Monday, September 25, 2017
Connecticut Workers’ Compensation Claims: Eligibility, Filing, and Appeals Understand how workers' compensation works in the state of Connecticut. By Sachi Barreiro Virtually all employers in Connecticut are required to carry workers’ compensation insurance. As in the rest of the country, the workers’ compensation system in Connecticut is a no-fault system designed to compensate injured workers for medical bills, lost wages, and permanent impairments resulting from their injuries. To take advantage of these benefits, injured workers must take certain steps required by Connecticut law. Who Is Eligible for Workers’ Comp Benefits? Workers’ compensation covers all injuries or illnesses that happen in the course of employment. In general, injuries that happen while you are performing your work duties or running work errands are covered by workers’ comp. On the other hand, injuries that occur while you’re off-duty are generally not compensated through workers’ comp. For example, if you were injured during your lunch break or during your commute to and from work, you will typically not be covered by workers’ comp. For more information, see our article on what types of injuries are covered by workers’ comp. Workers’ comp covers both traumatic injuries and occupational illnesses. Traumatic injuries are those that result from a one-time accident at work, such as a broken bone from a slip and fall. Occupational diseases are injuries or illnesses that occur over a period of time, including injuries caused by repetitive movements at work (such as carpal tunnel syndrome) and illnesses developed from exposure to toxic substances at the workplace (such as cancer from exposure to asbestos). What Should I Do if I’m Injured at Work? If you’re injured at work, you must report your injuries to your employer immediately. Your employer should complete an “Employer’s First Report of Injury” form and provide it to its insurer and to the state Workers’ Compensation Commission, along with a copy to you. In addition to giving notice, you will have to file an official workers’ comp claim by completing a Notice of Claim for Compensation (Form 30C). You must provide this form to your employer and the Workers’ Compensation Commission within one year of your accident or within three years of the onset of an occupational illness. You should do this in person or by sending the documents by certified mail with a return receipt requested. Once your employer receives your claim form, it has 28 days to accept your claim, deny your claim, or begin benefit payments “without prejudice” – meaning that your employer has agreed to pay your benefits while it continues to make a final decision about your claim. If the employer fails to do any of these within 28 days, your claim is deemed accepted. How Do I Get Medical Treatment? In an emergency, you can choose which doctor or hospital to seek treatment from. For all non-emergency care, your employer may choose which doctor you see for your initial treatment. After the initial treatment, you can select your own doctors, unless your employer has established a managed care program for treatment of work-related injuries. If your employer has established such a plan, you must select a doctor from a doctor within the plan’s network. In general, though, your employer must provide you with notice of the managed care plan prior to your injuries. What Benefits Can I Receive? All reasonable and necessary medical treatment related to your work injury will be covered through workers’ comp, including the cost of doctors’ visits, hospital bills, prescriptions, and prosthetic devices. You’ll also be reimbursed for the mileage you incur in traveling to and from medical appointments. In addition to medical benefits, you will also be eligible to receive temporary disability payments and a permanent disability award. Temporary Disability You will be eligible to receive compensation for wage loss during the time you are temporarily disabled and unable to work. Temporary total disability payments are 75% of your average weekly wages, subject to a maximum of $1,292 per week (as of October 1, 2016). You can continue to receive temporary total disability until your doctor finds that you’ve reached maximum medical improvement (MMI), meaning that your condition has plateaued and is not expected to improve. If you’re able to return to part-time or light-duty work while you’re recovering, but earn less than your normal wages, you may eligible for temporary partial disability benefits. Temporary partial disability benefits are 75% of the difference in your average weekly wages, subject to the same maximum weekly amount. Permanent Disability If you are found to be totally and permanently disabled, you will receive the same weekly amount that you received in temporary total disability payments: 75% of your average weekly wages, subject to a maximum of $1,292 per week (as of October 1, 2016). Permanent total disability benefits are available for as long as the disability continues. These benefits are available only to workers with severely debilitating injuries, such as the loss of both hands, feet, arms, legs, or eyes. Workers are considered totally disabled only if they cannot earn any wages in the same job or another job. For most other workers, permanent partial disability benefits are available. You will receive 75% of your average weekly wage, up to $1,063 per week (as of October 1, 2016). How long you’ll receive these benefits depends on a state schedule and the disability rating assigned by your doctor. Connecticut’s state schedule is comprehensive and lists injuries to certain body parts, including extremities and organs. For each body part, the schedule identifies the maximum number of weeks for a total loss of use of that body part. For example, a worker with a 100% loss of use of a dominant arm will receive benefits for 208 weeks. However, if the worker had a 50% disability rating, he or she would receive benefits for 104 weeks. You may also receive benefits for significant scarring or disfigurement to the face, head, or neck, or to another body part if it will impede your ability to find new work. These benefits are equal to the total temporary disability rate, subject to the same maximum amounts. Benefits are available for up to 208 weeks. What if My Claim Is Denied? If your workers’ comp claim has been denied, or the insurance company is disputing any portion of your claim, you have the right to request a hearing before the Workers’ Compensation Commission. To do so, you must file a form called a “Hearing Request” with the Workers’ Compensation Commission. A hearing will be held before a workers’ comp judge, who will issue a written decision. If you disagree with the judge’s decision, you may file an appeal with the Compensation Review Board. For more information on the appeals process, see our article on appealing a denial of your Connecticut workers’ comp claim.
Wednesday, July 12, 2017
Rate of CT workplace injuries, illnesses exceeds nation's Related Content Content by John Stearns More than 36,000 nonfatal workplace injuries and illnesses were reported among Connecticut's private industry employers in 2015, resulting in an incidence rate of 3.2 cases per 100 equivalent full-time workers and higher than the national rate of 3.0, the U.S. Bureau of Labor Statistics reported today. Connecticut was among 21 states that had an incidence rate of total recordable cases (TRC) significantly higher than the national rate, Regional Commissioner Deborah A. Brown said. Connecticut's findings from the 2015 Survey of Occupational Injuries and Illnesses include: • Incidence rates in private industry ranged from 0.9 in financial activities to 5.1 in education and health services. • Two supersectors accounted for 60 percent of the occupational injuries and illnesses: education and health services; and trade, transportation, and utilities. • In private industry, the injury and illness incidence rate ranged from 1.5 for small establishments (those employing fewer than 11 workers) to 4.4 for midsize establishments (those employing between 50 and 249 workers). • Connecticut's private industry incidence rate of 3.2 in 2015 was significantly lower than the rate of 3.5 in 2014. Of the 36,300 private industry injury and illness cases reported in Connecticut, 20,900 were of a more severe nature, involving days away from work, job transfer, or restriction. These cases occurred at a rate of 1.8 cases per 100 full-time workers versus a rate of 1.6 nationally. Among the state and local government workers in Connecticut, approximately 9,000 injury and illness cases were reported in 2015, resulting in a rate of 5.8 cases per 100 full-time workers. Nationally, the rate was 5.1. Almost 80 percent of injuries and illnesses reported in Connecticut's public sector occurred among local government work
Thursday, June 15, 2017
In the recent CRB case of Greene vs. Ansonia Copper and Brass the Claimant, who was represented by counsel, failed to attend a scheduled formal hearing to prosecute her claim for 31-308a post PPD discretionary payments. Unfortunately, the Claimant forgot about the hearing and at the appointed hour was in Virginia attending a family member's graduation . The Trial Commissioner dismissed her claim for benefits for failure to prosecute however the CRB reversed, essentially relying on the humanitarian purposes of the Connecticut Worker's Compensation Act as well as the notion that jurisdiction in a worker's comp case is continuous. Interestingly, the session which the claimant missed was in fact a session that had previously been continued 3 times at her own request.
Article by Attorney Gary S. Starr, Esquire of Shipman and Goodwin, LLP of Hartford. Used with permission. Employers who use a staffing company to supplement their employees may find themselves in for a rude awakening if the temp gets hurt at their worksite. Ordinarily, an employee injured on the job would be covered by the workers compensation insurance. A recent Superior Court decision rejected the idea that the temp is covered by the employer’s workers compensation insurance and is allowing a lawsuit to go forward against the employer. The court found that the temp was an employee of the staffing company and not the employer, even though the temp accepted the assignment with the employer, the work was being done for the employer, and the temp was under the control of the employer at the worksite, and not the staffing company. While there are several state court decisions that have found this arrangement to be a dual employment situation, other courts have rejected the concept of dual employment. Under dual employment, the temp would have been covered under the employer’s workers compensation insurance. Until an appellate court or the Connecticut Supreme Court rules on this issue or the legislature clarifies the statutory scheme, employers using staffing companies to fill out their employment needs, run the risk that if the temp gets hurt, they could be sued. Such a lawsuit would present a risk of liability that could exceed the workers compensation formulas, with possible punitive damages. Employers should be careful in their negotiations with staffing companies to try to establish a dual employment relationship with the temp, even having the temp sign a written agreement with the employer accepting the assignment with the employer. There should also be clarification of the scope of any indemnity. The employer should check with its workers compensation insurance carrier to ensure coverage of any temps. While these steps may not avoid the consequences described above, it may provide a basis for arguing for dual employment and for coverage under workers compensation. Of course, dual employment has its own set of challenges as well so employers using temps need to understand both the pros and cons in such a relationship.
Wednesday, June 14, 2017
Today's case was a reminder of the importance of making a timely filing for Social Security Disability should you become disabled from work on a long term basis. In order to be eligible to receive Title II SSD benefits, one must file their claim for disability within a certain period, typically 5 years, from the last date of full-time work. Today's client came to me in late 2016. She had applied for disability in December of 2015 claiming an "alleged onset date" in 2003. Her "Date last Insured" (DLI) was in December 2004. In such a case it is imperative that one have medical records supporting the existence of a disability prior to the DLI. While our client had voluminous recent records records substantiating severe medical problems that would ordinarily make her eligible for disability at an early stage of the process, she had very few records that pre-dated her DLI. Thus, it becomes a challenge for the lawyer to successfully argue such a case. This is especially true given that medical providers only need to retain their patient's records for 7 years. The moral of the story is to apply for Disability as soon as it becomes apparent to you that your condition may prevent you from working for 12 months or more. You do not do yourself, or your lawyer, a favor to wait years and years before deciding that maybe SSD is something you should look into. If you you have any questions concerning onset dates, DLI problems, or any other aspect of Social Security Disability law, feel free to contact us at any time. The initial consultation is always free.
From MedVal.com CMS, Liability, Medicare Set-Aside Blog, Medicare Set-Asides, MSP News on June 5, 2017 | Posted by Jennifer Alvarez, JD, RN, MSCC, CMSP We are currently four months away from CMS implementing their new workflows for Medicare Administrative Contractors (MACs), which outline how they will handle bills when there is a Liability Insurance Medicare Set-Aside Arrangement (LMSA) or No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA) involved in the settlement. You may be aware that, in February 2017, CMS took another step to clarify that, pursuant to the Medicare Secondary Payer Act (MSP) , Medicare’s interests need to be considered in liability insurance  and no-fault insurance  claims, wherein Medicare is a secondary payer. Interestingly, the news came from CMS in the form of a one-time announcement in a February 3, 2017 MLN Matters Article (Article) , which was noted to be intended for physicians, providers and suppliers that submitted claims to MACs; specifically, the Article advised the physicians/providers/suppliers and their billing departments that, effective October 1, 2017, the MACs will not pay for services or items that should be paid from an LMSA or NFMSA. Minimal direction, with respect to claim payments as related to LMSAs and NFMSAs, can be found in CMS’ publication, Change Request 9893 (CR 9893) . CR 9893 and the February 2017 CMS Article indicated that CMS will establish two new set-aside processes for LMSAs and NFMSAs; moreover, the system will be able to detect an LMSA or NFMSA record based on diagnosis codes, similarly to the way a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) record is detected. CR 9893 instructs MACs on when to deny payment for items or services that should be paid from an LMSA or NFMSA fund; specifically, when denying a claim based upon the existence of an open LMSA or NFMSA MSP record, the MAC should include the following remark codes as appropriate to the situation: N723—Patient must use Liability Set-Aside funds to pay for the medical service or item. N724—Patient must use No-Fault Set-Aside funds to pay for the medical service or item. MSN 29.33 – Your claim has been denied by Medicare because you may have funds set aside from your settlement to pay for your future medical expenses and prescription drug treatment related to your injury(ies). Where appropriate, MACs may also override and make payment for claim lines or claims on which: Auto/no-fault insurance set-asides diagnosis codes do not apply, or Liability insurance set-asides diagnosis codes do not apply, or are not related, or When the LMSA and NFMSA benefits are exhausted/terminated, and an accurate accounting has been completed. How Does CMS’ One-Time Announcement Impact You? At first view, the February 2017 CMS announcement appears to affect only the medical community; however, it should also absolutely serve as notice and a warning to those attorneys, claims professionals, and stakeholders, who have not been considering Medicare’s interests in liability and no-fault (including auto) claims for which Medicare is a secondary payer. CMS has clearly indicated that it is in the midst of establishing two new set-aside processes – for LMSAs and NFMSAs – with “the policies, procedures, and system updates required to create and utilize an LMSA and an NFMSA MSP record, similar to a WCMSA MSP record.” Again, this language is a notice to stakeholders that Medicare’s interests should be protected in liability and no-fault claims, where Medicare is a secondary payer. It’s Time to Be Prepared If you already have a plan in place and are currently considering Medicare’s interests in liability and no-fault (including auto) claims, we simply suggest you take a fresh look at your internal policies to ensure the proper protocols are in place to adequately protect Medicare’s interests and attain MSP compliance. If you do not have a plan in effect, it is time to make one. While we expect CMS guidelines (and, perhaps a formal CMS review program for those who opt to participate in the same), no such formal guidance is yet available; nevertheless, in an effort to achieve MSP compliance, we recommend you create a plan of action and establish internal policies to consider Medicare’s interests. As you develop your plan, we suggest consideration of the following: Establish proper internal protocols and best practices to identify the liability and no-fault claims for which Medicare’s interests should be considered; As you move toward settlement, complete a thorough medical-legal analysis for each claim; If an LMSA/NFMSA is determined to be appropriate, be aware that several factors may impact the actual funding of the LMSA/NFMSA, such as: insurance policy limits, statutory tort caps, case law, and negligence rules; and Have a plan to handle the potential for insufficient funds. The settlement of a liability claim for less than full value can pose a problem – and red flag – for CMS as, (1) CMS is entitled to full reimbursement of all medical expense payments made under the claim by Medicare (i.e. conditional payments); additionally, (2) regarding anticipated future medical expenses, CMS (as the secondary payer) has historically taken the position that it is the primary payer’s responsibility to set aside funds that will cover future Medicare-covered medical expenses related to the injury over the individual’s life expectancy. Unfortunately, CMS’ expectation of full recovery is inconsistent with liability cases that typically settle for less than the full value of the claim. Ultimately, the problem is that there may not be enough money to fully cover conditional payments, damages, future medicals, and other related costs; furthermore, CMS may not recognize apportionment of said costs, or the manner in which settlement funds are allocated per agreement by the parties. With insufficient settlement funds to cover conditional payments and/or fully fund the LMSA, the parties are unable to comply with MSP policies in accordance with CMS practices. The consequences could be profound as cases may not be able to settle or will require court intervention, thereby resulting in an inundated court system weighed down with an onslaught of expensive and time-consuming cases. Ensuring that Medicare’s interests have been considered in both liability and no-fault claims is mandatory. Failure to do so can impact all parties involved so that the Medicare beneficiary may be prohibited from obtaining medical care, and the attorneys could be subject to malpractice claims. Conclusions From CMS’ recent publications, it is clear: CMS is in the process of developing two new set-aside processes for LMSAs and NFMSAs. It is not yet clear, however, how these processes will be implemented; notwithstanding the same, awareness of the factors that could impact LMSAs and NFMSAs, and the resolution of liability and no-fault claims should be considered prior to October 1, 2017. The preparation of a reasonable and defensible LMSA or NFMSA should be supported with efforts to attain MSP compliance, and such actions should be documented and memorialized in every settlement. As an MSA provider, we are committed to helping you put the proper protections in place to achieve MSP compliance. If we can be of service to you regarding your Liability, No-Fault, or Workers’ Compensation claims, please contact us at firstname.lastname@example.org.  42 U.S.C. § 1395y(b)(2)(A)(ii) specifically mentions liability claims, but for years, a formal interpretation of the MSP Act as related to liability settlements did not exist.  Liability insurance is insurance (including a self-insured plan) that provides payment based on legal liability for injury or illness or damage to property. It includes, but is not limited to, automobile liability insurance, uninsured motorist insurance, underinsured motorist insurance, homeowners’ liability insurance, malpractice insurance, product liability insurance, and general casualty insurance. 42 C.F.R. § 411.50(b).  No-fault insurance is insurance that pays for medical expenses for injuries sustained on the property or premises of the insured or in the use, occupancy, or operation of an automobile, regardless of who may have been responsible for causing the accident. This insurance includes but is not limited to automobile, homeowners, and commercial plans. It is sometimes called “medical payments coverage”, “personal injury protection”, or “medical expense coverage”. 42 C.F.R. § 411.50(b).  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9893.pdf  https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1787OTN.pdf Share this post Monthly Archives Monthly Archives