Transcript South Carolina Workers’ Compensation System

South Carolina Workers’
Compensation: Nuts and Bolts
Medical Version
Sarah S. Alphin
Claimant alleges a work accident
• Employer investigation:
– Statement from Claimant
• Obtain written statement if possible
– Identify witnesses
– Document as much as possible in writing
Initial Medical Treatment
• Claimant sent to emergency room or other
urgent care, if needed
• Employer or Carrier has right to choose
medical provider
• Drug test performed
• Obtain work restrictions
Claim sent to Carrier
• Carrier should review Employer’s
investigation reports and physician report
• Carrier conducts further investigation
– Recorded statement of Claimant
– Obtain prior medical records
– Interview witnesses and Employer
representatives
Carrier must determine:
• Did the Claimant sustain
– (1) an injury by accident
– (2) arising out of and
– (3) in the course of employment
• Do any defenses exist?
– Notice: 90 days
– Statute of Limitations
– Intoxication/Willfulness
– Fraud in the Application
Accept or Deny?
Reasons to Deny a Claim
• It did not happen!
• Not compensable
• No EE/ER relationship (independent
contractor, volunteer)
• Heart attack/stroke/mental-mental only
compensable if unusual and extraordinary
conditions of employment
Is the injury compensable?
• An injury is only compensable if:
– An injury
• Must be unexpected
– By accident
• An unlooked for or untoward event
– Arising out of and
• Origin/cause of accident (must be caused by employment)
– In the course of employment
• Time, place, circumstances
Injuries that are not compensable
•
•
•
•
Idiopathic injuries (level floor)
Fights unrelated to work
Horseplay
Going and coming to work
– Exceptions: parking lot, ER provided travel,
EE paid for travel, or EE charged with task
If Claim is denied:
• No further medical treatment authorized by
carrier
• Initial treatment authorized by carrier still paid for
by carrier
• Claim can be denied at anytime
If Claim is accepted:
• Claimant is entitled to 3 types of benefits:
– Medical benefits
– Temporary compensation
– Permanent compensation
Medical Treatment
•
Section 42-15-60 of the South Carolina
Workers’ Compensation Act governs what
medical benefits are provided under the Act.
•
The employer/carrier is required to provide
medical care which is causally-related to the
work injury.
•
The statute states that the employer/carrier
shall provide medical treatment that will “affect
a cure or give relief.”
Medical Treatment
•
Medical care can continue so long as in the opinion of
the Commission it will tend to lessen the period of
disability.
•
Claimants are entitled to medical treatment after
maximum medical improvement if they can establish that
the medical care (medications, physical therapy, etc.)
will “tend to lessen their period of disability” or maintain
their level of functioning.
•
You will hear this referred to as “Dodge” medicals
because they are based on the Dodge case (Dodge v.
Broccoli).
Medical Treatment
• The employer/carrier is allowed to
choose the physicians the employee
receives care from.
• Prosthetic devices are covered for
repair or replacement for a claimant’s
life.
Regulation 67-1307
• Regulation 67-1307 of the South Carolina
Workers’ Compensation Commission addresses
the role of rehabilitation professionals. (see
attached)
• R. 67-1307 (A) reads as follows: “Rehabilitation
professionals are coordinators of medical
rehabilitation services, including but not limited to
state, private, or carrier based, whether on site,
telephonic, in or out of state.”
Regulation 67-1307
• R. 67-1307 (B) reads as follows: “The role of a
rehabilitation professional is to ensure the
primary concern and commitment in each
workers’ compensation case is to advance the
medical rehabilitation of the injured worker.”
• R.
67-1307
(C)
requires
rehabilitation
professionals to comply with Section 42-15-95
and R. 67-1308.
Obtaining Medical Records and
Communication with Physicians
•
•
•
Section 42-15-95 (A) – An employee who seeks
treatment for an injury or condition for which
compensation is sought CONSENTS to the
release of medical records related pertaining to
workers’ compensation claim
A request citing Section 42-15-95 as the
authority allowing you to obtain the records
Medical providers must provide records within
14 days
Obtaining Medical Records
• If carrier wants to investigate pre-existing
conditions or prior medical conditions, a
subpoena can be issued by an attorney
• If Claimant’s attorney wants prior records, the
Claimant can sign a written release
• A subpoena/release from Claimant can request
any and all records, even records prior to an
accident
Communication with Physicians
• Section 42-15-95 (B) governs communication
with health care providers.
• Issues that may be discussed:
-
Medical history
Diagnosis
Causation
Course of treatment
Prognosis
Work Restrictions
Impairments
Communication with Physicians
• Requirements to have such communication
-
-
-
Notify employee/claimant or claimant’s attorney
in timely fashion, in writing or orally, prior to
communication taking place (R. 67-1308 requires
10 day notice).
Advise employee of the nature of the discussion
or communication prior to the discussion or
communication
Allow claimant or claimant’s attorney to attend
the meeting or participate in the discussion.
Communication with Physicians
• If written questions are used, provide a copy
of the questions to the employee/claimant or
claimant’s attorney at the same time the
questions are submitted to the heath care
provider.
• Provide copy of response to questions to
employee.
• Any information obtained in violation of
these requirements cannot be used at a
hearing.
Communication with Physicians
• When a Form 14B is sent to a medical
provider, a copy of it should also be sent to
the Claimant or Claimant’s attorney.
• When a completed Form 14B is returned, a
copy of it should be sent to the Claimant or
Claimant’s attorney.
Form 14B
- Addresses MMI, permanent impairment,
work restrictions and future medical
treatment.
- Is future medical care needed “to
reasonable degree of medical certainty?”
- Not just that it may be needed in the future
- Is the injured body part rated?
a
Form 14B
• WCC requires a Form 14B in certain
cases
– 16A settlements
– Informal Conference settlements
• Form 14B to be completed by medical
provider
• Important to fully complete the Form 14B
Nurse Manager Communication
with Interested Parties
- Updates to adjuster and attorneys
regarding status of treatment
- Nurse case manager reports
- Request for reports from Claimant’s
attorney
- Discussions by phone with
adjuster/employer
Who Do Nurse Managers Work For?
- Services
are
engaged
by
the
carrier
- Request from Claimant, Claimant’s attorney,
Claimant’s family regarding specific things
they want
Who Directs the Medical Care?
• The employer/carrier has the right to direct
medical care under the South Carolina Workers’
Compensation System.
– Carrier selects physician
– If referrals are made by physician, carrier can still
direct the referral
• If a Claimant attempts to change appointments
without letting you know, Nurse Managers
should advise the physician’s office not to allow
the appointment to be changed unless it is
authorized by you.
While a Claimant is treating
• Carriers need copies of medical records
following appointments
– Needed to authorize additional treatment,
referrals, diagnostic testing, etc.
– Many times these things cannot be authorized
with the corresponding medical note
• Carriers need updated work
restrictions/status following appointment
While a Claimant is treating
• Light Duty work
– Physicians often allow Claimant's to return to
work restricted or light duty while treating
– Providing light duty reduces overall cost of
claim
– The longer a Claimant is totally out of work,
the harder it may be for them to return later
• Employers are not required to provide light
duty work in SC.
Questionnaires from Attorneys
• Why are questionnaires needed?
– Causation
– Issues not being address in narratives notes
• Practice used by both Defense and Claimant’s
attorneys
• Claimant’s attorneys can request questionnaires
without notifying carrier/Defense attorney
• Defense attorneys must copy Claimant on
questionnaires to comply with communication
regulation
Permanent Disability Benefits
•
If the matter is heard by a Commissioner, the
Commissioner determines the amount of
disability.
•
The amount of the disability will not normally be
the same as the impairment rating.
•
There are no exact factors or guides to
determine how much the disability award will be
and the Commissioners have great discretion in
determining the award.
Permanent Disability Benefits
• Different people with the same injuries
and ratings could be awarded a different
amount of disability
-
For example, a construction worker who has a
significant back injury and has lifting restrictions
because of his injury will most probably receive
a disability award that is higher than a person
who works in an office environment but is not
required to do any significant lifting, even though
their injury and medical impairment rating are
the same.
Permanent and Total Disability
•
A person is entitled to permanent and total
(P&T) disability benefits when they are unable
to work at their previous job or at any other
employment which is reasonably available in
the economy.
•
Maximum weeks allowed for permanent and
total disability is 500 weeks.
Permanent and Total Disability
•
A claimant is not entitled to lifetime indemnity
benefits for permanent and total disability.
•
P&T disability awards do include lifetime medical
care for medical conditions causally-related to their
injury.
•
Cases involving paraplegia, quadriplegia or physical
brain damage
-
no 500 week cap
lifetime weekly benefits
lifetime medical treatment
QUESTIONS?