Transcript Workers Compensation - Pesticide Health Effects Medical

Workers Compensation
What is it? How do I work with it?
Pesticide Health Effects Medical Education Database(PHEMED) 2010
An Insurance System
• Most workers in the US benefit from Workers
Compensation
• It covers injuries and illnesses which result from
work
• It is a no fault insurance system
– Worker does not need to sue to benefit
– Employer cannot dismiss worker claims because worker
was at fault
– Worker cannot sue employer for damages beyond
medical care, disability and lost wages.
When is illness or injury work related?
Any injury or illness resulting from or sustained
in the course of any occupation or employment.
Which means:
• “More likely than not” due to work or
• Work must be the “most likely” cause of the condition or
• “But for the work”, the condition would not exist
Exceptions to “Work Relatedness”
From Texas Worker Compensation Website
“Benefits are not payable for injuries that
are intentional or self-inflicted:
• Result from the employee’s horseplay or
voluntary intoxication (either alcohol or drug-induced)
• Arise from voluntary participation in off-duty
recreational, social, or sports events
• Result from “acts of God,” unless a person’s
job exposes him or her to a greater than
ordinary risk of injury from such acts
• Are inflicted by someone else for personal
reasons unrelated to employment.”
http://www.tdi.state.tx.us/pubs/consumer/cb030.html Accessed 6/2010
Who is covered and what is covered
differs from state to state.
For Example:
Washington: all employers are required to provide
worker compensation - Very strict
Wisconsin: Only if employer has three or more
full-time or part-time employees - Intermediate
Texas: does not require most private employers to carry
workers’ compensation insurance - Not strict
Who provides worker compensation?
Several state monopoly systems exist
- Washington, Connecticut, and a few others
Most states have private insurers
- e.g. Liberty Mutual, Farm Bureau, Great Northern
Most states have a state supported last
resort insurer for employers who cannot
obtain worker compensation through
another carrier.
Common Exceptions:
Workers Who Don’t Qualify
No coverage in many states
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Farmworkers
Household employees
Private contractors
Day laborers
In home healthcare workers
Other than State Systems
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Federal Employees
Mariners
Miners
Longshoreman
How to File a Claim
• Generally a form or forms are filled
out to initiate coverage
• States have one or more forms
• A critical question is always
included
• Your response has implications in
terms of decisions to cover or not
– Was this caused by work?
(or something along those lines)
What You Want Your Note to Say
In the case of Injuries
• Generally, injuries are easy to associate with
workplace events
• Identify the circumstances
• Confirm it occurred at work
• Make a simple statement of causation
What Your Note Should Convey
• The event or exposure occurred at work
• The frequency of the injurious activity is more
common at work (ergonomic injuries)
• The exposure is logically the cause of the
disorder (or has been shown in the literature to
be the cause)
• Mr. Jones suffered exposure at work, the
exposure caused the disorder, ergo, the disorder
is due to work.
What You Want Your Note to Say
Establishing Causation in Work Related Illnesses
Is a Bigger Challenge
• Many systems deal with work related Illnesses less well.
• You must educate the claims manager with your note.
• Your time is well spent finding and citing medical literature
the shows the disorder has been found to be caused by
the exposure your patient suffers.
• Stating clearly how much exposure the patient had and
how this resulted in the illness is important.
What to Say In Your Note
For Injuries:
• “Mr Jones was at his work station doing his usual job
when” or “Mr Jones was out on his job doing his usual
Blah Blah when”
For recurring illnesses:
• “Mr Jones develops symptoms within Blah Blah
minutes of working with Blah Blah (a substance)”
• “Mr Jones gets better when on vacation or away from
exposure”
For Chronic Illnesses:
• Mr Jones has worked for __ years doing Blah Blah. In
the course of these years he has routinely been
exposed to high concentrations of Blah Blah.
Special Circumstances
• Workers who are injured
while traveling for work
are covered for the injury
• Workers commuting to
and from home to work
are not covered in the US
Learn More
• Search the web for
Worker Compensation
and state name.
• Most states have a
Worker Compensation
page that describes
requirements, limitations
and benefits
Worker compensation + WA