Risk & Business Magazine Spectrum Insurance Magazine Fall 2018 | Page 31
WORKERS’ COMP CLAIMS RESOLUTION
WHY IS AN IME SCHEDULED?
Early in a claim, there may be a question of
whether or not the injury is work-related.
Is the injury a preexisting condition? Did
work actually cause the condition? Is
the medical condition directly related to
something at work? When these issues
arise, adjusters schedule the IME soon after
the claim is submitted.
Later in the claim, the adjuster may feel it’s
time for the worker to return to modified
or regular work. When treatment seems to
drag on, an IME may be scheduled. Perhaps
the worker had a new, nonwork accident.
An IME may help sort the work condition
from the nonwork condition. If the treating
doctor awards permanent disability higher
than normally expected, an IME may be
used to see if the rating is appropriate.
An IME may be scheduled more than once
on a claim. The insurance carrier is entitled
to examinations at reasonable intervals. If
you are concerned about any of these issues
and think an IME might help, speak to us or
your adjuster.
WHAT IS NURSE CASE MANAGEMENT?
With nurse case management, when an
employee is injured, a nurse is available on
a 24-hour hotline to assist the employee on
how to properly care for the injury. Nurses
intercept the claim at the point of injury
to ensure that employees obtain the right
type of care from cost-effective providers.
In severe cases, a nurse will recommend
emergency care. With minor injuries,
nurses are able to guide an employee
through first aid and self-care treatment,
or send the employee to an occupational
clinic or the employer’s preferred provider
network.
WHAT BENEFITS DOES NURSE CARE
MANAGEMENT OFFER?
• With immediate medical advice available
for employees, insureds may be able
to reduce the frequency, severity, or
duration of workers’ compensation
claims, ultimately lowering the cost
of workers’ compensation insurance
premiums.
• Nurses can triage injuries to the most
appropriate level of care, assessing
and assigning a degree of urgency to a
wound or illness. By making professional
decisions about treatment, the service
helps contain claims costs by, for
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example, minimizing unnecessary visits
to the emergency room.
Claims are reported on time, avoiding
penalties.
The hotline nurses handle required
paperwork, ensuring consistent,
complete recordkeeping and claim filing.
Return-to-work coordinators receive
immediate notification of the claim,
allowing them to send a job description
to the treating physician who can use the
information to make a more informed
and accurate decision on whether to
release the employee to full or modified
duty.
Efficient treatment accompanied by
prompt and open communication
minimizes dissatisfied injured employees
and consequently decreases costly
workers’ compensation litigation.
WORKERS’ COMPENSATION HEARING
APPLICATIONS
Workers, employers, or insurance
companies may file a hearing application
to resolve workers’ compensation disputes.
Most hearing applications are filed by
workers. The application notifies the state
of a dispute and initiates the legal process.
A copy is forwarded to the employer
and notifies them of the dispute. The
application explains the claim in general.
The claim may be for additional lost time,
additional permanent disability benefits,
penalties, or unpaid medical expenses.
Most workers are represented by an
attorney, but they are allowed to proceed
without representation if they wish.
Applications are delivered by mail. If you
receive a hearing application, contact your
adjuster immediately. An answer must be
filed within a specified time period of the
mailing. Many applications can be handled
and resolved by the adjuster. More complex
applications are referred to a defense
attorney. The adjuster and defense attorney
represent you. They should keep you
informed throughout the legal process. You
may contact them at any time. Your calls
display your concern in the matter and can
provide important information needed to
defend the claim.
HEARINGS
Once the application is filed, the state
allows time for the parties to submit their
proof. After a time, the state will schedule
a hearing. You will receive a Notice of
Hearing six to nine months after the
application is filed. The date of the hearing
is two or three months following Notice of
Hearing. Most hearings take four hours. A
company representative should attend the
hearing to display the company’s concern.
Also, workers tend to be more accurate
in their testimony when the employer
is present. The judge’s ruling is usually
rendered within thirty to ninety days after
the hearing. Therefore, it can take close to
a year to go through the legal process. Some
cases require more than one hearing and
can take longer. Cases can be settled any
time during the process. Settlement often
occurs within thirty days of the hearing
date.
WHAT DO I PAY A WORKER ON
MODIFIED DUTY?
Consider the scenario where a worker has
been off due to a job-related injury. Their
doctor says they can return to modified
duty, and you have identified a job for them.
When the doctor limits the number of
hours a worker can be at work, you offer
work up to that limit. What should the
worker be paid?
You could pay the worker
their normal rate while on
modified duty. The advantage
is they are being paid by you.
If they work a normal week,
insurance payments end. The
disadvantage is that you are
probably paying more than
the modified duty is worth. It
removes the incentive to return
to normal work. This can affect
the morale of coworkers.
Another option is to pay the rate for the
job being done. This may be less than the
worker’s regular pay, motivating the worker
to return to their regular pay promptly.
Most union contracts allow employers to
place a worker into modified work. If your
contract does not allow this, you may wish
to bring this up at the next negotiation.
The contract may address which jobs may
be considered, how long they are available,
and the wage while on modified duty. +