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Thin and Crumbling Skulls: The Impact of Pre-Existing Conditions on Workers Compensation in Ontario Canada


Introduction

Workers compensation
is premised on the concept that workers should be compensated for injuries or disablements sustained in the course of their employment. Causation is the key factor in determining whether a worker’s injuries are compensable. In determining questions of causation, issues often arise as to whether the injury was truly sustained in the course of employment or was the result of some pre-existing condition suffered by the worker. In such situations, a worker’s entitlement to compensation can be complex.

This article considers the role of pre-existing conditions on the issue of entitlement in workers compensation law in Ontario, Canada. It focuses on the use of the “thin skull” rule by Ontario’s Workplace Safety and Insurance Appeals Tribunal (“Tribunal”) and Workplace Safety and Insurance Board (“Board”). Finally, this article identifies relief available for employers who face situations where the severity of their worker’s injury is enhanced by the existence of a pre-existing injury.


Causation and the Thin Skull Rule

In Ontario
, a “significant contributing factor” analysis is used to determine whether a worker’s injury or condition is compensable. This test focuses on whether the work itself made a significant contribution to the worker’s injury. The work need not be the sole contributing factor to the injury. As long as the work makes more than a de minimus contribution to the injury, the worker will be entitled to workers compensation.

Where a worker’s
pre-existing condition contributes to an injury sustained in the course of employment, workers compensation adjudicators in Ontario apply a doctrine known as the “thin skull” principle. This doctrine originates from common law principles of causation. It provides that individuals are to be taken as they are found, frailties and all. In the context of workers compensation law, this rule means that where a non-compensable pre-existing factor may have rendered a worker more susceptible to injury, such increased susceptibility will not preclude entitlement to benefits. Providing the work related accident/disablement was still a significant contributing factor to the injury or subsequent disability, the worker will be entitled to benefits.

The rationale behind
applying the thin skull rule to workers compensation cases was explained in the Tribunal's Decision No. 915 at p. 136:

The thin-skulled doctrine also applies in Workers Compensation cases and for two reasons. One reason is that permitting compensation to be denied or adjusted because of pre-existing or pre-disposing personal deficiencies would very substantially reduce the nature of the protection afforded by the compensation system as compared to the Court system for reasons that would not be understandable in terms either of the historic bargain or the wording of the legislation. The other reason is that in a compensation system injured persons become entitled to compensation because they have been engaged as workers. They have functioned as workers with any pre-existing condition they may have had. It seems wrong in principle that conditions which did not affect their employment as workers should be relied upon to deny them compensation as injured workers.

Thus, workers
will be entitled to compensation for injuries sustained in the course of employment, even if such injuries resulted from a pre-existing condition, provided that the work itself was a significant factor in the injury.

The Crumbling Skull Exception to the Thin Skull Rule

Canadian common law
has recognized a limit to the thin skull principle in situations where a pre-existing condition is so large a causal factor in an injury that it overwhelms the significance of the conduct of the tortfeasor. This concept is known as the “crumbling skull” rule.

The crumbling skull
rule has been applied by the Tribunal to limit entitlement for workers with pre-existing symptomatic conditions. Its application was expressed in Decision No. 1870/07:

If a pre-existing condition is symptomatic and is so large of a causal factor in the subsequent disability that it overwhelms the significance of the accident, then triers of fact might conclude that the accident, compensable or not, was not a significant contributing factor to the subsequent disability. In such a case, the disability or condition would not be compensable.

In applying the
crumbling skull principle, the Tribunal often focuses on whether the pre-existing condition was symptomatic or asymptomatic. In cases of symptomatic pre-existing conditions, the Tribunal will, on appropriate facts, find that the crumbling skull exception applies. (WCxKit)

Relief for Employers with Thin Skulled Employees

The Board operates
a Second Injury and Enhancement Fund (SIEF) to provide employers with financial relief where a pre-existing condition enhances or prolongs a work-related disability. By providing employers with such financial relief, the SIEF encourages employers to hire workers with disabilities.

The SIEF is
only available to Schedule I employers (those employers, largely in the private sector, who are covered by the Board’s insurance fund). Schedule II employers (those employers, largely in the public sector, who are self-insured) must pay for all Board costs, whether or not they can be attributed to a pre-existing condition.

The Board’s policy
regarding the SIEF defines a pre-existing condition as an underlying or asymptomatic condition which only becomes manifest post-accident.  This definition implicitly recognizes the distinction between compensable asymptomatic pre-existing conditions, and non-compensable symptomatic pre-existing conditions embodied in the crumbling skull exception to the thin skull rule.(WCxKit)

If it is likely
that a pre-existing condition either contributed to the work-related accident or prolonged or enhanced the work-related disability, employers may be entitled to relief under the SIEF. The percentage of employer costs transferred to the SIEF depends on a consideration of the medical significance of the pre-existing condition in conjunction with the severity of the accident. While, in most cases, 50% of employer costs are transferred to the SIEF, employer relief under the SIEF can reach 75% and above in appropriate circumstances.

Contributing Author:
Joseph Cohen-Lyons is an associate lawyer at the Hicks Morley Toronto, Canada office and currently practices in all areas of labour and employment law providing advice and representation to employers and management. Contact him at: joseph-cohen-lyons@hicksmorley.com  or 416-864-7213.


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NEWSLETTER: 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Canada Workers Comp, Employment Law Issues, Medical Issues |


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New Co-Managers Join Workers Compensation Roundtable


We are pleased  to announce some changes  to the Workers’ Compensation Roundtable, run by Rebecca Shafer and the Workers Comp Kit Blog Team, that will make it an even more effective tool for employers and the workers’ compensation community. Effective immediately, Bob Wilson, Kathy Lella and other key staff from www.WorkersCompensation.com will be sharing the responsibilities of managing this group with Rebecca Shafer of www.LowerWC.com. Rebecca started this group in 2009, and has done an excellent job in laying a strong foundation and establishing clear objectives for its purpose. With the addition of the WorkersCompensation.com team, we will continue to lead discussions on cost containment issues for both employers and WC professionals, but will also be taking a stronger focus on legislative discussion and review.


We believe
this new team management approach will provide a very strong ability to meet the information needs of the workers’ compensation community. Rebecca’s experience and expertise in targeting and reducing workers comp cost burdens for employers across the nation is unmatched by anyone. For over 11 years WorkersCompensation.com has been widely recognized as a definitive source of news, information and valuable legal data for the entire nation. Together they will provide an excellent resource for the members of the Roundtable.


Effective immediately
, the Workers Compensation Roundtable is designated as the official Employers and Professionals Forum for WorkersCompensation.com. It will also be linked from its members’ subscription area, WorkCompResearch. We wish to welcome those professionals to this new service.


If you know an employer
or professional that could benefit from membership to the Workers’ Compensation Roundtable, please invite them today. The group link is: http://www.linkedin.com/groups?mostPopular=&gid=1922050


Please let us know
how we can better serve your needs. You may contact Rebecca, Bob or Kathy through the LinkedIn system.


Thank you for your continued support of the Workers’ Compensation Roundtable.

The Workers’ Compensation Roundtable Team
Robert Elliott
Rebecca Shafer
Robert
Wilson
Kathy Lella

 
WC IQ TEST:  http://www.workerscompkit.com/intro/
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NEWSLETTER: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Risk Management, Seminars and Courses, WC 101 |


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Common Sense Considerations for Hiring Safer and More Productive Employees


One of the easiest ways for an employer to control the cost of workers compensation is to hire employees who are unlikely to have a job related injury. To identify and hire employees who take safety seriously takes some efforts but makes great economic sense. To find the best people to hire is easier if you have a hiring plan that includes identifying the requirements of the position you are trying to fill and the capabilities (both physical and mental) of the person you are considering for the position. By creating a standardized hiring plan and using it, you identify the best job applicant for your company. Risk Management starts with hiring the right employee.
 
1- Job Analysis
The hiring of the best applicant for the job is a lot more than reading a resume and having an interview. With all the self-help books and internet websites on how to write a great resume and shine in the interview, a job applicant may make a good impression but be a poor choice for your company. A job analysis will assist you in determining if the job applicant is a good fit for your company. (WCxKit)
 
 A job analysis breaks the specific position being filled down into its component parts. Each part of the job is separated into its essential features including skills, abilities, knowledge and attitudes needed to perform the job. By identifying the task and responsibilities of the position, the employer will be able to compare job applicants against the criteria of the job. Each job applicant can be tested (see Testing below) to measure their capabilities in each of the essential features of the job.
 
A job analysis for a manual labor position could include the applicant's ability to lift weights, carry weights and the strength to push or pull a weight. The frequency of performing these tasks – never, occasionally, frequently or constantly – is determined when the employer creates the job analysis. The applicant's ability to do each can be measured and tested prior to making a job offer. 
 
In addition to strength testing for the manual labor position, the applicant's ability to bend, turn, twist, squat, crawl, climb, reach out, reach up, grasp and pinch can be tested. Again, the frequency of these activities should be established when the employer creates the job analysis. By establishing the applicant's ability to perform the physical demands of the job before hiring the job applicant, the probability of an on-the-job injury is greatly reduced.
 
The job analysis for a clerical position could include the applicant's ability to use a keyboard, operate word processing programs and perform other computer skills. The frequency of these activities and the speed in which they need to be accomplished should be established by the employer prior to the start of the hiring process.
 
2- Job Descriptions & Specifications
Each job position should have a written job description that specifies what the employee will be doing on an everyday basis. It should identify the task to be completed, the equipment or machinery that will be used, whether he/she will be working as a part of a group or have individual responsibilities and whether or not the employee will be supervising either processes or people.
 
The skills, abilities and knowledge needed for the job should be established. This includes any requirements for prior experience or specific education. For instance, the job description can include the requirement to operate a forklift safely, or the requirement to close a difficult sale successfully, or the requirement to have a law degree.
 
3- Testing
To compare the job applicants capabilities against the job description and specifications of the job, screening and testing is needed. The employer who has the expertise in testing job applicants can perform the necessary testing, but most employers elect to hire a vendor who specializes in performing pre-hire testing. The testing can include:
1.      attitude and integrity assessment profiles
 
2.      functional capabilities testing
 
3.      pre-offer agility and strength testing
 
4.      post offer comprehensive medical screen to identify pre-existing medical limitations and cumulative trauma
 
4- Screening and Background Checks
All pre-employment screening and background checks must comply with federal law and the state law where the employee is being hired. Pre-employment drug testing (as well as post-employment drug testing) should be a condition of any job offer. Thirty-eight to fifty percent of all workers' compensation claims are related to substance abuse according to the Tennessee Department of Labor. The employers who actively manage their drug-free workplace program benefit from higher productivity, fewer work related accidents, lower absenteeism and lower medical cost (both from medical insurance claims and workers compensation claims). At least a dozen states require the workers compensation insurers to offer your company a premium discount if your company has a drug-free workplace program.
 
The job applicant should agree to a background check which includes checking the applicant's background for hidden criminal records, drug arrest, prior employment history, prior academic achievements and credit history {a good reason to use an outside vendor is to let the vendor comply with the Fair Credit Reporting Act.} The pre-hire job screening and testing vendor should be a Designated Agent approved by the Department of Homeland Security so they can do the E-Verify Legal Right to Work check. 
 
5- Psychological Testing
Psychological testing can be used to screen potential employees. There are three primary types of psychological testing. They are:
5.      Personality testing that provides insights into the values, ethics and behavioral characteristics of the potential employee.
 
6.      Aptitude testing that evaluates job candidates reasoning skills. The test measure verbal, numerical and abstract thinking.
 
7.      Motivational testing that identifies the areas of interest and importance to the job candidate and identifies what motivates the person.
 
Personality testing and behavioral testing adds an element of objectivity to the pre-employment screening process. The pre-employment assessment testing will provide the employer with information on the aptitudes and behavioral traits of the potential employee. The pre-employment assessment can provide the employer with information on the ethics, values, honesty and integrity of the job applicant. Often the behaviors identified in the personality testing can be confirmed through reference checks and background screening. 
 
6- Without Discrimination
Nothing will mess up your hiring plans more than a lawsuit brought by a job applicant who believes there was discrimination in the hiring process. Be fully up to speed on the requirements of the Americans with Disabilities Act (ADA), the Civil Rights Act, the Equal Pay Act and the Age Discrimination in Employment Act. Any job applicant can file a lawsuit with the Equal Employment Opportunity Commission (EEOC). 
 
All hiring decisions should be based on the job applicant's ability to do the job as measured in the testing you have done. If you let a job applicant's disability, ethnic background, gender or age influence your hiring decision, and the job applicant proves it, the legal remedies include the lost wages, compensatory damages, legal fees, and in severe cases of discrimination, punitive damages. (WCxKit)
 
Safe Hiring
By establishing the criteria of the job through the job analysis, including the physical requirements and the job specifications, the employer can eliminate most of the job applicants who do not have the physical capabilities to perform the job safely. This prevents many work comp claims from ever occurring. The pre-offer and post-offer job testing can identify job applicants who have medical limitations, while the workers compensation background check can verify the veracity of the job application in regards to prior workers compensation claims.
 

Author Rebecca Shafer, President of Amaxx Risks Solutions, Inc. is an attorney  and national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.  Contact:  RShafer@ReduceYourWorkersComp.com.

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in EEOC Discrimination Laws, Employment Law Issues, Risk Management, Safety and Loss Control |


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Mandatory Insurer Reporting Timetable Delayed for Some


On November 9, 2010 CMS Announced:   Revised Implementation Timeline for TPOC Liability Insurance (Including Self-Insurance) Settlements, Judgments, Awards or Other Payments
 
Medicare has delayed the required submission of Mandatory Insurer Reporting data for all Liability Insurance initial claims reports with no Ongoing Responsibility for Medical (ORM) involvement until 1/1/2012. Liability and Workers' Compensation claims with ORM have not been delayed and will be required to submit claims records in Q1 2011. All claims/settlements involving Medicare beneficiaries during this interim period must comply with the Medicare Secondary Payer Statute (MSP) and will be reported to the Centers for Medicare and Medicaid Services (CMS) if they meet the requirements.
 
Liability insurance (including self-insurance) Total Payment Obligation to Claimant (TPOCs) must be reported if the TPOC Date is on or after 10/1/2011. 
 
The current rule requiring reporting of Non Group Health Plan (NGHP) TPOC dates as of 10/1/2010 has been changed to 10/1/2011 but only for liability insurance (including self-insurance) TPOCs.
 
The reporting date requirements for TPOC Dates of 10/1/2010 and thereafter associated with no-fault insurance or workers' compensation claims remain unchanged.
 
The reporting date requirements as documented in the User Guide for all NGHP ORM remain unchanged.
 
Initial Claim Input Files for reportable claims continue to be due during the Responsible Reporting Entity (RRE's) assigned file submission timeframe for the first calendar quarter of 2011. RREs that have reportable claims must commence production reporting in first calendar quarter 2011 and will include liability insurance (including self-insurance) TPOC reporting in the first calendar quarter of 2012 for TPOC Dates of 10/1/2011 and thereafter.
 
Medicare has also extended the Interim Dollar Thresholds for all lines of insurance. The new extension gives relief to settlements in Liability and Workers Compensation cases with TPOC amounts under $5,000 and executed prior to 1/1/2013. The threshold falls to $2,000 in year 2013 to 2014; then drops again to $600 in 2014 through 2015.
 
CMS cautions that the obligation to protect Medicare's interests remains unchanged in all lines of business. While the reporting dates have been extended regarding Liability claims with TPOC only, workers' compensation cases and No Fault cases are unaffected.
 
Time during the delay should be aggressively utilized by liability RRE's and TPAs to improve processes and procedures regarding Mandatory Insurer Reporting and Medicare Secondary Payer Compliance.


If you chose
a Reporting Agent who has been unable to successfully complete testing of the reporting requirement after more than 2 years of notice and development, now is the time to explore the options and make a change without penalty. Gould & Lamb is prepared to take on additional MIR clients immediately and can successfully integrate both small clients and large clients regardless of needs and system complexities.

Contributed by Gould & Lamb. Contact Kip Daniels, Vice President of Strategic Services, at kip.daniels@gouldandlamb.com  or 866-672-3453 x 1077.


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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Uncategorized |


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Self-Help Tool to Improve Safety Culture in New Zealand


A new tool to help New Zealand businesses assess and improve their safety culture has been released by the Department of Labor.
 
Safety culture is about how everyone thinks and acts on safety in the workplace. (WCxKit)
 
Research shows that a positive safety culture means fewer workplace injuries and reduced staff turnover. It can also enhance a firm’s reputation and lead to higher productivity. 
 
The new Safety Culture Snapshot tool aims to help businesses interested in creating a better safety culture.  It is practical self-help tool with a step by step process and supporting resources.
 
The tool was developed and tested directly with large and small workplaces and the help of safety culture expert Dr Hillary Bennett.
 
“One of the best ways to improve a safety culture is to start measuring it. This tool gives businesses the guidance they need to understand what’s working well and where there is room for improvement,” says the Department’s Workplace Services Group Manager Maarten Quivooy.
 
“It can be used by any industry or business that is motivated to improve its health and safety performance. Ultimately it will help a business make a start diagnosing its culture and, most importantly, planning for change.  Building a better safety culture builds a better business.”
 
The Safety Culture Snapshot contributes to the Workplace Health and Safety Strategy’s vision of healthy people in safe and productive workplaces. (WCxKit)
 
For information and to access the Safety Culture Snapshot  www.dol.govt.nz/safetyculture


Author Robert Elliott
, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  Info@ReduceYourWorkersComp.com or 860-553-6604.

 
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SUBSCRIBE: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Safety and Loss Control, WC in Other Countries (International) |


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The Aging Workforce and Workers Compensation Webinar – THURSDAY November 18, 2010


THE AGING WORKFORCE WEBINAR  (FREE)
Register NOW for Tomorrow!
From:       Broadspire_info@choosebroadspire.com
Subject:  What are you doing about America’s aging workforce?

AGING UP
A WEBEX ON WORKING WITH MATURE EMPLOYEES
November 18th, 11:00 AM EST 
 
In 2000, there were 18.2 million workers over the age of 55 in America.
In 2008, there were 25.2 million, a 38% increase.
In 2025, AARP estimates there will be 31.9 million, a 75% increase.
 
Prepare your company and your department for the maturing of America’s workforce. Join us for information on accommodating your aging employee population.
 
The presentation covers:
- An overview of our country’s aging demographics and what it will mean for your company
- The ramifications of these growing numbers on operations
- Safety issues for older employees and customers
- Controlling workers compensation costs
- Ways to return more mature employees to work
 
FREE Registration: Broadspire_info@choosebroadspire.com or Call 1-866-625-1662. 
 
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NEWSLETTER: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Professional Development Issues, Seminars and Courses |


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How to Grade Your Workers Compensation Claim Adjuster


In school an “A” grade is the standard that everyone wants to meet. Whether you are in elementary school or working on your master's degree, your performance results in a grade being given to the work you complete. To earn an A grade requires having at least 95 percent of the school work done correctly. Following the same basic grading principles – A, B, C, D, F – you can measure the performance of your workers compensation adjuster. 
 
The following is a grading outline you can use to measure the performance of your workers' comp adjuster on each claim. There are ten categories with 10 points each, or 100 points total. When your review your adjuster's file on-line, grade each category against the measurements listed here. [If your Best Practices give the adjuster different time lines then what is given here, use your own Best Practice guidelines in grading your adjuster]. Give the adjuster the number of points (zero to ten) earned in each category. (WCxKit)
 
Category 1 – Employee Contact:
The adjuster should contact the injured employee within 24 hours of the receipt of the claim (same day contact would be more points than next day contact). True contact entails an exchange of information between the adjuster and the employee, not just leaving a message on voice mail. If the adjuster was unable to reach the employee within 24 hours by telephone (or in person on severe claims), a contact letter should be sent to the employee along with a medical authorization or any state required forms. On any claim involving questionable compensability or subrogation, a recorded statement should be obtained from the employee. You're looking for a "quality contact."
 
Category 2 – Employer Contact:
The adjuster should easily score all ten points in this category by contacting the employer by phone (in person with extreme employee injuries) within 24 hours of receipt of the claim (same day contact would be better). On any claim involving questionable compensability or subrogation, a recorded statement should be obtained from the employee's supervisor. Also, any witnesses to the accident should be contacted if the injuries are severe.
 
Category 3 – Medical Provider Contact:
The office of the medical provider should be contacted within 24 hours of the report of the accident to confirm the nature and extent of the accident, and the ability of the employee to return to work on modified duty/light duty. In the jurisdictions that do not require a medical authorization to obtain the medical records on the employee's injury, the medical records should be requested during this initial contact.
 
Category 4 – Investigation:
If the adjuster has done a quality job in the three contact categories, earning points for completion of the investigation should be rather easy.The investigation should address all issues that impact coverage, the nature and extent of the injuries, the benefits owed, subrogation and subsequent injury fund (where applicable). An ISO Index Bureau search should be filed. If the investigation has been completed properly, the adjuster should be able to make a decision on the compensability of the claim. All of this should be accomplished within the first 14 days the claim file is open.
 
Category 5 – Average Weekly Wage and Benefits:
To earn points in this category, the adjuster should obtain from the employer the wage records or wage documentation on the proper state approved form. It is not acceptable for the adjuster to take the hourly rate off the Employer's First Report of Injury form and estimate the average weekly wage. The weekly wage and the calculation of the indemnity benefit should be clearly documented in the adjuster's file. In addition to calculation of the indemnity benefits with proper documentation of the wages, if owed, they are issued timely. Also, all medical bills are reviewed and paid timely.
 
Category 6 – Reserves:
The initial file reserve should be set by the adjuster within 72 hours of the file receipt, but after completion of the three contacts – employer, employee and medical provider. After the adjuster has obtained the initial medical records, within 60 days of file receipt, the reserves should be reviewed for accuracy. Throughout the course of the file the receipt of any information, medical or otherwise, that would impact the files, the reserves should be updated. On severe claims that remain open for an extended period of time, the adjuster should review the reserves every 6 months to verify their accuracy.
 
Category 7 – On-Going Contact:
A mistake that way too many adjusters make is not staying in contact with the employee, the employer and the medical provider. Consistent and on-going contact with the employee will maintain rapport with employee and eliminate many of the reasons that could delay the progress of the claim.The adjuster should maintain the file on diary to ensure all on-going contacts and necessary follow-up is completed. If the adjuster stays in contact with the employee at least monthly until the claim is resolved, and stays in contact with the employer and medical provider as needed, award all 10 points in this category.
 
Category 8 – Medical Management:
When the adjuster makes the initial medical provider contact, medical management begins. In the initial contact the adjuster should learn the diagnosis, prognosis, the treatment plan and the return to work status.The adjuster should coordinate with the employer and the medical provider to allow the employee to return to work on modified duty as soon as possible. If the injury is severe enough, the adjuster should provide the medical provider with the information on utilization review and pre-certification, plus a nurse case manager should be assigned to the claim timely. If a medical bill review service is used to audit medical bills, the adjuster should ensure all medical bills are sent to the appropriate audit vendor for review and processing.

Important note: To grade this portion of the score, have an MD review the file to make sure the injury is, in fact, work-related. Also analyze whether all medical reports are in the file, that complex medical language is recognized, and that medical care is appropriate, e.g. that nurse case management made a difference in the file and did not simply replace duties an adjuster should be doing. My view is that the best qualified person to review a medical file is a DOCTOR. Use TPAs that have appropriate MD resources for services such as peer-to-peer. If the nature of a claim is unrecognized or inappropriate, it won't matter how many administrative details are done well, because the claim shouldn't have been paid in the first place. Keep this in mind.

 
Category 9 – Litigation Management:
Any time a workers' compensation board hearing or a court hearing is requested by the attorney for the employee, a prompt referral to pre-approved defense counsel should be done. The initial referral to defense counsel should outline the status of the claim, request a litigation budget and provide instructions to defense counsel on how the adjuster wants defense counsel to proceed. (If the adjuster does not instruct counsel on what the adjuster wants done, deduct at least 5 points in this category). The adjuster should continue to provide on-going instructions to counsel throughout the course of the claim.
 
Category 10 – File Documentation:
Every activity completed by the adjuster should have a clear, concise file note stating what was done and how it impacts the claim. All medical reports, reports from defense counsel and any other file development should be outlined in the file notes.
 
Bonus Points:
Occasionally, their will be other important activity in the file that is not included in the 10 categories noted above. For instance, the adjuster's pursuit of subrogation to recover the cost of the claim deserves 5 or 10 bonus points based on your evaluation of how much extra effort the adjuster put forth to recover the subrogation. 
 
Another area for consideration for bonus points would subsequent injury funds or other offsets. Any effort made by the adjuster to mitigate the cost of the claim should be recognizes by the award of bonus points. (WCxKit)
 
Overall Grade:
Tally the number of points (from zero to ten) you gave the adjuster in each category. Compile the scores from all the claim files you review. Using the A, B, C, D and F grading system you had in school, does your adjuster deserve an “A”? If not, what category/area(s) did the adjuster consistently fail to earn all ten points? Identify the weak areas and ask your adjuster to strive to comply with your Best Practices in those areas. Some TPA's grade their own adjusters; this can be valuable information for you to learn.
Check our directory of services or email us to find qualified claim reviewers to grade your files. I have several qualified claims reviewers and MDs I use.  
 

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com.

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php
 
JOIN LINKEDIN GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
NEWSLETTER: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Assessment & Diagnostics, TPA and Claims Administration |


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Metroliner Crash Leads to Proposed Increase in Railroad Accident Liability Cap


A California congressman recently introduced a bill that could change liability in train accident cases. 
 
Rep. Elton Gallegly, who first put this bill forward, is looking to change a federal law that mandates a $200 million limit on damage payouts to victims of train crashes. (WCxKit) 
 
This $200 million dollar cap is a provision of the Amtrak Reform and Accountability Act of 1997, and applies to the aggregate of all passenger claims including punitive damages.  Rep. Gallegly’s bill looks to increase the cap to $500 million dollars.
 
There is much conjecture that the impetus for this bill is the Metrolink crash of 2008, as the one of the provisions of the bill is that the new $500 million dollar cap would apply retroactively. 
 
The Metrolink crash occurred on Sept. 12 of 2008 in Los Angeles, taking the lives of 25 people and injuring more than 100.  It has been said that the train engineer was texting on his cell phone leading up to the crash.  Gallegly feels strongly that $200 million dollar cap is far from adequate in compensating the victims of the Metrolink crash. (WCxKit)
 

According to Gallegly, “I met with many of the victims of the crash last month.  Through no fault of their own, many now have injuries that will require a lifetime of medical treatment. Others lost a spouse or parent who was their primary means of support. The current cap will not even meet the medical needs of the survivors of one of the worst passenger train accidents in modern history.”


 Author Robert Elliott
, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  Info@ReduceYourWorkersComp.com or 860-553-6604.

 
WC IQ TEST:  http://www.workerscompkit.com/intro/
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php
 
WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com. 

Posted in Legal Doctrines |


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Manitoba Prison Guards Protest Health and Safety Issues Due to Overcrowding


Prison guards in Manitoba (Canada) held a recent protest outside Stony Mountain Penitentiary over health and safety problems at the facility.

Members of the Union of Canadian Correctional Officers say the government hasn't responded to its concerns about inmate overcrowding and a recent outbreak of scabies. (WCxKit)

 
Canada is reportedly spending $35-million to build 96 new, maximum security beds at the medium security facility located 11 kilometers north of Winnipeg.


It has been
reported that StonyMountain is meant to hold 546 inmates but is already 60 inmates over capacity.

Prison guards report they're already working in deplorable conditions. Four inmates have tested positive for scabies, a skin disease that has left at least one correctional officer hospitalized.

Spokesman Lyle Stewart claims the union has sent letters to Public Safety Minister Vic Toews (taves) about the problems, but he hasn't responded.(WCxKit)

Stewart said the protest was scheduled to coincide with a news conference by Toews, who was expected to announce an expansion of the StonyMountain prison last week.

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  Info@ReduceYourWorkersComp.com or 860-553-6604.

 
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php
 
JOIN OUR WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
NEWSLETTER: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Canada Workers Comp, Safety and Loss Control, WC in Other Countries (International) |


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Underreporting Payroll Leads to Workers Comp Fraud Charges


A Memphis businessman was recently indicted on criminal fraud charges of underreporting his payroll for his labor subcontracting companies to deprive insurance companies of more than $1 million in workers compensation premiums.

The individual reportedly had a suitcase packed and was preparing to leave town when authorities took him into custody. (WCxKit)

The man is the owner of Xpress Services, Express Services, Labor Fast, Fast Track Systems and CSI Services, Inc. The companies provide workers for a variety of construction jobs, mostly for drywall work.

Authorities report the man had some 110 employees, but only claiming having half that many and paid no workers comp on the others. The alleged offenses occurred between January 2006 and July of this year. (WCxKit)

 He was indicted on four state counts of workers comp fraud over $60,000, felonies that carry up to 12 years behind bars on each count.

 
Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  Info@ReduceYourWorkersComp.com or 860-553-6604.

 
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php
 
WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@WorkersCompKit.com.
Posted in Employment Law Issues, Fraud and Abuse |


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