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Anatomy of a Workers’ Compensation Claim. Anatomy of a Workers’ Compensation Claim. It’s all so confusing! Where do I go for information?. - PowerPoint PPT Presentation
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Anatomy of a Workers’ Anatomy of a Workers’ Compensation ClaimCompensation Claim
Anatomy of a Workers’ Compensation Claim
Bewildered and confused by the process of workers’ compensation, Nicholas hopes to gain an understanding of how to handle work injuries at his place of employment. Luckily there is hope, and Nicholas is not alone. . .
It’s all so confusing! Where do I go for
information?
Nebraska Workers’ Compensation Court
Phone: 800-599-5155
Web address: www.wcc.ne.gov
Now that Nicholas knows where to go for information, he’d like to know about the Worker’s Compensation Court. He calls Judy, a friend of his who works as a supervisor with another company, to see if she’s got the scoop on how the court operates.
Of course I can tell you a little about
the Workers’ Compensation Court. They’ve
helped me out in the past!
Court Structure
Seven Judges
Court Administrator
Clerk of the Court
Legal Counsel
Public Information
Coverage & Claims
Vocational Rehabilitation
Nicholas is feeling much more confident about understanding workers’ compensation. He has also become more handsome. Yet, questions still nag at the corners of his mind. He must have answers . . .
I just don’t know which employers are covered by the Workers’
Compensation Act. Are all
types of workers covered? Are
there any exceptions? Oh the humanity!
The Following ARE covered by the Workers’ Compensation Act:
Employers with one or more employees
Part-time Employees
Minors
Charitable Organizations
The Following ARE NOT covered by the Workers’ Compensation Act:
Federal Employees
Railroad Employees
Some Agricultural Operations
Self-Employed Persons, Sole Proprietors, Partners, L.L.C. Members
Volunteers
Independent Contractors
Who is covered by the Workers’ Compensation Act?
I think I understand most of that. I remember a co-
worker, Sally, who had trouble understanding that ‘Independent Contractor’
classification . . .
Independent Contractor or Employee? Sally’s tale of woe
followed by insight.Norma helps Sally with her dilemma.
I have a worker who was injured on the job. How do I tell if he is an employee or an independent
contractor?
Well Sally, even though the question is determined on a case-by-case basis, there
are some guidelines.Let’s see, where is that list of factors?
Aha! Here it is . . .
How to Determine Independent Contractor Versus Employee
It was no trouble, Sally! I’m glad I could help with your workers’
compensation question!
So that’s how you figure it
out! Thank you!
Nicholas stirs from his
daydream. He must know more .
. .
Hence, Norma helped Sally solve the dilemma of independent contractor versus employee
status.
As compelling as the lesson is, Nicholas becomes impatient . . .
Nicholas would be well advised to table his complaints and be aware that this area of workers’ compensation law is quite complex. Additionally, it involves math.
Look, this is super fascinating, but I’m a busy man. Why don’t you move
along to benefits?!
Now,
on to
BENEFITS
Types of Workers’ Compensation Benefits
Indemnity/Wage Loss
Death Benefits
Medical Expenses
Vocational Rehabilitation
I thought you said this would be
complicated. It’s easy . . .
I’ll tell you how life ain’t so easy for one girl named Sue, but first . . .
Before we get into the nitty gritty of the benefits, can you
explain the waiting period I’ve heard about?
Fred was injured on the job on May 9, 2005.
The waiting period . . .
The first 7 days are not paid unless the employee is
disabled for 6 weeks or more.
Fred was not disabled for 6 or
more weeks. He is entitled to benefits beginning on May
16, 2005.
Now, Sue. . .
I hurt my wrist in an accident arising out of
and in the course of my employment! Sue goes to Dr. Mend.
Because Dr. Mend has taken Sue off work temporarily, she is entitled to Temporary Total Disability Benefits.
TTD is calculated as 2/3 of Sue’s average weekly wage for the six weeks that Sue is off work.
Sue, I’ve examined
your wrist. I’m going to recommend that you be off work for six weeks
due to your wrist injury.
Thank goodness for the Worker’s Compensation Act!!
But how do I figure my
average weekly
wage?!?
“as many of the preceding 26 weeks as the employee worked for that employer”
Vacation weeks (and other off-work weeks) are not counted
Earnings from previous employer are not counted
Earnings from another employer are not counted
Bonuses and fringe benefits are not counted UNLESS part of the hiring agreement
Sue makes $1,500.00 per week. She has made this amount during all of the past 26 weeks . Sue
has an AWW of $1,500.00.
Back to calculating
Sue’s disability benefits!
Sue has an AWW of $1,500. She is entitled to 2/3 of $1,500 for
Temporary Total Disability. This comes to $1,000.
Sue’s employer finds Sue a position within her restrictions, but the new position pays less than Sue made at
her old position.
BUT WAIT!!! Nebraska law sets a maximum weekly benefit for
injuries. The maximum for 2014 is $747.00. Sue can only
receive up to the statutory maximum; her benefits are
capped at $747.00.
So, I’ll be off work for six weeks because of my work injury. That means TTD benefits
are $747.00 per week for the six weeks I’m off work. We’ll see
what Dr. Mend has to say after six weeks. . .
Six weeks later . . .
Well Sue, you’re doing better, but
you’re not quite fully recovered. I am
going to let you go back to work, but
only at light duty for another six weeks.
I can work, but I’ll make less money! Am I entitled
to any more indemnity benefits for my injury?
Because Dr. Mend has allowed Sue to return to work, but with light duty restrictions, she is entitled to Temporary Partial Disability Benefits.
TPD benefits equal 2/3 of the difference in wages at the time of injury and the earning power after the injury.
Sue you have reached maximum medical
improvement because your wrist has healed as much as possible. I’m
afraid, however, that you have a permanent
impairment rating of 10% loss of use of your left
wrist.
What does this impairment rating
mean for my workers’ compensation claim?!
Six weeks later, Sue returns to Dr. Mend . . .
Read on for the answer . . .
Permanent Partial Disability Benefits
Two types of PPD
“Body as a Whole”
Injuries to the trunk, neck, or head.
“Member Injuries”
Loss or loss of use of a member.
300 weeks of PPD benefits for ‘body as a whole’ (inclusive of any weeks of TTD or
TPD).
The number of weeks of PPD for a ‘member
injury’ depends on the type of member
and the amount provided by statute. So, my wrist injury was a
member injury, and my PPD benefits are based on the # of weeks specified
by statute!
Member InjuriesTypes of Injury and Number of Weeks
Member I njury Number of Weeks Thumb 60 I ndex finger 35 Second fi nger 30 Third fi nger 20 Fourth or little finger 15 Great Toe 30 Any other toe 10 Hand below elbow joint 175 Arm at or above elbow 225 Foot below knee 150 Leg at or above knee 215 Loss of 1 eye 125 Hearing loss in one ear 50 Both hands, f eet, arms, legs, ears, eyes, or any two such losses in the same accident
Permanent Total Disability (PTD)
Neb. Rev. Stat. Section 48-121(3)
Poor Sue!
Being hurt at work wasn’t easy for Sue, but if you think that’s bad, let me tell you a story about a man named Jed . . .
One day, while at work, Jed was hit on the head with a piece of equipment. When he regained consciousness, he
was in a great deal of pain.
Ouch!!! That hurt!!!
Unlike Sue, Jed has a ‘body as a whole’ injury because he sustained an injury to his head. Jed is entitled
to 300 weeks (inclusive of TTD or TPD received) for his ‘body as a
whole’ injury.
• inability of employee to “earn wages in the same kind of work” or similar work, or any other kind of work he or she is capable of
• benefits are owed until PTD ceases
• training that helps an employee work again can end PTD
• total loss or total loss of use of two members in one accident is PTD
• “odd lot” employment does not end PTD
Another type of disability benefit is Permanent Total Disability.
That kind of disability benefit sounds
complicated. Good thing it doesn’t
happen very often!
In addition to indemnity benefits, the Workers’ Compensation Act also
provides death benefits.
It’s a good thing Jed and Sue both survived their injuries. What happens if an employee dies as a result of a work-related
accident?
• Burial expenses up to $10,000.00 (July 19, 2012)
• Spouses are entitled to benefits for life or until remarriage
• Children are entitled to benefits until age 19 or until age 25 if they are full-time students
Alright, so we’ve been
through indemnity
benefits and death
benefits. You mentioned something about job training or ‘vocational
rehabilitation’. Can you tell
me more about that?
In order for Nicholas to understand vocational rehabilitation, let’s look in on Veronica the vocational rehabilitation expert. . .
My 4 o’clock client, Stan, should be here any minute. Let’s review his file. Looks like he was unable to
return to his previous job or to any other employment with his previous
training and experience. He was injured at work and he just didn’t
have the physical ability to return to work. Because he had only a high school education, there were no
jobs within his physical abilities that he could do without more training.Stan arrives for his
appointment with Veronica.
Hi Veronica. I’m here to talk about my vocational rehabilitation situation. I’ve requested vocational
rehabilitation services from my employer’s workers’ compensation insurer.
Excellent. Also, in cases where the insurance carrier does not agree to the need for VR services, or to the selection of a particular counselor, the Workers’ Compensation Court
can appoint a counselor.
I see, so where do we start?
• Return to previous job with the SAME employer
• A new job with the SAME employer
• A job with a NEW employer
• A period of formal retraining which is designed to lead to employment in another career field.
Ok, so because I can’t do my old position, and there is no job within my abilities at my same employer, a vocational rehabilitation counselor will help find me a new employer
with a job position within my abilities.
You got it. It’s called “job
placement”.
Well, Stan, first there are some
established priorities for vocational
rehabilitation counselors.
If the job placement doesn’t work and you still aren’t able to find a
job you can do within your restrictions, you could undergo a period of training to gain skills for
a new career.
Cool!
Neat, vocational rehabilitation is easy. So what about doctors. Who picks the
doctor?
EMPLOYEE CHOOSES when:
• Employer does not give notice of choice, or
• Employer gives notice of choice and the employee chooses a ‘family physician’
Choice of Physician Rule 50
EMPLOYER CHOOSES when:
• Employer gives notice of choice and employee fails to choose a ‘family physician’ or makes no choice at all
Once a physician is selected, there
can be NO CHANGE unless
both the employer and
employee agree.
But REMEMBER . . . restrictions on change of physician only apply
when the employer has given the
employee notice of the right to choose!
So we’ve been through just about all of the things employees are entitled to when they are injured on the job. What do you do if there is a dispute as to
an employee’s entitlement to benefits?
There are a few options for resolving a workers’ compensation dispute . . .
Informal Dispute
Resolution
Litigation Before the Workers’
Compensation Court
Please tell me more about each option!
Litigation in the WCC
• Employee may file a petition with the Workers’ Compensation Court
• The petition must be filed within 2 years of the date of the accident or the date of the last payment of compensation
• Upon receipt of the petition, the WCC will notify the employer/insurer
• The defendants have 14 days to answer the employee’s petition
• The case is then set for trial before one of the seven judges of the court
• There are procedures to appeal a trial court decision
Informal Dispute Resolution
• IDR is an alternative to trial
• It is provided by the court at little or no cost to the parties
• It’s speedy
• It’s voluntary and confidential
• It’s available to anyone involved in a workers’ compensation dispute
• IDR is conducted by staff attorneys employed by the Workers’ Compensation Court
Issues settled in IDR
Payment of medical
bills
Compensability of injury
Vocational rehabilitation
Necessity of medical
treatmentChoice or change of physician
IDR sounds like an efficient and effective way to resolve disputes at
little or no cost. And you don’t even need a lawyer to do it!
Reporting an injury
What else should I know?
The employee must notify the employer of the injury ‘as soon as practicable’. Generally, employers notify the insurance
carrier.
Reportable injuries must be reported to the court by the insurance carrier via electronic filing.
Lump Sum Settlements
Workers’ compensation benefits can be paid out periodically (weekly) or in a lump sum settlement
The parties reach an agreement and usually will submit the documents for approval by the court
Generally the employee must have reached MMI and returned to work at the time of the settlement.
Payment of the settlement total must be made within 30 days of the date the court approves the settlement
So Nicholas gained a greater understanding of how
workers’ compensation operates.
He also got to meet some interesting characters along
the way.
If Nicholas has any more questions, he can
always contact . . .
The Nebraska Workers’
Compensation Court
800-599-5155
www.wcc.ne.gov
Now I know the anatomy of a workers’ compensation
claim!
Nebraska Workers’ Compensation Court
800-599-5155
www.wcc.ne.gov
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