It's that time of the year where schools everywhere are holding their annual "field days." For those of you who are unfamiliar with field days, they are a competitive event held by schools where students compete against each other in various events and physical challenges. Where am I going with this...? It got me thinking about overcoming obstacles, challenges and hurdles in the WC system.
There are specific hurdles that must be overcome prior to becoming entitled to a suspension of wage benefits, and each set of hurdles depends on the jurisdiction (state) in which an injured worker is receiving benefits. Each state has its own WC laws and regulations that govern the duration, frequency, calculation and amount of workers' compensation benefits an injured employee is entitled to. Eastern provides some fantastic resources regarding what ecovery looks like in your state on our website, so we won't go into the details in this forum. In general, each state has its own set of hurdles to suspend or terminate benefits. Your Eastern claim representative is well-versed in your state's requirements, so feel free to contact them with any particular questions.
Maximum Medical Improvement (MMI)
MMI is the point in recovery from an injury at which an injured employee will no longer benefit from any future medical treatment or intervention. Basically, they are as recovered as they will ever be. In some states, employers/carriers may unilaterally stop benefits once MMI is attained.
Full Duty
Full duty is when a physician releases the injured worker to return to their pre-injury job without restrictions.
Full Recovery
Full recovery is the point at which an injured employee is no longer sustaining any residual symptoms attributable to the work injury.
Post-injury wages exceed Pre-injury wages
When an injured employee returns to work without a loss of earnings, wage benefits may be suspended (in most states).
Proof of Earning Capacity that exceeds Pre-injury wages
In states like PA, if there is not a job for the injured employee to return to, the employer/insurance carrier may be required to prove that there are jobs that exist which the injured employee is capable of performing (physically and vocationally) that pay just as much, if not more than, what the injured employee previously earned prior to the work injury.
Refusal of Suitable Employment
In most jurisdictions, if an injured employee is offered a suitable job (either modified or regular duty) and they refuse the job offer, the insurance carrier may suspend the injured employee's benefits during the period of refusal. Typically, to be reinstated benefits, the employee would need to demonstrate that they had a reasonable basis for refusing the job.
Undocumented Worker
Each state may have a different provision in their statutes/regulations that govern workers' compensation benefits for injured, undocumented workers. Some states only require the worker to be released to perform some type of work -- regardless of pre-injury wages or pre-injury job requirements. Some states have requirements that vary depending on whether or not the employer knowingly hired an undocumented worker.
Statutory Cap on Benefits
The majority of states have some type of cap on wage loss benefits. Caps may vary regarding the type of benefit, such as Temporary Total Disability (TTD) benefits and Temporary Partial Disability (TPD) benefits. In Virginia, for example, an injured employee is not entitled to more than 500 weeks of any combination of TTD, TPD or PPD (permanent partial disability) benefits. In Indiana, TPD benefits are capped at 300 weeks, while TTD benefits are capped at 500 weeks.
Each state has its own "hurdles" to overcome prior to being able to legally suspend or terminate wage benefits. Knowing what an employer must overcome can help them make a more informed decision regarding their ability to offer modified duty. Do you really want to risk paying out 500 weeks of TTD at $429.00 per week ($214,500)? When determining availability of modified duty, consider how long the injured worker will receive TTD benefits and compare the costs to the benefits of modified duty. The non-financial benefits of modified duty (not just the dollars and cents) far outweigh any costs associated with modified duty.
Another somewhat related point to be made here is that the contextual details of each claim do not change the hurdles (statutory and legal obligations) put in place by the WC system in your state. Typically, the law does not take into consideration the character of the injured employee, their activities outside of work, or the unsubstantiated rumors that come from a rumor mill when someone is out of work. No matter what the background factors surrounding the claim are, one must overcome the hurdles in their state. Know the requirements in your state so that you can evaluate your options and make a well-informed decision.
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