Transcript Colville Confederate Tribes Workmen’s Compensation

Colville Confederate Tribes
Workmen’s Compensation
What is Workmen’s Compensation?
General Information
 If you are hurt on the job after January 1,
1984, you are covered under the Tribes SelfInsurance Program. The tribe will pay medical
cost and time loss.
 If injured prior to January 1, 1984 will
continue to be the responsibility of the State
Department of Labor and Industries.
Medical Costs
 Your employer will pay all related costs
according to an agreed fee schedule.
 You are not to charged for any authorized
treatment. If you find it necessary to pay a bill,
submit it to the tribe or service company for
reimbursement.
Time Loss Compensation
 Qualification: You must
 1. Disabled and unable to work due to the
injury or disease.
 2. Under care of and treatment by an
authorized practitioner.
 3. Authorized to be off work by the authorized
practitioner.
Time Loss
 Amount:
 The rate of time loss compensation is
determined by your marital status and
number of dependents.
 The maximum available is 75% of injured
employee’s wage. The minimum available is
60% of injured employee’s wage.
Time Loss
 Waiting Period:
 1. No payment is made the day of the injury.
 2. No payment is made for the first three days
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following the date of injury.
Duration:
You will continue to receive time loss benefits until:
1. Your doctor releases you for work and you return
to work.
2. You return to modified work which your doctor
approves.
3. You refuse or obstruct reasonable treatment.
Time Loss
 Closure and Openings:
 Your claim will be closed when no further
curative treatment is indicated.
 The tribe may authorize reopening of your
claim if medical evidence indicates further
curative treatment is warranted.
Permanent Awards
 Permanent partial disability is based on medical
evidence that you have lost a percent of the function
of a body part due to injury or disease. The monetary
value is decided by the tribe.
 Permanent total disability is an industrially-related
condition supported by medical vocational opinion
which prevents you from being able to perform
gainful employment. Such condition may qualify you
for lifetime pension.
 Survivors benefits are pension benefits available for
your dependents should you suffer an on-the-job
fatality. In such case, you dependents should apply
for survivors benefits.
Reconsideration and Appeals
 Any action take on your claim can be
protested should you disagree. You should
put your protest in writing and submit it to:
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Executive Director
P.O. Box 150
Nespelem, WA 99155
Or call (509) 634-2238
Workman’s Compensation Appeal
 Decision by Insurer: Notice to Claimant and Tribes (including
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instructions on appeal rights)
30 Days: Notice of Appeal to Board by Claimant (Board is
Executive Director, Medical Personnel, HEW Chair) Board may
use Tribal attorneys for legal advice.
45 Days: Written Presentation to Board by Appellant (Claimant).
45 Days: Written Presentation to Board by Insurer and Appellant
(Sedgwick and The Tribe)
15 Days: Written Response to Insurer’s and Appellant's
presentation by Appellant (Claimant)
90 Days: Board decides in writing by Majority Vote – or
Claimant receives full benefits claimed in appeal – no further
appeal – final for Tribes.
* Benefits allowed to Claimant by Insurer shall continue to
be paid during appealing process.
Worker’s Compensation Program
 Employees of the Tribe and its Enterprises
becomes INJURIED on the job are entitled to
file a claim.
 Which can include: Time Loss payment, and
payment of medical billings related to the on
the job injury.
 The employee and employer must have file a
claim for these benefits.
How to file a claim:
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The employee reports the injury or illness immediately to the Supervisor or Manager,
however, the employee is not required to file a claim at that time. The employee has 1 (one)
year from the date of injury to file a claim. Keep in mind that time loss payments will not be
issued until a claim has been filed.
If outside medical attention is necessary, the Supervisor will supply the injured employee
with a Worker’s Compensation Claim Packet, which includes the Industrial Accident Report,
Physician’s Initial Report, Supervisory Accident Investigation Report and Report of Return
to Work of Injured Employee. These forms can be obtained at the Benefits/TOSHA office.
It is imperative that the Industrial Accident Report, the Physician’s Initial Report and the
Supervisory Accident Investigation Report are completed in order to submit and initiate a
claim. In addition, it is also imperative for the final two forms (consent to Develop Medical
and Wage information and the Report of Return To Work of Injured Employee) to be
completed in a timely manner to initiate time loss payments. This is important especially if
the injured employee is missing work due to their injury.
After completing all forms you must return the forms to Benefits/TOSHA Office. Currently, all
completed forms will forward to the third party administrator – Sedgwick CMS.
Upon receipt of the Worker’s Compensation claim packet, Sedgwick CMS creates a claim
file and will initiate time loss if needed. The injured employee will not return to work until they
obtain a Physician’s release to work. The goal in each case is the restoration of the injured
worker to maximum bodily function and gainful employment.
Return all forms back to Workers Compensation program. If you have any questions call
Benefits Office at (509) 634-2010 or ext. 2020, 2019, 2018.