Posted: May 25th, 2022

Personal injury caused by accident on the job

Case Studies:

Janet works as a branch manager for a large banking firm. Her job requires her to travel by personal vehicle to different branch offices several times each week. Janet has lower back problems from a result of a skiing accident many years ago, which is further aggravated by long periods of sitting while driving. Janet was returning from the branch office to the home office on Thursday afternoon when another driver struck her car from behind. A physician examined Janet and determined that the accident aggravated her pre-existing back injury. The physician ordered Janet to remain off work for at least two weeks.

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Is this injury covered under workers’ compensation? Yes

Rationale for your decision: Personal injury caused by accident on the job

If covered, identify the appropriate injury category: Injury with temporary disability

Frank works as a clerk in a local convenience store with a non-smoking policy. On a personal work break, Frank stepped outside the building to smoke a cigarette. As Frank walked across the parking lot, he slipped on a patch of ice and fell, breaking his wrist and injuring his outstretched hand.

Is this injury covered under workers’ compensation? No

Rationale for your decision: Did not arise out of employment

If covered, identify the appropriate injury category: N/a

Tom is an electrician who works for Eagle Electrical Company as an independent contractor. Last Tuesday, the company dispatched Tom to a local business office to investigate a wiring problem. While checking the circuit box, Tom sustained severe burns to his hands and upper torso when a faulty switch caused an electrical arcing event. Tom’s medical bills totaled over $750,000.

Is this injury covered under workers’ compensation? No

Rationale for your decision: Independent contractors are not covered (additionally, failed to use safety equipment/take precautions)

If covered, identify the appropriate injury category: N/a

Rich works for Home Solutions Experts as a carpet installer. The company actively promotes workplace safety and provides ergonomic equipment to all employees. Rich has had ongoing pain in his knees, and it is progressively worsening. After an examination, his physician determined he was suffering from bursitis, commonly known as “carpet layer’s knee.” This required an arthroscopic knee aspiration, a minimum of three weeks off work, and physical therapy.

Is this injury covered under workers’ compensation? Yes

Rationale for your decision: Unexpected result over time (repetive stress) that occurred during the normal course of employment

If covered, identify the appropriate injury category: Injury requiring vocational rehabilitation

Bonnie works as a transportation security officer for the Office of Homeland Security. During the course of a routine airport baggage screening, a passenger became agitated and shoved Bonnie, causing her to stumble backwards over a pile of luggage. As a direct result, Bonnie experienced severe back pain, which her physician diagnosed as a strained muscle. He ordered her to remain off work for at least one week and on light duty for three weeks after.

Is this injury covered under workers’ compensation? Yes

Rationale for your decision: Occured during course of employment

If covered, identify the appropriate injury category: Injury with temporary disability

The Claims Process

When a worker suffers an injury while on the job, the first step they must take in filing a worker’s compensation claim is informing their employer of the injury. In most states, this must occur in writing, which also helps protect the interests of both the employee and the employer. Each state also specifies the time period within which this notification must occur, again protecting both parties. After the employer receives written notification from an employee regarding an injury, the employer must then notify their insurance carrier and the state’s worker’s compensation office. After all of the notifications are accomplished, the employee is required to see a physician selected by the employer or the insurance carrier, or sometimes by the managed healthcare provider to which the employer subscribes. Refusal to cooperate with the physician selection on the part of the employee could result in a termination, cancellation or simple refusal of benefits.

This physician, the first to treat the patient regarding the work related injury for which the claim is filed, is known as the physician of record. The physician of record has certain duties and obligations to both the patient and the other parties concerned with the worker’s compensation claim. Their primary concern is, of course, the treatment of the condition that caused the claim, and the general health of their patient. As part of this treatment, the physician of record has the responsibility to determine the extent of the disability, as well as the date on which the employee can safely return to work. Their report can also allow for further treatments, such as physical therapy. In addition to treating the patent, the physician must keep the insurance carrier apprised of any significant changes in the patient’s condition, especially those that might affect the employee’s ability to work or otherwise alter the status of the claim.

This leads to one of the controversies surrounding worker’s compensation: the right to medical privacy. The federal HIPAA Privacy Rule and almost all state medical privacy laws allow or even require that a patient’s worker’s compensation files containing their protected health information be made entirely available to review by the insurance carrier claims adjusters and the employers. Normally, such information cannot be distributed to anyone without express written consent of the patient, and indeed most laws make it clear that other pre-existing conditions with which the patient is diagnosed or for which they are treated cannot be disclosed to employers or insurance carriers. The implications for this exception to the medical privacy rule reflect a general distrust not only of the worker filing a claim based on a workplace injury, but even a certain mistrust of the physician of record. The only purpose behind the insurance review of medical documents in this case would be to make sure that no fraudulent claims are being made, which could only occur if the physician was involved in some level of conspiracy with the patient. The fact that it is the government that is at financial risk of fraud in worker’s compensation instances might have something to do with the way the law allows for full disclosure of protected health information in these instances, but does not allow it in other insurance claims.

The employer’s responsibilities during the claims process are to file the proper notifications within the time frame provided for by state law, though sometimes it is the physician who files this “first report of injury.” This time span can be anywhere from twenty-four hours to ten days after receiving written notification from an employee claiming a workplace injury. After receiving this first report of injury, the insurance carrier must then determine whether or not the injury is covered by worker’s compensation rules. If it is, then the insurance carrier notifies the employer with an Admission of Liability. Any wage compensations due to the patient are mailed by the insurance directly to the worker. In addition, all medical bills are submitted directly to and paid by the insurance carrier. if, however, the insurance carrier finds that the injury does not fall under the events covered by worker’s compensation, they will file a Notice of Contest, and the employee becomes responsible for their medical bills. If a claim is denied or terminated, the worker may appeal, first through mediation, then through successive levels of the state’s courts, eventually going so far as reaching the state’s supreme court or the worker’s compensation board, depending on the state. If at any point it is determined that the claim was justified, the employee will receive compensation for any medical bills already paid in addition to back wages they are entitled to.

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