Worker’s compensation 05.09.12

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A primer for nurses who are unfamiliar with the way workers compensation functions, particularly in Georgia.

Transcript of Worker’s compensation 05.09.12

Workers Compensation

Workers Compensation

The Rules of the Game

Alice M. Adams, RN

May 14, 2012




hospital nursing background (ICU, orthopedics, family practice)

Atlanta Medical Psychology since 1985, >5000 wc patients and their medical records

Ongoing care, IMEs


Define the parameters of an accepted work-related injury and the employers possible defense to that injury.

Identify the nursing role in attending IME appointments with patients and assisting attorneys with controverted claims

Careers in Legal Nurse Consulting

Saturday July 21, 2012



These are the objectives to keep in mind as we move through this discussion.

If you have questions about these topics at the end of my soliloquy, please be sure to ask me or email me.


Commonalities among states


Medical Only vs Lost-Time

What is Workers Compensation?


WC as we know it today came into being in the US in 1902 in the state of Maryland. Prior to that time, an injured worker who claimed an injury had to prove it was the fault of the employer and then sue for medical care.

Workers' compensation is a system in which an employer must pay, or provide insurance to pay for, the lost wages and medical expenses of an employee who is injured on the job.

Do not need to be a legal citizen or even have a valid SSN

Do not have to be full time worker

Independent contractors not covered

Comp law is governed by statutes in every state but some features are consistent. An employee is automatically entitled to receive certain benefits when an occupational disease or accidental personal injury arises out of and in the course of employment. And that phrasing is very important.

Benefits may include cash or wage-loss benefits, medical and career rehabilitation benefits, and in the case of accidental death of an employee, benefits to dependents.

The Negligence and fault of either the employer or the employee usually are immaterial with a few exceptions that well cover.

Because the employer is covering the cost of health care, the employee gives up the right to sue the employer or fellow employees. They can still sue a third party, and some examples might include product liability for a defective machine, or premises liability; an example would be a truck driver who is injured off-site in the delivery of a shipment by the gross negligence at this other location. Third party suits do not change the rights and care of the injured worker, but may affect the proceeds of any third party settlement if the employer has the right to recover any of the money they have spent because of the accident.

One huge difference between private health care and employer health care is that HIPAA rules do not apply regarding release of medical and/or confidential information. This is something that not every injured worker understands. And although employee rules and rights are clearly outlined by the Board of each state and available in handbooks, not all injured workers can read.

There are two basic types of injuries; one is medical-only in which there is no or minimal lost time and the employee RTW even if they are still receiving medical care. The other is known as a lost time injury, which is just what it sounds like.




There are many ways to get hurt in Texas, and it is the only state in which employers do not have to provide traditional workers comp insurance.

However, Texas employers who do not carry workers compensation insurance have to report this, and they have to report work-related injuries and illnesses to the Texas Department of Insurance, Division of Workers Compensation (TDI-DWC).

Employers are also required to notify their employees if they do not carry workers compensation insurance.

Employers who do carry workers compensation insurance coverage are required to report any work-related injuries and illnesses to their insurance carrier.

Although a Texas employer may choose not to have coverage, non-covered employers must comply with certain workers compensation requirements and if they have five or more employees must report all work-related injuries or illnesses to the TDI-DWC by the seventh day of the following month.

Employers that fail to meet these requirements commit an administrative violation and may be subject to administrative penalties.





California has a very important distinction from Georgia.

TheMedical Unitis a unit within the state Division of Workers' Compensation (DWC) that manages medical issues in workers' compensation and appoints qualified medical evaluators to help resolve medical disputes in the workers' compensation system by issuing medical opinions that can be used as evidence before the Workers' Compensation Appeals Board.

In California, a workers compensation claim does not require a physical injury.

A psychological or stress claim without injury is possible.

In order to have a viable stress claim you must have been employed for at least 6 months... UNLESS the psychiatric injury is caused by a "SUDDEN AND EXTRAORDINARY" employment condition.

The six month employment requirement is not applicable for treatment for psychological injury (pain and depression / anxiety ) that is a compensable consequence of a physical injury.




2. In Georgia, there must be a physical injury, regardless of the severity.

This injury must either be new, or be a substantial aggravation of a pre-existing injury/illness (degenerative disk disease, prior surgery, etc.)

Workers compensation coverage begins the first day of employment. Employers with three or more employees are required by law to provide coverage.

Rules and fee schedule for reimbursement subject to amendment or change on July 1 of every year.

Employer is required to post a list of at least six doctors or the name of the certified WC/MCO which provides medical care. You may choose a doctor from the list and transfer care to another doctor on the list without the permission of your employer.

Temporary medical care from any doctor until an emergency is over; then you must get treatment from a doctor on the posted list.

You are entitled to weekly income benefits if you have more than seven days of lost time due to an injury. Your first check should be mailed to you within 21 days after the first day you missed work.


General Concepts

What is workers compensation

When does coverage begin

What is considered an injury

Report within 30 days, file within one year

Horseplay, haste and inattention

Exclusive remedy

Lawsuit/subrogation lien

Lawyer fees

Loss of benefits


Workers compensation is a benefits program created by state law that provides medical, rehabilitation, income, death and other benefits to employees and dependents due to injury, illness and death resulting from a compensable work-related claim covered by the law.

Q. When am I covered?

Workers compensation coverage begins the first day of employment. Employers with three or more employees are required by law to provide coverage.

Q. What is considered an on-the-job injury, illness and death claim?

Any injury, illness or death arising out of and in the course of employment is by definition a compensable work-related claim. This means if employees are injured while performing assigned job duties during assigned work hours, they are covered under the workers compensation program. Injuries sustained while engaging in unassigned duties, during lunch and breaks, are not covered. In addition, injuries that occur during an employees normal commute to and from work are not covered.

Q. If I am injured on the job, what should I do?

You should IMMEDIATELY report your injury to your employer. Obtain and fill out the paperwork

Q. Are employee misconduct claims resulting from on-the-job injuries covered?

No. Workers compensation does not provide benefits for an injury or accident resulting from an employees willful misconduct (i.e. fighting, horseplay, willful act of third party for personal reasons, injuries related to alcohol or drug abuse).

Q. Are injuries resulting from haste and inattentiveness covered?

Yes. These types of injuries would be covered under the workers compensation program. However, employees are encouraged to follow company policies and safety rules and may subject themselves to company discipline if these rules are not adhered to.

Q. Can I receive money damages in addition to workers compensation benefits if I am injured on the job?

No. Workers compensation is the exclusive remedy a worker has against his/her employer for damages resulting from an on-the-job injury.

Q. Can I sue anyone for a work-related injury?

If your injury was caused by the negligence of a third party other than another person who is also an employee of the company for which you work, you may have a right to sue that party. If you sue and receive a dollar award, your employer may have a right to recover some or all of the cost expended in your workers compensation claim. This is known as a subrogation lien. The lien would only be recoverable after you had been fully compensated for your loss resulting from your on-the-job injury.

Q. How much will an attorney charge