1. Why should we ask for medical slips before returning a worker to full duty?

It protects both the injured worker from further harm medically and protects an employer by making certain the person has a full release or a specific listing of any work restrictions.

Suggestion from the consultant: If there is a doubt whether the release is accurate, check with the adjuster at the insurance carrier or verify with the doctor’s office. Only accept return to work slips that either state”Released for full duty” or actually list any temporary restrictions. A simple return to work without clarification can lead to increased costs.

Back to the top


2. Why is completing an employer’s report accurately important? They take too much time to complete from an employer’s standpoint.

In seasonal employment situations and questionable claims, the first line of defense is what is recorded on the employer’s report of work injury. It is not an admission of liability and an employer can convey accurate and timely information.

Insurance companies must use the reported wages on the employer’s report to calculate the temporary and potential permanent disability rates. If an employer marks “permanent full time” and the person truly is a seasonal worker, an overpayment will commence from the beginning of the claim. On all seasonal workers a wage statement of one year prior to the injury will be required. Also, please indicate how long the season would have lasted had the injury not occurred. This can be done by comparing other workers length of service that had been hired at the same time as the injured worker. Remember overtime is part of the wage calculation. Should a person be disabled and is provided housing, and that is not available, a value of the housing will need to be established.

In questionable claims, as the claim is on delay, the more detailed the initial information given to the carrier the faster an investigation can be initiated and a denial, if appropriate, can be sent sooner. With the recent change on questionable claims, employers are responsible for up to $10,000 in medical payments UNLESS a denial has been sent.

Suggestion from the consultant:  When submitting a Workers’ Compensation claim be sure that correct wages and any extenuating information has been detailed on the employer’s report or with an addendum added for clarity. Were witnesses asked for their version of an occurrence just after it was reported?

Back to the top


3. Why is it valuable for an employer to use modified work while a person is recovering from an injury?

Statistically, the longer an employee is off work the higher the likelihood of permanent disability being awarded , and a direct cost of the claim is increased. The increased reserves will influence the Experience Modification Factor which can influence future premium costs.

Suggestion from the consultant:   After 40 years of claims involvement, this is the single most valuable cost saver to employers. It eliminates a person losing contact with their employer, it shows other employees that their contributions are valued, and best of all, if light or modified work is offered and an injured worker chooses not to come to work, they do not receive temporary disability. With the appropriate written Return to Work program and monitoring system in place dramatic savings can occur.

Back to the top


4. If my employee has returned to work why does it take so long for the claim to close?

Due to the recovery period usually lasting beyond just the return to work date, and doctor’s caution in terminating treatment, a claim may not be processed for closure for months after the return to work date. If a worker litigates, the claim can not be resolved until the litigation is resolved, which delays all aspects of claims, settlement and closure.

Suggestion from the consultant:   Diary a worker’s return to work date and in two months start asking the adjuster when a closure can be expected. A worker must be Permanent and Stationary before a resolution can be obtained. If a worker has not had surgery,and the claim has not been closed within 6 months of the return to work, you may need to discuss the claim with the claims supervisor and indicate you need specific information about the expected resolution of the claim.

Claims departments are still experiencing high turnover and high caseloads and it is a financial advantage for employers to monitor claims closures.

Remember, only at the Unit Stat Filing time will the reserves have a financial impact on premium costs.

Back to the top


5. When a worker returns to work, sometimes they continue to receive payments, why?

Insurance companies and self-insured employers are required to make advances against any potential permanent disability that has occurred as a result of the impairment of an injury. They must pay 3 days after someone returns to work or after the condition is declared permanent and stationary, whichever comes first. Mandatory letters are sent with the first payment explaining these are advances and credit will be taken at the time of the resolution of the claim.

Suggestion from the consultant:   The insurance industry is required to make the advances unless the worker asks that they be held until the settlement. The real key to cost-effective resolution of claims is getting the file to the permanent and stationary level and a settlement reached as quickly as possible. Only then is the true exposure of the claim known.

Back to the top


6. It seems that initial reserves on claims have become much larger than in past years, why is that happening?

As a result of the many failed insurance companies and independent studies concluded that the industry was underreserved for the expected outcome of liability. Back claims are routinely 3-4 times more costly than a few years ago as a reaction to the underreserving and benefit increases in benefits over the past few reforms.

Suggestion from the consultant:   Be concerned with assisting the insurance company in bringing the case to a conclusion, not the initial reserves. If the file proceeds, without unnecessary delays, it will be closed for the resolved appropriate liability before the Unit Stat Filing.

Back to the top


7. What if an employee asks to go to their own doctor, can an employer authorize the treatment?

It would not be wise to authorize any medical treatment or change of doctors under the new ACOEM guidelines( American College of Occupational and Enviromental Medicine). The rules are very strict for treatment and certainly in an emergency situation it may be appropriate, but not under any other circumstances. Let your insurance representative use the guidelines so that each worker is treated fairly under the California Labor Code laws.

Suggestion from the consultant:   Please review your emergency plan so that you are referring employees for treatment to the suggested locations. If an emergency occurs, call an ambulance, if needed or use the nearest hospital. We should encourage the highest level of medical treatment available, as it will offer the best treatment and be most cost-effective to the employer.

Back to the top


8. How can a person who has quit their employment report an injury when the employer was never informed?

The Post-termination defense will apply if a worker did not report an injury OR receive medical treatment that can be medically determined as being related to work by the examining physician prior to the termination. Supervisors should be questioned whether any mention of an injury was made prior to a person leaving their employment. If an injury was mentioned, but not reported to the carrier, it will be found as “notice” of an injury in the Court system with jurisdiction over Workers’ Compensation claims, the Workers’ Compensation Appeals Board.

Suggestion from the consultant:   Before telling the carrier that an injury was never reported, be sure to ask all supervisors and also co-workers whether any mention was made before a worker terminated. Their testimony may be needed in Court to deny benefits.

Back to the top


9. Now that rehabilitation has been eliminated, why would an employer want to take back a worker with restrictions?

Care should be taken to avoid Americans with Disabilities(ADA) claims and Discrimination claims(132a ) , neither which are insurable.

Suggestion from the consultant:   Employers should be aware that applicant attorneys have become aware that filing in Federal Court can replace some of the income they have lost as a result of the recent Workers’ Compensation reforms. Care should be taken when a decision is made that a worker can not be reasonably accommodated.

Back to the top


10. How can employers keep up with all the changes and requirements dealing with Workers’ Compensation claims?

Fortunately, employers do have opportunities to influence their insurance companies in bringing cases to a timely cost-effective conclusion. Attend seminars, depend on your insurance Broker for guidance and be sure to treat all employees fairly and equally.

Suggestion from the consultant:   Ask questions, be involved. Workers’ Compensation is very expensive to employers in California and every effort should be made to approach the issues with a teamwork approach with each team member performing at their best to control costs and deliver appropriate benefits to legitimately injured workers, and to be prepared to participate in the defense of questionable claims from the beginning to the resolution of each claim.

Back to the top