 contesting compensability
within the 28 days
allowed
by law.
10/24/2017
57
Workers’ Compensation- Filing a Claim
(Continued)
Voluntary Agreements
•
The insurance company
MUST
issue a
Voluntary Agreement
for
all
undisputed
claims
involving lost work time within
3
weeks
from the date the employer knows that the
disability will extend past the 3 day waiting
period.
This is a mandatory step in the
Workers’ Compensation process
.
10/24/2017
58
Workers’ Compensation- Filing a Claim
(Continued)
•
Once the insurance company has decided to
accept liability
they may not
discontinue benefits
without the appropriate district commissioner’s
approval.
•
If the respondent intend to discontinue or reduce
benefit a
Form 36
must be mailed to the
commissioner as well as the claimant
•
The
Form 36
will be approved unless the
claimant requests a hearing to contest it
within
15 days from the date of receipt.
10/24/2017
59
Workers’ Compensation- Filing a Claim
(Continued)
•
Things an employer can do after an injury occurs
•
BE INVOLVED/BE DILIGENT
•
WC insurance is not auto insurance
•
i.
Pay attention to progress of employees
•
ii.
Express your value of the employee’s pre-
injury contribution to the work place
•
iii.
Claims handler and squeaky wheel get grease
10/24/2017
60
Questions?
•
Thank you!
10/24/2017
61
This presentation provides an overview of the Connecticut Workers' Compensation Act, explaining who is entitled to benefits and the types of benefits available. It delves into the history of workers' compensation laws in Connecticut, highlighting the Triangle Shirtwaist Fire as a turning point in the adoption of such legislation. The presentation emphasizes the essence of the remedy, which includes medical care, wage replacement, and specific indemnity for workers who sustain injuries in the course of their employment.
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Presentation Transcript
Workers Compensation Presentation for DOL October 31, 2017 John A. Mastropietro Chairman Connecticut Workers Compensation Commission 10/24/2017 1
Workers Compensation- An Overview Simple Definition Provides medical and monetary benefits to workers who sustain an injury in the course of their employment 10/24/2017 2
Workers Compensation Who s entitled to Workers Compensation benefits? What kinds of benefits are available under the Workers Compensation Act? 10/24/2017 3
Entitlement Any employee who sustains a personal injury which arises out of and in the course of his employment. The Act does not require proof of negligence Changing work force and types of injuries 10/24/2017 4
Workers Compensation System 2013 Marked the 100th anniversary of Connecticut s Workers Compensation Act Before Workers' Compensation Act Injured workers could bring a claim for damages in civil court for injuries sustained at work Workers had to show negligence on the part of the employer produced the claimed injury 10/24/2017 5
Triangle Shirtwaist Fire On March 25, 1911 fire broke out on the 8th, 9th and 10th floors of the building where the Triangle Shirtwaist Factory operated Within minutes 146 employees were killed People were trapped, an exit door was locked to prevent employee theft Impetus for adoption of Workers Compensation legislation Connecticut adopted its Act in 1913 10/24/2017 6
Connecticuts Workers Compensation Act Connecticut adopted its Workers Compensation Act in 1913 System has been tweaked over the years but the essence of the remedy remains the same Medical Care Wage Replacement 10/24/2017 7
Remedy Medical Care Monetary Benefits Wage Replacement Specific indemnity (payment for the loss of use or function of a body part) 10/24/2017 8
Remedy-Wage Replacement Permanent Total Must meet specific statutory criteria 31-307(c) Temporary Total Provides a wage replacement for the period claimant is healing 31-307(a) 10/24/2017 9
Temporary Total Disability Amount and rate depends on what the statute allowed at the time of the injury Consists of claimant s compensation rate with a COLA if applicable. Claimant s compensation rate paid during the period the claimant is unable to perform any work Compensation rate computed on a percentage basis of the claimant s average weekly wage 10/24/2017 10
Temporary Total Disability Current Computation of Compensation Rate Average Weekly Wage computed for 52 weeks prior to the injury Total earnings for the 52 weeks divided by the number of weeks of employment Claimant is entitled to 75% of his average weekly wage once state income tax, federal income tax and social security deductions are made 10/24/2017 11
Temporary Total Date of Injury Compensation Rate Average Weekly Wage 26 weeks 66 2/3 of gross 10/1/67- 9/30/91 26 weeks 80% AWW less federal income tax and FICA deductions 10/01/91- 6/30/93 52 weeks 75 % AWW less federal, state income taxes and FICA deductions 7/1/93- current 10/24/2017 12
Temporary Partial Paid for the period between the date of injury and the time that the claimant is able to return to some work even if unable to return to his regular employment (Light Duty) 31-308(a) Employer is obligated to provide light duty if available 31-313 10/24/2017 13
Permanent Partial Disability Also referred to as specific provides compensation for the loss of use of the body part or its function Compensation for loss enumerated in 31- 308(b) Paid in accordance with schedule set out in 31-308(b) 10/24/2017 14
Wage Loss Differential Additional benefits provided in 31-308a. Such benefits are within the discretion of the Commissioner Capped by the number of weeks awarded pursuant to 31-308(b) [Specific] Must be available to work in Connecticut. 10/24/2017 15
Medical Benefits (generally) Claimant is entitled to reasonable or necessary medical care Must be curative not palliative However palliative acceptable if it increases functionality, e.g., improves ability to work 10/24/2017 16
Workers Compensation The Process 90-95% of all claims are resolved without resorting to the Workers Compensation dispute resolution process Last year the Commission held ____hearings 10/24/2017 17
Workers Compensation The Process Begins with an injury Filing of a Claim Written notice of claim Identification of a dispute Request for a hearing 10/24/2017 18
Hearing Process Dispute Resolution Process Begins at the District Level Informal Hearing Pre-Formal Hearing Formal Hearing 10/24/2017 19
Hearing Process-Informal Hearing (Continued) Informal Hearing Short informal meeting between the parties in a workers' compensation case Presided over by a Workers' Compensation Commissioner First level of dispute resolution Purpose to narrow issues 10/24/2017 20
Hearing Process-Informal Hearing (Continued) How do you get an informal hearing? File a hearing request The hearing request form requires that the parties attempt to resolve issues before requesting the hearing 10/24/2017 21
Hearing Process-Pre-formal Pre-formal Hearing -analogous to a Superior Court's pretrial proceeding Generally allows one last chance to try to resolve issues before proceeding to a formal hearing May include a discovery schedule order 10/24/2017 22
Hearing Process Pre-Formal (Continued) Discussion of formal hearing logistics; witnesses to be called time to be allotted particular accommodations (e.g., need for interpreter) firm identification of issues 10/24/2017 23
Hearing Process Formal Hearing Formal hearing Analogous to a bench trial in Superior Court Parties put on evidence Live Testimony - Witnesses Deposition Medical Reports Claimant has the burden of proof 10/24/2017 24
Hearing Process Formal Hearing (Continued) The burden of proof standard in the Workers Compensation forum is the same as it is in civil court proceedings; the party who carries the burden must establish the existence or non-existence of a fact by a preponderance of the evidence 10/24/2017 25
Hearing Process Formal Hearing (Continued) Commissioner acts as an ALJ Makes factual findings based on evidence presented Considers and applies appropriate law to findings Draws legal conclusions Renders decision in the form of a Finding and Award/Finding and Dismissal 10/24/2017 26
Hearing Process Appellate Hearings Appellate Hearing If a party is of the opinion that the trial commissioner committed legal error then they can appeal to the Compensation Review Board [CRB] CRB is the first tier in the appellate process CRB opinion can be appealed to Appellate Court and Supreme Court 10/24/2017 27
Hearing Process Appellate Hearings (Continued) The CRB forms the basic body of case law, i.e., interpretation of statutes. Courts often refer and defer to the agency s interpretation and view on statutes and policy . Principals of Stare Decisis Decisions of CRB available on the agency s web page 10/24/2017 28
Hearing Process Appellate Hearings (Continued) What is the principal of Stare Decisis? To abide by, or adhere to, decided cases. Policy of courts to stand by precedent and not to disturb settled point. Doctrine that, when court has once laid down a principle of law as applicable to a certain state of facts, it will adhere to that principle, and apply it to all future cases, where facts are substantially the same; regardless of whether the parties and property are the same. 10/24/2017 29
Workers Compensation Up Close What can the employer do to assure compliance in a cost-effective manner? 10/24/2017 30
Employers Perspective -Medical Care As soon as an employee tells you he has sustained a work-related injury you must provide him with immediate medical care. One of the goals of Workers Compensation is to restore the injured worker to health and a return to work 10/24/2017 31
Employers Perspective Medical Care (Continued) If you belong to a Workers Compensation approved Managed Care Plan you must provide the employee with the list of physicians from which they may choose their treater. If you do not belong to a Managed Care Plan the employee may choose any physician licensed to practice medicine in the State of Conn. Under NO circumstances may you direct you employee s medical treatment. 10/24/2017 32
Employers Perspective - Medical Care (Continued) Medical provider fees subject to the Workers' Compensation medical provider fee schedule Hospital, Ambulatory Surgical Center fees subject to the hospital/ambulatory surgical center fee schedule 10/24/2017 33
Employers Perspective - Medical Care (Continued) Medical provider fees subject to the Workers' Compensation medical provider fee schedule Hospital, Ambulatory Surgical Center fees subject to the hospital/ambulatory surgical center fee schedule 10/24/2017 34
Employers Perspective- Wage Loss Benefits You must pay the employee the full day s wages the day of injury. Thereafter, the insurance company will mail any checks directly to the employee, or his attorney. You must submit a wage statement to the insurance company listing all income earned by the employee for the last 52 weeks prior to injury, including OT, shift differential and bonus pay. You must allow the employee to receive treatment on company time with no loss of wages. 10/24/2017 35
Employers Perspective- Wage Loss Benefits (Continued) Unless you are a state or municipal employer, you do not have to maintain your employee s medical coverage while they are out on comp. You must, however, offer them COBRA benefits for up to 18 months. If your business requires you to replace your injured employee you may do so, as there is no job protection mandated under the Workers Compensation Act. If your employee s claim is denied you must file for any other available medical or disability benefits to which the employee would be entitled. 10/24/2017 36
Employers Perspective- Wage Loss Benefits (Continued) A few caveats Maintenance of health benefits through COBRA should occur only after the claimant is separated from employment. During period Claimant is on temporary total with an expectation to return to work for the same employer, claimant is liable for any premium contribution 10/24/2017 37
Employers Perspective- Wage Loss Benefits (Continued) Caveats - Continued Employer must be aware that they cannot terminate an injured worker or treat them disparately because they filed a Workers' Compensation claim. Claims for wrongful discharge may be pursued in the Workers' Compensation forum or Superior Court Costs and damages relating to wrongful discharge are not covered by a Workers Compensation insurance policy 10/24/2017 38
Employers Perspective- Wage Loss Benefits (Continued) Caveats continued Courts have held discharge permissible if part of a mutually applied absence control policy Reminder claimant's absence may be subject to FMLA Courts have held discharge permissible if part of a mutually applied absence control policy 10/24/2017 39
Workers Compensation -Medical Care Plans An employer can choose to participate in a Workers' Compensation approved medical care plan The objective of such plans is to provide a network of providers to treat injured workers thereby assuring quality of care at lower costs Providers are generally paid at a discounted rate off the provider fee schedule 10/24/2017 40
Workers Compensation -Medical Care Plans (Continued) Network providers are generally providers with experience in treating injured workers They are educated in all the obligations assumed by physicians in rendering treatment under the Act 10/24/2017 41
Workers Compensation -Medical Care Plans (Continued) Allows employees to continue to exercise their right to select a treating provider Allows the Workers Compensation Commission greater control over the provider s participation Allows employers to provide quality medical care at a reduced cost 10/24/2017 42
Workers Compensation Administration of Medical Care The Workers Compensation Tool Box To Avoid Litigation Guidelines for Cooperation Between Providers and Payors Medical protocols When in Litigation Guidelines for Cooperation between Attorneys and Medical Providers 10/24/2017 43
Workers Compensation Administration of Medical Care (Continued) Purpose of Guidelines for Cooperation Between Payors and Providers- Facilitate Communication Assure timely decisions so as provide injured workers with the best and most appropriate treatment in the most timely manner. Assure productive use of hearing docket 10/24/2017 44
Workers Compensation Administration of Medical Care (Continued) Give each side to the dispute a framework for how they are to conduct themselves and what they may reasonably expect from the other side May serve as framework for determining if a respondent has engaged in undue delay or violated other sanctions under the Act 10/24/2017 45
Workers Compensation Administration of Medical Care (Continued) The Guidelines provide examples of medical treatment/diagnostics where payor s pre-approval not required The Guidelines provide deadlines by which telephone call and inquiries must be responded to 10/24/2017 46
Workers Compensation Administration of Medical Care (Continued) Why do the Guidelines work? Because if we, the stakeholders, don t regulate conduct a remedy will be imposed by the legislature Generally such statutory remedies carry unintended consequences that disserve both payors and providers 10/24/2017 47
Workers' Compensation Medical Protocols Medical Protocols Opioid guidelines Cervical Spine Lumbar Spine Hand, Wrist, And Elbow Shoulder Knee Psychological Pain Assessment and Management Foot and Ankle (in development) 10/24/2017 48
Workers' Compensation Medical Protocols (cont d) The Medical Protocols Serve as Guidelines Foster Communication as it provides a basis for treatment expectations Serve as a de-facto governor Indicates what is acceptable treatment and therefore narrows the field of reasonable contests to treatment disputes 1/6/2014 UCONN Health Center 49
Workers Compensation Administration of Wage Replacement Benefits Another toolbox Light Duty Self Insurance Health and Safety Committees 10/24/2017 50
