Benefits of Offering Modified Work to Injured Workers

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

There are many things the employer is required to do after a work related injury occurs. There are also additional things an employer can and should do after an employee is injured, though not required by any regulatory agency, like offering modified work. 

Obviously, there is the immediate need to address the injury itself. This is usually done by the lead, foreman, or supervisor and would include stopping the bleeding, placing ice on the injured area, etc. The injured worker’s injury then needs to be assessed by a medical professional. There are options for having the injury medically assessed. For minor injuries, it may be by calling a triage service or having a medical triage specialist (nurse or paramedic) go to the injured worker to determine if this minor injury can be taken care of with self-care or if the injured worker needs to be seen at an occupational medicine clinic. With referring your injured worker to a clinic, you should determine if the injured worker can drive themselves or if they need a company representative to drive them.

After the injury is properly addressed, focus on the reporting of the claim. Gather the forms and reports that need to be completed or obtained to provide to the insurance adjuster. Your next decision comes after the treating physician completes their initial evaluation. The physician should provide doctor notes, the mechanism of injury, how the injury occurred, and any other additional information. The physician may also provide wound care, sutures, x-rays, ace wraps, medications, ointments and make referrals for physical therapy, acupuncture and/or chiropractic treatment, etc.

The treating physician then provides their recommendations on the injured worker’s ability to return to work. For more severe injuries, the treating physician may want the injured worker to remain off work completely and could recommend temporary total disability. After some time off work and with some provided treatment, the doctor usually recommends that the injured worker return to work, but with some restrictions, such as not lifting over a certain amount of weight, not exceeding so many hours of weight bearing, etc. The restrictions provided are usually consistent with the body part(s) that were injured.  

So, the treating physician is releasing the injured worker to return to work but not to full, physical capacity. This is called a release to modified work, restricted duties, or light duties. From the insurance claims perspective, this is referred to as temporary partial disability. The modified work restrictions are usually slowly decreased while the injured worker continues the treatments and recovers from the work injury. This gradual recovery continues until the injured worker is able to resume all their physical work activities. This is called being released to full work activities, unrestricted duties, or to their usual and customary duties.

When the injured worker is released to modified work (i.e., restricted, light) duties, the employer decides if they can provide the injured employee duties that allows them to work while avoiding certain physical activities consistent with the doctor’s return to work recommendations.  

Benefits to the Employee

Providing modified, restricted, light duty work serves many purposes. First and foremost, providing modified work can reassure an injured worker that their employer cares for them personally, professionally, and psychologically. A work injury can be a very traumatic event, and returning to work as soon as possible after a work injury can help the injured worker feel confident their employer will be there for them and their family as they recover from the accident. This is one of the ways the employer can show their support of, and gratitude for, their employees and all the hard work they provide.  

Many studies have shown that providing modified work results in injured workers recovering quicker and more completely. It allows the injured worker to maintain their earnings and usual working schedule, while maintaining their relationships with the foreman, supervisors, and co-workers. Modified work also allows the injured employee to remain physically and mentally active while also allowing them to focus on their treatment and recovery.

Effect on the Business

For a business, a work injury can be very disruptive. The disruption of a work injury usually causes employers to move employees around to compensate for a lost employee. Employees working together as a team would see a change in work partners. Crews would be short a person who would be responsible for a certain part of an assignment resulting in changes in each crew member’s responsibilities. A work injury may affect how quickly the team can complete a job or project, how quickly the crew completes their daily tasks, and even how the employer is able to bid on future jobs or projects. 

Work injuries are stressful for an employer and the remaining employees. Besides the lost productivity from an injured worker, there may also be an emotional strain to other employees, or concerns about their own safety, about how they would be able to handle such an injury or how they would be treated if they were injured. 

Assigning an injured worker to modified work allows the employer to address other items of their business that may not get addressed when all employees are working at full capacity or when there are not enough employees to address these other areas. Assigning an injured worker to modified duties can allow an employer get caught up on cleaning certain areas, re-organizing a storeroom, updating inventory, etc. 

Benefits to the Business

Providing modified work allows an employer to have a direct impact on the overall cost of a work-related injury claim. By providing modified work, the employer pays the injured worker’s wages instead of the claims adjuster paying temporary disability benefits. If the employer does not offer modified work for an injured worker, instead of being temporarily partially disabled, the injured worker is then considered temporarily totally disabled. The claims adjuster would then be required to pay the injured worker temporary disability benefits at 2/3 of the injured worker’s average weekly wage. This is calculated from the 52 weeks of previous earning information you provide the adjuster when the claim was being created. This is also a tax-free benefit. 

However, getting these temporary disability benefits can also be a disincentive for injured workers to return to their normal work duties sooner than they are required. There is an increasing trend of injured workers refusing to return to modified work offered by their employers. Whether they want to stay home and collect temporary disability benefits, complete a side job they were working on while concurrently working for the employer, or if they believe they will recover quicker by simply staying home, injured workers can make it difficult to provide modified work. They can be disruptive, argumentative and provide poor quality of work while performing modified work. They can be insubordinate while performing modified work and can arrive late, leave early, take too much time for doctor or treatment appointments, etc. They can frustrate the employer so much that the employer may want to reconsider offering modified work to this injured worker. If the employee declines the employer’s modified work offer, the injured worker would no longer receive any wages from the employer and they would not be entitled to any temporary disability benefits/payments from the adjuster.   

Injured workers retain legal counsel for work-related injuries for a wide variety of reasons. Disagreements over returning to modified work is one of the most common of these reasons. When an attorney becomes involved in a workers’ compensation claim, there are usually disagreements over a number of issues, but the modified work dispute from the attorney is usually that the employer did not properly advise or instruct the injured worker about their responsibilities related to modified work offers. 

The lost time from work issue, after modified work is declined by the injured worker, usually becomes a monetary issue that is documented at the time, then later becomes one of the issues to negotiate or resolve when the claim is being settled. Usually a dispute like this is negotiated somewhere between the full value of the time lost from work and zero. This adds to the overall cost of a workers’ compensation claim. The development of this issue, however, can be completely avoided if the employer were to document the offer of modified work in writing. The employer can draft their own offer of modified work letter. The claims adjuster, their return to work specialists, or your claims advocate can also provide assistance with drafting of this letter. 

When an injured worker declines modified work offers, they sometimes get state disability benefits from the State of California Employment Develop Department (EDD), who in turn file a lien (or bill) for the lost time benefits paid to the injured worker on the workers’ compensation claim.  If the attorney and the claims adjuster are unable to resolve this issue, the documentation obtained (The Modified Work Offer letter) when the modified work was offered will usually be sufficient evidence for not reimbursing EDD for any of their lien, and/or for the workers’ compensation judge to agree with the employer and claims adjuster on this issue. 

Offering modified work is a very good thing to do for injured workers, for their recovery, and for the employer. It is also a very effective and proven strategy for handling workers’ compensation claims. Offering modified work can speed up the injured worker’s recovery. This allows the workers’ compensation claim to move quicker through the claim process to resolution or settlement. This usually results in the injured worker’s return to their normal work activities, their continued employment with the employer, and in reducing the cost of the workers’ compensation claim.

Workers’ Compensation Claim Advocacy: Distinguishing Good from Great

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

As the new normal continues evolving through this pandemic, advocates are needed across all industries and sectors. Businesses and their employees exposed to the risk of workers’ compensation injuries and illnesses need the highest level of advocacy now, more than ever. 

Like so much of what we experience in our daily interactions, establishing a baseline of competence in any field has varying levels of effectiveness. That is, there are good claim advocates and then there are great ones; high-level claim liaisons that can make organizations more knowledgeable and stronger. 

What are the characteristics that make up the great ones? And, what should you expect with their involvement in your workers’ compensation program?

The first pre-requisite for any workers’ compensation claim advocate is experience. Ideally, having multiple years working as a claim adjuster and managing a case load for an insurance company is vital. While this creates a solid base, stopping here can limit the effectiveness for employers in other critical areas. In order to begin to go from good to great you should expect your advocate to have one or more of the following experiences to offer the broadest perspective possible for your team:

• Background with return-to-work programs, in development, implementation and management.

• Experience from being a workers’ compensation administrator for a self-insured employer with the State of California and Department of Industrial Relations

• Obtaining years of training in diagnosing and treating industrial injuries from occupational medicine, orthopedic surgical, spinal surgical and pain management physicians.

• Providing years of training to workers compensation physicians on treatment and disability management of work injuries and preparing  med-legal reports and addressing permanent impairment ratings, causation, apportionment, contribution and all other issues.

• Or the very rare experience of suffering a work injury, requiring surgeries and rehab, concern for losing one career and starting over in another, and going through the entire workers compensation process through settlement

Secondly, using these technical experiences in review and oversight of claims is both tangible and measurable. That includes:

• Ensuring the accuracy of claim statuses and plan of actions.

• Recognizing when claim reserves are adequate or inflated.

• Pushing for claim closures in the most efficient and cost-effective resolutions.

• Forming a deep, consultative bond that elevates a claim advocate to that of a trusted partner.

The final component in establishing a superior workers’ compensation advocate is building strong, respectful relationships with adjusters and employers. This requires the most experienced advocate creating a “partnership environment” that allows for continual open dialogue, which very often expedites the entire claim process. The most effective of these professionals build this environment through direct communication with the adjuster(s), supervisors, and even claim department managers. That information is then thoroughly and simply shared with employers in regular intervals through formal claim reviews, safety committee meetings, and/or pre-renewal meetings involving the broker.

As a 35-year industry veteran of the claims management field, I proudly serve the Rancho Mesa team with a core commitment to providing great contributions to the claims management process. These contributions are predicated on bringing my extensive knowledge and experiences from all sides of the workers’ compensation claim process, to my advocacy role for you, my client… the employer.

What Employers Need to Know Before a Serious Injury Occurs in the Workplace

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

Timely reporting of an employee’s work-related serious injury, illness or death can pose a challenge to the employer. As of January 1, 2020, these incidents (including any hospitalizations, unless the injured worker is admitted for medical observation or diagnostic testing) must be reported immediately to Cal/OSHA. Immediately means as soon as practically possible but not longer than 8 hours after the employer knows or, with diligent inquiry, would have known of the serious injury, illness or death.

Monitoring the employee’s status at a hospital can be difficult if the employer has not put in place procedures and policies that will authorize a healthcare provider to disclose information that is covered by the Health Insurance Portability and Accountability Act (HIPAA). For example, the employer must follow-up with the hospital providing care to the injured employee to determine if the incident must be reported to Cal/OSHA. The employer will need to know if the employee has been moved from the emergency room and admitted to the hospital for in-patient treatment. 

Ensuring policies and procedures are developed and implemented to restrict the use and disclosure of protected health information (PHI), are important elements of HIPAA compliance. If health information is used for purposes not permitted by the HIPAA Privacy Rule, or is deliberately disclosed to individuals not authorized to receive the information, there are possible penalties for the covered entity or individual responsible.

HIPAA permits PHI to be used for healthcare operations, treatment purposes, and in connection with payment for healthcare services. It can be argued that employers need this information to comply with State and Federal OSHA laws. Information may be disclosed to third parties for said purposes, provided an appropriate relationship exists between the disclosing covered entity (i.e., the hospital) and the recipient’s covered entity or business associate (i.e., the employee or employer). A covered entity can only share PHI with another covered entity if the recipient had previously or currently has a treatment relationship with the patient. The PHI has to relate to that relationship. In the case of a disclosure to a business associate, a Business Associate Agreement must have been obtained. Disclosures must be restricted to the minimum necessary information that will allow the recipient to accomplish the intended purpose of use. 

Prior to any use or disclosure of health information that is not expressly permitted by the HIPAA Privacy Rule, one of two steps must be taken:

1. A HIPAA authorization must be obtained from a patient, in writing, permitting the covered entity or business associate to use the data for a specific purpose not otherwise permitted under HIPAA.

2. The health information must be stripped of all information that allows a patient to be identified.

Employers may consider obtaining signed business associate agreements or HIPAA authorizations from their employees before any injury or accident occurs. This will ensure they are able to get the appropriate protected medical information from the hospitals so they can report “serious injury or illness” accurately and timely to Cal/OSHA. 

Therefore, it is extremely important for employers to learn the existing laws and new changes to these laws and have a plan of action in place to address these concerns before the next serious injury, illness, or death occurs.

Currently, reporting to Cal/OSHA can be made by telephone or e-mail. With these reporting changes, Cal/OSHA has also been directed to establish an on-line mechanism for reporting these injuries. It is always important to document when these incidents are reported to Cal/OSHA. Until an online mechanism is established, use of e-mail would be such method for documentation. Monitoring of the Cal/OSHA website for implementation of the on-line mechanism of reporting is also suggested.

For more information on how to report serious injuries and illnesses to Cal/OSHA, please reference “Cal/OSHA Updates: AB 1804 Changes How Injuries and Illnesses Are Reported.”

For more information about what is considered a serious injury or illness under Cal/OSHA, please reference “Cal/OSHA Updates: AB 1805 Changes Definition of Serious Injury or Illness.”

Don't Let Your Communications with Employees Hurt as Much as Their Injuries

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

A work-related injury is a traumatic event for your employee and their family. Even though your employees are trained and educated to immediately report work injuries, it is sometimes difficult for them to do so. Employees can be similar to athletes in that they do not want to do anything that might disrupt the team. There are a lot of emotions that can come into play when a work injury occurs. One of the strongest emotions may be guilt or embarrassment after sustaining an injury. There may also be misperceptions of what others are really thinking after an injury occurs. These feelings and misperceptions are usually the main reasons why communication with an injured worker can decline after an injury.

The injured worker may feel as though they have let down their employer after sustaining an injury. They may feel guilty for missing time from work, disrupting the work shifts and schedules of their co-workers, being physically challenged, putting their careers in jeopardy, being able to provide for their families and for causing the company increased premiums associated with a work related injury claim. They realize the cost of these claims are difficult for their company to absorb and may decrease funds for other employee benefits.

It is quite common for injured workers to not want to speak with their employers after an injury. They usually have misconceptions of what their supervisors and co-workers, are thinking about their injury and lost time for medical treatment. Some injured workers feel as though the employer is upset with them for filing a claim. The employer is obviously upset a claim has been reported, but is more concerned with the well-being of the employee and their recovery from the work injury. 

Workers oftentimes assume the employer won’t believe them, even thinking they are exaggerating or faking their injuries. The employee may believe the employer thinks they are trying to get away with something by getting out of work or placed on modified duties, or trying to get medical treatment for injuries or conditions that are not actually related to a work injury.  

All these beliefs, misconceptions and even paranoia usually leads to a breakdown in communication. So, what do you do if this occurs?

Keep reaching out to the employee. Inquire how they’re feeling, how much they like and trust their doctors and therapists, and communications with the claim adjuster. Continue to reinforce your concern for their injury and recovery. Remind them of how important they are to the company and how much you need/want them back. Reinforce you are not “mad at them” for getting injured, filing the workers’ compensation claim or missing work. Let them know you’re more focused on helping them get through a sometimes complicated workers’ compensation injury and understand the claim process. Promise them you will do everything you can to help them with answers to their questions. Help them express their concerns or problems with the claim adjuster and assist in their recovery and progression through the claim process. Be an advocate for your employee. Help them get the very best in medical treatment possible and assist with the claim.

Lack of communication and not addressing these misperceptions with your injured worker is one of the biggest factors leading to legal representation. They often do not know the workers’ compensation system and don’t know the questions to ask. You can maintain a dialogue with them by providing insight on what to expect next with their claim, provide options or even just listen to their concerns and decisions they may have to make during their recovery. 

Lack of communication can result in the injury not being reported timely by the employee, not reported timely to the insurance company or not responding quickly to a request for treatment, which can lead to litigation. A litigated claim increases the cost of the claim by 100, 200 or 300%! Litigation usually increases the life of the claim by several months and even years. It results in further, if not complete breakdown, of communication with the employee. Litigation can oftentimes results in the loss of your employee, possibly increasing the cost of the claim.

Injured workers retain attorneys for a wide variety of reasons. Interruption of communication with the employer is one reason. Another is they have nowhere else to turn. Occasionally, employees may retain an attorney and does not realize they actually hired them. Reassure them you will maintain your communication with them even though they’re being represented. You are still their employer and you still want to help them through the claim and return to work. Oftentimes they realize retaining an attorney was not the best avenue to take. If that is the case, you can reassure them they can terminate their relationship with the attorney with a single sheet of paper. Their representation can be undone as easy, if not easier, than their retaining of counsel. 

Maintain communications with your injured employee. Prevent or break down the barriers that can interrupt your employee’s normal recovery and return to work after an injury.

Workers’ Compensation Fraud Is Not a Victimless Crime

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

Fraud can happen in every industry, including workers’ compensation. According to standard definitions, “in law, fraud is intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right. Fraud can violate civil law, a criminal law, or it may cause no loss of money, property or legal right but still be an element of another civil or criminal wrong. The purpose of fraud may be monetary gain or other benefits, for example by obtaining a passport, travel document, or driver's license, or mortgage fraud, where the perpetrator may attempt to qualify for a mortgage by way of false statements.”

Within workers’ compensation claims, fraud is a term that can be overused by employers who may not agree with a claim, or a condition that has been considered work-related/work-aggravated. Many times, instead of fraud, there is simply a difference of opinion as to whether a specific work incident caused an injury. For these disputes, it usually comes down to a medical opinion addressing whether something is work-related or work-aggravated.   

Examples of Workers’ Compensation Fraud

A claim can become fraudulent when the employee lies about how the injury occurred or about their ability to work. The treating physician may be asked to provide their opinion as to whether the injured worker mislead them about how their injury occurred, and the significance of their complaints or physical capabilities. The doctor is provided records or sub rosa videotape contradicting information previously provided by the injured worker. Fraud can also occur when the injured worker lies under oath during a deposition, thus becoming a felony. 

Workers’ compensation fraud is not limited to employees, but others within the system can also knowingly participate in the fraud. Physicians can be fraudulent in their billing for services not rendered, for accepting kick-backs, or realizing financial benefit for referrals to and from other physicians, vendors or other entities. Employers can commit insurance fraud by understating their number of employees, under-reporting payroll or misclassifying employees into cheaper job/class codes in order to secure cheaper insurance policy rates and premiums. Vendors can commit fraud by billing insurance carriers for products or services never provided. Attorneys can use illegal capping schemes to retain injured workers for clients. 

Combating Workers’ Compensation Fraud

Each insurance company is now required to have a Special Investigative Unit (SIU) that provides ongoing monitoring and investigation of questionable activities related to claims. Fraud continues to cost tax-payers millions of dollars (some estimates are up to $80,000,000) per year. The money and resources the employers and insurance carriers are spending to combat fraud are also increasing each year. 

In the event of a fraud conviction, fines or assessments, prison sentences, or restitution can be ordered. Workers’ compensation fraud is not a victimless crime; from the losses caused by fraudulent activities, to the money used to combat and prosecute fraud. The money lost to workers’ compensation fraud can never be replaced, but we are all responsible to do our part in remaining vigilant and reporting suspected fraud to the appropriate person or agency. 

Steps to Understanding and Managing Subrogation

Author, Daniel Frazee, Executive Vice President, Rancho Mesa Insurance Services, Inc.
Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

Definition

Subrogation is defined as the substitution of one person or group by another in respect of a debt or insurance claim, accompanied by a transfer of any associated rights and duties. It occurs in property/casualty insurance when a company pays one of its insured’s for damages, then makes its own claim against others who may have caused the loss or contributed to it. Subrogation crosses into many areas of the insurance world including workers compensation, general liability, property, and auto. As an employer, developing an effective Incident Investigation Plan is a key first step to managing the potential impacts of subrogation on your organization. 

Employer Level Investigation

Identifying the potential for subrogation should occur immediately after an injury or accident occurs with an employer-level investigation. This includes visiting and securing the scene of the accident. If there are hazards or dangerous conditions still present, address them by taping off the area or removing the hazardous element. All potential witnesses need to be identified with securing their name, employer, telephone number, address, copy of their driver’s license, etc. These witnesses should be provided a witness statement for their completion. 

It is also imperative that the employer preserve the evidence by taking possession of the tool or equipment that caused the injury. If a ladder broke causing a fall and injuries, take possession of the ladder and keep it secure until needed later. If a tool malfunction is the cause of injury, take possession of that tool until it is needed for the next step of the investigation. Removing the injury-causing item prevents the chance of additional injuries or accidents. 

Additionally, take photographs or measurements of the entire area, building as much visual evidence as possible. Be aware too that changes can and will occur to the scene of the accident within minutes or hours of the incident. Entire crews are known to be removed from the area to avoid being identified as potential witnesses of an at-fault third party incident. 

Referring a Claim and Protecting the 2 year Statute

As you continue with your internal investigation, ensure that the claim’s assigned adjuster sends your third party information to the insurance company’s subrogation department. Most claim professionals do not have experience nor handle the details of subrogation cases. As a subrogation adjuster and attorney build their respective files, they will benefit significantly from the information obtained in a thorough post-injury investigation. They can then focus on obtaining additional discovery that can solidify their subrogation efforts. Reach out promptly to your subrogation adjuster and attorney as they will value your contribution to the investigation. We also recommend requesting regular updates, which would include participating in regular interval claim reviews. 

Be aware that the California Statute of Limitations for personal injury cases is 2 years from the date of the injury and/or accident. “Protecting” this statute means ensuring your insurance company formally files a civil lawsuit against the identified third party in a timely fashion.

Pursuing Subrogation

While injured employees are barred from suing their employer for their workers compensation injury due to the Exclusive Remedy Rule, that same employee may still bring a personal injury claim against a third party who shares responsibility for the injury. The employer also has the right to bring a civil claim against a third party to be reimbursed for the workers compensation benefits it is providing. If the employee pursues the third party, the workers compensation carrier can join as a party to this litigation. In this scenario, the workers compensation carrier simply provides a summary of their costs, or their workers compensation lien. The carrier then has first lien rights once a judgment is reached against the at-fault party. 

As subrogation cases move toward settlement, there are many factors impacting the net recovery for the injured worker and insurance company (employer). Many incidents have shared negligence alleged by the employer and even by the employee. The civil arena does not have the same thresholds or tolerances for extent of injury, need for medical care, resulting temporary disability, permanent disability and / or future medical care as does the workers compensation system. Many times the workers compensation liens are considered liberal and excessive by the civil arena. Therefore, it is difficult for the workers compensation carriers to be fully reimbursed for the total costs of their claims.      

Waiver of Subrogation

In the Construction space, many trade contractors are asked via contract to provide waivers of subrogation in conjunction with other insurance requirements. Waivers do not prevent a subcontractor’s injured worker from filing suit against the general contractor. The waiver bars the subcontractor's workers compensation carrier from pursuing subrogation in the event the employee does not pursue relief from the aggrieved party. If the employee files suit, the subcontractor’s work comp carrier can then join the action. If the employee does not file suit, then the subcontractor’s carrier cannot pursue subrogation on its own against the General. Consider this example: A general contractor responsible for erecting scaffolding on a jobsite subcontracts drywall work to a subcontractor who will use the scaffolding in the scope of their work. An employee of the drywall contractor falls from the scaffolding and it is later determined that the General did not secure the base of scaffolding properly. Typically, the employer’s workers compensation carrier could look to subrogate the costs of the work comp injury claim incurred by the injured worker from the general contractor. However, the drywaller provided a waiver of subrogation to the general as a condition of securing the contract. Therefore, their right to subrogate against a general contractor has been waived. Subrogation between subcontractors; however, remains a viable avenue of subrogation if the involved parties are subcontractors.    

Closing

Becoming comfortable with the many facets of subrogation is crucial as your team builds an overall plan to manage risk. This process includes incorporating third party questions into your Incident Investigation Plan, overseeing the claim and recovery process, creating reasonable expectations as settlement draws near and paying closer attention to waiver requirements. While these are only initial steps, they represent a solid base to building a greater awareness and deeper understanding of subrogation. 

To learn more, email Daniel Frazee at dfrazee@ranchomesa.com or Jim Malone at jmalone@ranchomesa.com.

What Does the Employer Do After a Work Injury?

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

A work related injury can be a very traumatic event for the injured worker, but also for their
co-workers, employer, family and friends. Some injuries occur from a specific event when everybody knows the injury occurred. Other times, incidents occur during the work day, or repeatedly over time, where the employee needs to report these incidents, accidents or developing symptoms to his supervisor, manager, or human resource manager according to company protocol. 

Prompt reporting of a work injury is very important for the employer and their continued responsibilities. The employee reports the injury or accident to his supervisor, manager, or appropriate employer representative. The employer than has 5 days to report the incident to the insurance carrier.

Once reported, the employer can examine the scene of the accident and verify the mechanism of injury. Witnesses can be identified and their statements can be obtained. If the cause of the accident was another person, that person can be identified and their information can be obtained. If caused by a tool or apparatus, that tool or item can be removed from the work place and kept in a secure area for future reference. If caused by a dangerous condition, the condition can be corrected or barricaded to prevent additional injury. 

Work injuries usually result in instances where the injured worker reports the injury to their employer and they are interviewed and referred to an occupational medicine facility. There are companies that provide medical professionals that triage, the injury with the employee via telephone, or a visit to the workplace. The employee may be allowed to drive themselves to this facility or may have to be driven by a supervisor or foreman. The employee is instructed to provide the employer the Work Status form from the physician immediately after each and every examination or follow up visit.  If he is released to work, his employer needs the physician’s release to allow a return to work and if they are released to modified duties, the employer then determines if modified work is available. If modified work is not available, the employer than sends the injured worker home until his next visit or until modified work becomes available. 

When the injury is addressed, there are forms that need completed for the work related injury. The most important document is the DWC 1 Claim Form. This form MUST be provided to the injured worker within 1 DAY of when the employer knows of the injury. This form starts the claims process with the insurance company. It is a two part form where the employee completes the top part and the employer completes the bottom. Upon completion, the form is submitted to the insurance company and copies are provided to the injured worker and kept by the employer. The employer is then to complete the Employer’s First Report of Occupational Illness of Injury Report (ER’s 5020 form). Then, they obtain the Supervisor’s Report of Work Injury Report and any witness statements that may have been obtained. All these forms and reports are submitted to the insurance adjuster upon receipt and/or completion.

Now that the claim has been created, the employee is obtaining medical treatment, and all the forms have been completed and submitted, the employee’s progress will be monitoring during their recovery.  Maintaining good communication with the employee and claims adjuster is very important for helping the employee get through this recovery process. 

For additional information, please contact Rancho Mesa Insurance Services, Inc. at (619) 937-0164.   

Reporting Serious Workers’ Compensation Injuries

Author, Jim Malone, Workers’ CompensationClaims Advocate, Rancho Mesa Insurance Services, Inc.

Workers’ Compensation injuries occur every day. The majority of these injuries are minor incidents which require no medical treatment or loss of time from work. For others, the injury is reported to the insurance carrier, the injury is addressed, forms are provided, and the recovery from the injury is monitored until the employee is released back to work and a discharge from care is provided.

However, serious injuries, illnesses or even deaths occasionally occur at work because of a work related accident. These incidents usually require 911 calls, hospitalizations, emergency surgeries, family contact, and a longer road to recovery. They may also require immediate (within 8-24 hours) reporting to the California Occupational Safety and Health Administration (Cal/OSHA), if they meet the criterion that has been established.

As defined in the California Code of Regulations Title 8 §330(h), serious injury or illness means any injury or illness occurring in a place of employment, or in connection with any employment that:

1. Requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation.

2. Results in a loss of any member of the body.

3. Results in a serious degree of permanent disfigurement.

4. Results in the death of the employee.

Does not include any injury, illness, or death caused by the commission of a Penal Code violation, except the violation of Section 385 of the Penal Code, or an accident on a public street or highway.

The California Code of Regulations Title 8 §342(a) states, “every employer shall report immediately by telephone or telegraph to the nearest District Office of the Division of Occupational Safety & Health any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment. Immediate means as soon as practically possible but not longer than 8 hours after the employer knows or with diligent inquiry would have known of the serious injury or illness. If the employer can demonstrate that exigent circumstances exist, the time frame for the report may be made no longer than 24 hours after the incident.”

The 8-24 hour time frame begins when the employer knows, or “with diligent inquiry” would have known of the serious injury, illness, or death. The “employer” means someone in a management or supervisory capacity.

As with any injury or accident, it can be a difficult and confusing time for all those involved and affected. It may seem like many things need to be done all at once. That is, of course, impossible. So, prepare yourself now. Make a list of your responsibilities and important contact numbers before a serious injury or accident occurs.

The order in which you perform each of these responsibilities may differ, according to the type of injury or accident that occurs. However, you will still have your checklist and contact numbers ready to use to ensure you do not forget any particular step or obligation. This emergency list of telephone numbers may be your broker, safety/loss control specialist, claims administrator, or workers’ compensation claims advocate. We are all available to provide you with any assistance you may need.

For those in California, the Cal/OSHA District Office contact list is below. Ask for the officer of the day.

Concord (925) 602-6517
Oakland (510) 622-2916
San Francisco (415) 972-8670

Cal/OSHA Link: www.dir.ca.gov/title8/342.html

For additional information, please contact Rancho Mesa Insurance Services, Inc. at (619) 937-0164.

3 Practical Reasons for Timely Claims Reporting

Author, Jim Malone, Claims Advocate, Rancho Mesa Insurance Services, Inc.

When a work-related accident occurs, as a business owner or manager, it is our nature to want to analyze the situation in order to learn how to avoid it in the future. However, the reporting of the incident is equally as important. With the recent requirement to report first aid claims, timely reporting for all claims is recognized as being critical for a number of reasons. 

Employee Morale

First and foremost, timely reporting allows for immediate care of any injuries that may have occurred as a result of the incident. It promotes prompt referral for medical evaluation, documentation of the bodily areas affected, and provides recommendations for treatment. 

Promptly reporting an injury shows the injured employee, and their coworkers, that the company cares about them. When an employee knows the employer cares, they are less likely to litigate the claim, which can significantly reduce the overall cost to the employer.  

Elimination of Hazards

Timely reporting can trigger the immediate assessment of the scene and cause of the accident. The initial focus is to document the area and determine if there is still an injurious exposure or condition present that may need to be addressed to prevent further incidents or injuries. Timely reporting also allows for prompt investigation of the accident and the scene of the accident, identify witnesses, secure faulty tools or equipment for safety and subrogation purposes, and to convey a sense of responsibility and concern for the employee that their safety is of extreme importance.

Prompt investigations into the cause of a near miss, accidents, and injuries can lead to an understanding of the factors that lead up to the incident. Thus, the employer has the opportunity to make changes in processes and improvements in safety in order to prevent future near miss events or accidents from occurring.

Cost Savings

Timely reporting can directly affect the overall costs of a claim. Decreased medical costs are realized when injuries are promptly assessed, allowing for treatment to start immediately. Injured employees tend to recover quickly when treatment is provided right away. Swift recoveries usually result in shorter periods of temporary total and/or temporary partial disability, fewer diagnostic studies, physical therapy visits, injections, surgeries, permanent physical limitations, work restrictions or permanent disability percentages, and lower future medical care needs. This translates into lower financial resources allocated to these claims.

The timely reporting of a claim promotes positive morale among employees; helps remove potential future hazards from the workplace and can significantly reduce overall the cost of incidents.

 
For more information about claims reporting, contact Rancho Mesa Insurance Services, Inc. at (619) 937-0164.