“There was an uptick in the number of mega workers’ comp claims in Accident Year (AY) 2016,” according to NCCI. “Ten claims of at least $10M have been observed for AY 2016 evaluated at 24 months. This is more than for any of the previous 15 AYs at a comparable maturity.”

The organization’s latest research brief drills down further and outlines additional revelations:

• These multimillion-dollar mega workers’ comp claims are frequently the result of motor vehicle accidents or falls from elevated levels.
• It is the Contracting industry group that has by far the greatest share of mega claims
• The carpentry classification has had more mega claims than any other class over the past 15 years.
• The trucking classification — representing short-haul and long-haul — ranks 2nd in both mega claims and all lost-time claims.
• Central nervous system injuries (neck/spine or head/brain) and injuries to multiple body parts account for nearly 95 percent of mega claims. For lost-time claims, these categories make up only 16 percent of the claim total.
• Hospital inpatient and home health care account for more than half of the mega claim medical costs. This is in stark contrast to all lost-time claims where physician expenses and hospital outpatient represent most of the medical costs.
• Approximately two out of three mega claimants spend at least three months as a hospital inpatient, and approximately one in five are in the hospital for more than a year.

Armed with this knowledge, workers’ compensation stakeholders should focus their efforts on preventing these injuries — especially in the industries affected most.

Auto Accidents

Even though strains and slips/trips are the leading causes of loss for all lost-time claims, motor vehicle accidents accounted for more than 30 percent of $10 million+ claims. These are also the #1 cause of work-related deaths, accounting for more than 40,000 fatalities in 2016. The 14 percent increase from 2014 represents the largest jump in more than 50 years.

The federal government says fatalities from distracted driving grew nearly 9 percent in 2015, outpacing the overall increase in traffic accidents.

The three types of distractions for drivers are:

• Visual — eyes on the road.
• Manual — hands on the wheel.
• Cognitive/mental — mind on driving.

Cell phones, one of the main causes of motor crashes lately, involve all three forms of distraction. One big problem is that drivers talking on cell phones may not realize they are mentally distracted. Also, this type of distraction usually lasts much longer than either visual or manual distractions.

Despite common thinking, hands-free talking on cell phone while driving does not reduce the risk — due to the mental distraction. The argument that it is similar to talking with passengers flies in the face of research. Actually, adult passengers share awareness of the driving environment and having them in the vehicle lowers the crash risk.

Unfortunately, educating employees will not lead to voluntary compliance. Employers need to implement and enforce specific policies about driving. These should state that employees who are driving:

1. Are not allowed to use electronic devices, either handheld or hands-free.
2. May not answer calls. Incoming calls must be directed to voicemail.
3. Are prohibited from reading or responding to text messages and emails.
4. May make an emergency 911 call can only after parking the vehicle in a safe location first.

The driving policy should include:

• Clear language.
• Documented training and communication.
• A requirement for all employees to sign the policy.
• Disciplinary action for violating the policy. This could consist of warning for the first two violations and termination for the third incident.

The effort to encourage safe driving should involve senior leadership, as well as managers throughout the organization. A person high up in the organization can send a letter to employees explaining that the policy is going into effect for any employee using a motor vehicle associated with company business and/or electronic devices owned or used for company business.

Falls

While half the fatal falls in 2014 occurred from a height of about 20 feet, 12 percent of them were from less than 6 feet high. Construction workers are at most risk, although falls can happen to anyone, anywhere.

Falls are 100 percent preventable. OSHA has a three-fold plan to avoid falls:

• PLAN ahead to get the job done safely
• PROVIDE the right equipment
• TRAIN everyone to use the equipment safely

Whether work is being done from a ladder, scaffolding or on a roof, all three of these mandates apply.

5. Employers must look ahead to ensure a job is done safely. That means identifying how the job will be done, the tasks involved, and the safety equipment that will be needed. Safety equipment should be included in a job’s cost estimate.

The area where the work will be conducted should be scanned for potential hazards ahead of time. For example, there should be level ground if ladders are to be used.

6. Workers exposed to potential fall risks must be given the proper tools and equipment to ensure they get the job done safely. Depending on the job, that might include

• Fall protection such as personal fall arrest systems and safety gear that is fitted properly to each worker.
• A ladder or scaffold that is appropriate for the job.
• Slip-resistant shoes
• Harnesses
• Safety nets.
• Stair railings and/or handrails

Holes in which employees could fall should be guarded with a railing and toe-board or flor hole cover.

7. Every employee who works at a site with fall risks must be trained on how to set up the area and proper use of any equipment to be used. All fall-protection equipment to be used should first be inspected.

Summary

Employers and payers are spending millions of dollars and watching their employees suffer for years over claims that are completely avoidable. Implementing and enforcing some simple steps can protect the entire organization.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Members of the claims management team are required to conduct diligent investigations into workers’ compensation matters, investigate the mechanism of injury, and address issues of compensability.  This is a task that requires them to determine if the information they receive fits the type of injury claimed.  This includes not only injuries involving a specific incident, but also claims that culminated over a period of time.  Failure to properly accomplish this task can result in protracted management of a claim and added costs to any workers’ compensation program.

The Anatomy of a Work Comp Injury

There are essentially two types of injuries employees sustain in the workplace.  Each type of injury is unique in how they occur and the evidence one examines when deciding matters of primary liability.

• Specific Incident/Sudden Onset: This type of injury is often easy to identify as it encompasses a specific injury that is easy to identify and occurs at a specific moment in time.  These injuries include slip/falls, striking an object, an immediate onset of pain, or a fracture of a bone/joint dislocation.

• Workplace Exposure/Repetitive Trauma: This is often more difficult to identify as to when the “injury” occurs as it primarily happens over a period of time.  Common examples include the inhalation of dust, irritants or other substances that result in an injury/respiratory condition.  In other instances, problems occur over a period of time that results in the degeneration of joints and discs.  Questions as to the “date of injury” are often subject to contentious litigation as each jurisdiction defines when these injuries culminate.  Examples include when the employee started missing time from work, when the employee first received medical treatment, or when the employee reasonably believes they have sustained a work injury.

Regardless of the type of injury, a complete investigation is required.  Only deny claims in good faith.

Investigating the Mechanism of Injury

It is important for members of the claims management team to investigate and determine if the mechanism of injury (how it occurred) matches the claimed injury.  It is also essential to analyze where the work activity is attributed to the work injury, or if the work condition was aggregated and/or accelerated due to work activity.  Additional issues to consider include:

• Did an injury occur as a result of the work activities?

• Was the employee performing work activity consistent with the claimed injury?

• If there was, in fact, a work injury, what body parts are actually involved? Defining an injury by ICD-10 codes may also be important given the reporting requirements for Medicare and Medicaid coordination of benefit

• How long did the employee engage in the work activity for it to result in a work injury? Was it a substantial contributing factor in the disability and/or need for medical care and treatment/disability?

• If not a specific incident-type injury, when did the injury culminate?

Questions regarding these issues may involve a medical director, nurse case manager, or someone with an advanced understanding of medicine.

Making Informed Decisions Regarding Primary Liability

It may be difficult for a member of the claims management team to make a legally defensible position when it comes to primary liability.  This can be due to a number of factors beyond their control.  If that is the case, utilize the service of a peer review physician or medical advisor to obtain further insight on an action plan for the claim.

Conclusion

Members of the claims management team are charged with a variety of tasks.  Chief among them includes collecting applicable evidence and making reasoned decisions based upon the facts of the case and the law.  This also involves seeking information on the mechanism of injury and determining if the claimed injury fits.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

One of the most important and often difficult roles of a claim handler is to issue a workers’ comp claim denial.  It is important that the claim handler conduct a diligent claims investigation and issue denials that are supported by the facts of the claim and the law.  Failure to do so is not only unethical but contrary to the letter and spirt of the law.

Back to the Basics – “Arising Out Of” and “In the Course and Scope”

Issuing a workers’ comp claim denial requires understanding a basic premise of all workers’ compensation laws – both “arise out of” and “in the course and scope of” the employee’s employment.  This is a legal standard that is complex to understand and depends on the facts of each case.  When analyzing these threshold standards, it is important to understand the following:

• Arising Out Of: This generally refers to a factual determination of whether the injury occurred within the parameters of one’s direct work  In other words, there must be evidence of a causal connection between the injury and the employment.  Courts often struggle with issues concerning whether there was an “increased risk” presented by the work environment that is tied to the injury.  Factors that are subject to litigation and interpretation include slips/falls on various surfaces (flat hallways, stairwells, ice on sidewalks, etc.), assaults/actions by third persons and idiopathic injuries; and

• Course Of: Determinations regarding this element are more clearly defined, but also create concern and litigation.  Generally, this question involves one of the time, place, and circumstances under which the accident/injury occurs.  Notwithstanding its appearance, questions of compensability also include litigation when it concerns the hours of employment (breaks, meals and errands), ingress/egress issues and traveling employees.

When considering these issues, it is important for the investigation to involve questions as to specific activities involved and whom else may have been involved in the injury.

Pre-existing Conditions and Questions of Compensability

The presence of a pre-existing condition does not necessarily preclude the compensability of a work-related injury.  Given the rather liberal standard of what constitutes a “personal injury,” the better question that needs to be asked is whether the work injury or activity “aggravated or accelerated the underlying condition.”  If this is the case, more often than not the claim will ultimately be found to be compensable.

When investigating these matters, obtaining the proper medical evidence is key to any investigation.  Areas of concern should include the following:

• Chiropractic care and treatment;

• The existence of prior imaging, including MRIs, CT scans and EMGs; and

• History of athletic or MVA related accidents/injuries.

Notice and Statute of Limitation Defenses

Most workers’ compensation statutes require an employee report their injury promptly.  There are also limits as to when an employee can obtain a report from their work injury.  This is where it is important to understand how notice and statute of limitation provisions can prevent recovery and serve as a valid legal defense to a claim.

• Notice Defense: An injured worker is under the legal obligation to report their work-related injury in a timely manner.  The rationale behind this concept is this allows the defense interests a reasonable amount of time to investigate a claim and prevent the spoliation of evidence.  Notice defenses are often not successful given the fact “constructive notice” is often imputed on the employer.  It also comes down to a question of credibility of the employee.  Notwithstanding these limitations, it is something to consider when defending a claim.

• Statute of Limitation Defense: Once a workers’ compensation injury is reported, there is a time limit place on the employee for them to make a claim for  In many instances, the statute of limitation defense is limited to a period of six years.  What this means is if the employee reports and injury, but does not incur wage loss or medical benefits within the prescribed time period, they are forever barred from seeking benefits related to the matter.  This defense is used to deny claims made on trivial injuries and provides certainty.

Conclusions

Members of the claims management teams are on the front lines when it comes to claims investigations and determinations of primary liability.  Issuing a proper workers’ comp claim denial includes determining if the incident falls within the parameters of the workers’ compensation act and other issues of liability.  This requires a claims handler understands the law and is able to investigate a claim to make good faith determinations regarding compensability.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

It is a horrible tragedy when an employee is killed at work.  While we hope this never happens, over 6,000 people are killed every year in workplace accidents.  This averages out to about 14 workplace death claims per day and nearly 100 per week.

The impact of an employee death is heart wrenching and impactful for an organization.  It is essential for members of the claims management team to understand how to effectively deal with workplace deaths.

Conducting an Effective Death Claim Investigation

It is important to conduct an effective and prompt investigation once someone is killed due to a workplace incident.  In addition to the steps normally taken, it is important to obtain the following information:

• Reports regarding the incident. This includes police and ambulance reports.  Other important documents include OSHA generated forms and safety logs, along with information concerning any tools or equipment involved.  Make sure no evidence is destroyed.

• Determine whom may be entitled to benefits. This includes the marital status of the deceased employee, information concerning their dependents and the location of where these people were living.  Questions often arise when the employee and their spouse are separated or are in the process of getting a divorce.  Domestic partnership status is also important to know and understand.

• Validate important documents concerning family relationships. This is important in cases where marriage or parentage is not clear-cut.

Most workers’ compensation laws require a workplace death is reported to the state industrial commission within 24 to 48 hours of the incident.  Ensure the proper report is made in a timely manner.

Dealing With Other Special Issues

Determining issues of a spousal relationship or parentage can become complex issues.  This is the result of the chaining definition of what constitutes a family, dependents and the legalization of same-sex marriages.  When investigating these issues, members of the claims management teams should closely scrutinize the following issues:

• Establishment of residence: In many jurisdictions, marriage to another person does not automatically qualify the spouse for dependency benefits.  If the couple is separated (even not in a legal sense), the survivor may be excluded from additional compensation;

• Recognition of marriage: This issue can arise in several different instances.  The most common is couples who were married under “common law” in a jurisdiction that recognizes such practices but later moves to a location that does not recognize that form of marriage.

• Parentage: The increased use of genetic testing has helped resolve some of these issues over the years.  However, questions may still remain if there was not legal recognition of the relationship prior to death.  Legal battles may ensue of the deceased employee is cremated prior to testing being performed.

Most Important: Demonstrate Care in Difficult Situation

Demonstrating care and empathy is critically important in the face of a tragic death claim. Steps to prepare your organization include:

• Create a dedicated team to handle all workplace death claims. This will allow for others on the team to better allocate their time on other cumbersome files and allow for a more effective response.

• Educate employers and other interested parties on workplace safety issues. This is especially true when working with employers who fall into high-risk categories.  This includes construction jobs that involve employees working at heights, the operation of dangerous equipment and machinery and those who work in the lumber and logging industries.

• Go beyond what is required by the law. This can include random acts of kindness such as sending flowers to the next-of-kin.  Members of the claims management team should also avoid blaming the deceased employee – it was someone’s son or daughter who died.

• Promote efforts that go beyond safety training. Encourage interested stakeholders to look beyond the incident and understand the events leading up to the fatal incident.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Conclusions

A workplace death is an event all employers hope they never experience.  However, it is important for members of the claims management team to be properly prepared.