1. I CAN! A Step Above Insurance Career Advancement Now Workers’ Compensation The Other No Fault Insurance

2. INTRODUCTION

3. Workers’ Compensation Insurance  1913 Wisconsin enacted the first Workers’ Compensation Law.  Prior to that injured workers went without treatment and families without income.  Employees had to sue and prove the employer was negligent.

4. Workers’ Compensation Insurance  Workers’ Compensation was enacted for the public good.  Employees received wages and medical care regardless of fault.  Employers were shielded from law suits and possible uncapped civil verdicts if found negligent.

5. Workers’ Compensation Insurance  Workers’ compensation policies by language incorporate the laws of the states covered to provide the benefits required.

6. Workers’ Compensation Insurance Four monopolistic states  North Dakota  Ohio  Washington  Wyoming Federal Workers Compensation Coverage  Longshore and Harbor Workers Compensation Act  Defense Base Act  Non Appropriated Fund Instrumentality Act  Outer Continental Shelf Land Acts

7. Workers’ Compensation Insurance If an employer doesn’t purchase insurance they:  Lose protection from civil suits  Can receive penalties and fines from the state  Have to pay for benefits from their own pocket

8. Part II – Employer’s Liability Coverage Employer’s Liability provides coverage for bodily injury arising out of the course and scope of employment for:  Action Over Suits  Consequential Injuries to the Employee’s Immediate Family  Injuries arising out of their employment for you in a capacity other than as the employer

9. Workers’ Compensation Income Premiums are based on a formula Job Classification x $ XE-mod=premium

10. Workers’ Compensation Insurance Employee: Anyone who enters into a contract to perform work or services for another in exchange for valuable consideration/ compensation

11. Workers’ Compensation Insurance Independent Contractor vs. Employee  The key element is the right to control the work performed – how it is done not just the result.

12. Workers’ Compensation Insurance  Coverage for owner, officer, partner or sole proprietor  Is there automatic coverage under the law or must they opt in by endorsement to be covered?

13. Workers’ Compensation Insurance  Traveling Employees and Dual Jurisdiction

14. Workers’ Compensation Insurance When is traveling or the commute in the course and scope of employment?  All employees unless they telecommute travel to their job each day.  Injuries in the daily commute are excluded under the Coming and Going Rule unless the facts meet an exception to the rule.

15. Workers’ Compensation Insurance Exceptions to Coming and Going Rule  Special Errand  Use of their personal vehicle is required for their job duties.

16. Workers’ Compensation Insurance The true traveling employee  Their job doesn’t require them to report to an office or set location  They may go from home to their appointments or a job site  They may travel out of town, state or country on business  They are covered portal to portal

17. Workers’ Compensation Insurance Jurisdiction is governed by:  State of hire – where contract of employment is made  Location of injury  State of employee residence  State of employer incorporation and business  State where payroll is issued and taxes withheld  For injuries outside of the United States there must be an endorsement extending coverage

18. Workers’ Compensation Insurance An employee reports an injury, you  Listen, obtain detailed information and ask clarifying questions  Provide medical care – direct if the state allows you to do so to your designated doctor  Do on scene investigation:  Take pictures  Secure evidence  Obtain statements form the witnesses  Report it to your agent and/or carrier right away.

19. Workers’ Compensation Insurance An employee sustains a serious injury:  Call 911  Obtain what facts you can quickly from the scene and witnesses  Secure the evidence and equipment  Take photos  Report it to your carrier and/or agent right away  Include the details you have  Include where the employee was transported

20. Workers’ Compensation Insurance Nature of Injuries  Sudden and traumatic  Cumulative  Aggravation Exacerbation  Industrial disease  Psychological o Mental/mental o Physical/mental o Mental/ physical  Hearing loss  Hernias

21. Workers’ Compensation Insurance  AOE / COE  To be compensable it must be in the course and scope of employment  Course of Employment: The employee is where they are supposed to be when they’re supposed to be there for their job.  What constitutes the employer’s premises?

22. Workers’ Compensation Insurance  AOE / COE  To be compensable it must arise out of the employment  Arising out of their employment- caused by work  Did the job activities lead to the employee’s resulting injuries or diagnosed condition?  Was work the sole cause or significant contributing factor?  Was the employee at greater risk of injury in his vocational life than non-vocational life?

23. Workers’ Compensation Insurance  Both AOE (Arising out of) and COE (Course and scope of employment) must be met to be compensable.

24. Workers’ Compensation Insurance An injury will be covered under your policy if:  It happens in a covered state  It happens in the coverage period  The injured worker is a covered class of employee  The injury is compensable under the state WC laws

25. Workers’ Compensation Insurance  Workers’ Compensation benefits are NOT determined by the policy language.  The policy language incorporates that the benefits that are payable under the policy are based upon the Workers’ Compensation laws of the state.

26. Workers’ Compensation Insurance Standard benefits in all states  Indemnity – lost or reduced wages  Medical – medical care to cure or relieve the effects of the injury.  Doctors  Hospitals  Prescriptions and Durable Medical Equipment  Physical Therapy

27. Workers’ Compensation Insurance Benefits – Medical can vary by state as to:  Nature of medical care covered. Is it homeopathic or faith healing covered?  Duration of treatment covered. Is there a limit of weeks or sessions covered?  Is it a mandatory Utilization Review state?

28. Workers’ Compensation Insurance Additional Indemnity Benefits allowed in some states  PPD or PPI as set by the AMA guides or statutory schedules  Future loss of earnings: Settlements  Permanently: Totally disabled form all work

29. Workers’ Compensation Insurance Vocational rehabilitation  Not mandatory in all states  Covers expenses related to finding a new job  Covers cost of retraining to help find a new job

30. Workers’ Compensation Insurance What if an employee can’t return to work?  Increased costs of the claim due to:  continuing benefits  employee is found 100% disabled or PTD  cost of vocational rehabilitation  higher settlement value

31. Workers’ Compensation Insurance Covered Expenses Under Your Policy  Legal defense and discovery costs  Private investigator and surveillance  Independent adjuster/ investigator for on scene  Experts for subrogation or disability issues  Independent Medical Examinations (IME)  Medical record/ record copy fees  Medical bill review/PPO fees

32. Workers’ Compensation Insurance  If you question the injury, tell your carrier you question it and why.

33. Workers’ Compensation Insurance Investigative tools used in Workers’ Compensation  Recorded statement of the employee  Obtain specific information regarding what happened  Obtain information regarding prior injuries  Obtain information on health and prior treating doctors  Obtain specifics on injuries, symptoms  Obtain names of witnesses  Verify no discrepancies in the history  Recorded statement of witnesses

34. Workers’ Compensation Insurance Investigative tools used in Workers’ Compensation  Obtain medical from the treating providers  Obtain medical records from prior injuries  Obtain workers compensation records for prior injuries  Secure a medical opinion on causation from treating or IME doctor

35. Workers’ Compensation Insurance Investigative tools used in Workers’ Compensation  Do ISO/ NICB search  If pattern or red flags are found involve SIU  Internet search  Social media  Sports league websites  Criminal and civil legal activities including bankruptcies  News and media websites for coverage of the accident/incident

36. Workers’ Compensation Insurance Investigative tools used in Workers’ Compensation  Scene Investigation  Examine and photograph area to confirm history  Obtain video surveillance or security footage of area at time of injury  Secure evidence and items involved in injury

37. Workers’ Compensation Insurance Investigative tools used in Workers’ Compensation  Obtain police, fire department or EMS report  Talk to investigating officer  Talk to accident reconstructionist

38. Workers’ Compensation Insurance Investigative tools used in Workers’ Compensation If disability is questioned or if you believe the employee is working  Obtain an activity check  Obtain surveillance

39. Workers’ Compensation Insurance Subrogation – Injury due to a 3 rd party’s negligence  Workers’ compensation is the exclusive remedy  Carrier/ employer is subrogated to the rights against the 3 rd party of the injured worker  Secure and protect the evidence from destruction or alteration  Put the 3 rd party and the injured worker on notice of your subrogation lien  Can obtain reimbursement of benefits provided in full or a percentage  Can obtain credit against future benefits owed

40. Workers’ Compensation Insurance What can you do to reduce the cost of workers’ compensation?  Document a detailed history of what happened form the injured worker  Do an on scene investigation  Get witness information  Send to your designated doctor  Report the claim right away to your carrier  Cooperate with the insured investigation  Have a light duty / RTW program  Communicate what to do in the event of an injury  Investigate every accident or near accident

41. Workers’ Compensation Insurance In Closing

42. Workers’ Compensation Insurance Questions ?