I have an employee who is going to be having surgery for a w/c injury. She is going to be out of work for 6 weeks. If I'm reading the code correctly in AR there is a 7 day wait for compensation to kick in. As long as the disability extends for a period of 2 weeks, compensation back pays from the 1st day of disability.

Based on these codes I'm not planning to pay wages from the day of surgery (tomorrow) until she is released to come back to work. Since disability only pays 66 2/3% the employee wants to take sick/vacation pay for part of this time. I don't think that is possible since it would in essence double pay her.

Is this correct? Our w/c claims processor doesn't respond to our messages. Unfortunately we have been pretty much kept in the dark as to what is going on. We were notified this morning about the 6 weeks off. We had previously been informed it would be 5 days off so we didn't research the loss of wage issue.

Thanks!!

Why isn't your worker's compensation carrier going to be paying indemnity payments while this employee is off work? That's what you pay them for.

Unless I'm missing the boat here, any disability benefits your company offers are for non-occupational illnesses and injuries. The WC carrier should be picking up lost wages when it's a WC claim.

If your WC carrier isn't returning your calls and keeping you informed of the status of the WC claim, then you should contact your business insurance agent and the manager of the WC claims office and insist that they do so. You are the customer and you are paying them a premium each month - you are entitled to the service for which you're paying.

I also suggest you keep in touch directly with the injured employee and that you let him/her know they need to be contacting you (the employer) regularly about their status, when they might be able to return to work, whether the doctor has given them any work restrictions and so on. Even if your WC carrier walked on water, you still need to be talking directly to your employee about those things.

Thanks Beth,

To answer one of your statements - we have been kept out of the loop by both the employee & the w/c rep. The entire surgery is all the sudden being rushed through. This happened in May and the employee has been at work the entire time. We have informed w/c that the claimant had a prior injury and surgery (non work related) on the same area but no one is listening to us. I've called our local agent to discuss the situation and our concerns with them. But our local rep didn't get any better response than we did.

We have repeatedly asked both verbally & in writing for information from the employee. Things like how long she is going to be out, restrictions when coming back, things we need to adjust or have ready for her when she comes back. We just keep getting told "it's being handled between the Drs office & work comp" or that we are asking them to violate HIPAA Laws for even asking for an update.

We are a small non-profit business that has not handled a claim that has gone to this extreme before so we're kind of out in unchartered waters. We thought we would get help through our insurance agent but haven't had any success. We were beginning to think we were crazy for thinking they should be available to help us since that's what we're paying them for. Thanks for at least giving us some validation to that opinion.

We have informed w/c that the claimant had a prior injury and surgery (non work related) on the same area but no one is listening to us.
If the employee's job aggravated a pre-exisiting condition, then you may well be on the hook for the claim. The claim most certainly should have been heavily investigated by the WC carrier though.

I've called our local agent to discuss the situation and our concerns with them. But our local rep didn't get any better response than we did. You and he need to continue to make a stink with the WC carrier. Their not responding to your calls simply is not acceptable. Continue to contact the WC carrier and start going "up the food chain" up to and including the President of the company if that's what it takes.

We have repeatedly asked both verbally & in writing for information from the employee. Things like how long she is going to be out, restrictions when coming back, things we need to adjust or have ready for her when she comes back. We just keep getting told "it's being handled between the Drs office & work comp" or that we are asking them to violate HIPAA Laws for even asking for an update. Your employee is playing you. (a) WC situations are expressly excluded from HIPAA, and (b) you still have every right to require that an employee advice you of their medical status, leave status, and so even if it this weren't WC. If you don't mind some advise, you need to quit letting this employee off the hook. You need to let her know in no uncertain terms that she is REQUIRED to contact you on a regular basis to advise you of her status. Send her a letter as well, stating her obligations to the employer, and then hold her to it.

We were beginning to think we were crazy for thinking they should be available to help us since that's what we're paying them for. Nope, you're sure not crazy. Call the Manager of the claims office and make a complaint. If that doesn't result in a marked improvement, then call the the Regional Manager and so on.

Your WC carrier ignoring your calls, not aggressively investigating this claim, and not informing you of how the claim is being managed at their end simply is not acceptible.

By the way, at the employer's end HIPAA only applies to medical information obtained on an employee through your group health plan. HIPAA absolutely does not prevent you from asking an employee the nature of their illness, what kind of surgery they're having, now long they're going to be off, when they will be returning to work, what restrictions they have and so on.


Good luck.

Hi everybody I'm still trying to deal with this employee and her claim. The w/c agency is finally doing an investigation into this claim. Since they didn't start it until after her surgery I'm not really sure what they are going to accomplish. We finally did get the supervisor's name and sent a letter detailing all of our issues and letting them know come renewal time we would be seeking coverage elsewhere.

Now my current problem is...we have now been told (by the employee over the phone) that her return to work date would have to be pushed back at least another 3 weeks, 9/14/05 (claims to be holding a note from doctor). She informed us of this on 8/4/05 even though the original note (the only thing we have) from the doctor had a return date of 8/26/05. We asked her the reasons why it needed to be extended when it's still 3 weeks until the original date. She informed us that the doctor informed her she wasn't healing as well as he thought she would. In this same conversation she also said it could be as late as October before she will be able to return. Now her job is as a women's advocate. Her duties are basically answering the 24 hr crisis line & making notations in the computer regarding these calls, maybe 3 calls a night if it's really busy. Her shift is 11 PM to 7 AM M-F.

We only have a staff of 9 full time, 1 part time and 2 substitutes (who have full time other jobs). We can't keep covering this shift indefinitely. Can we terminate her and fill her position if she has to be out longer than the 6 weeks? Any help you can give would be greatly appreciated.

Thank you Beth for your prior advice it helped tremendously :)

You need to talk to a local WC attorney before deciding whether you can lawfully pull the plug on this employee.

It sounds as though you're taking an awfully passive stance in dealing with this employee and her WC claim. (a) You can insist that the employee give you a copy of this doctor's note she claims to have. (b) This is a worker's comp claim. That means the customary medical privacy/patient-doctor confidentiality laws do not apply. Call her doctor up, discuss this employee's status with him, inform the doctor what her job duties are and ask whether he will release the employee to return to work.

When you have a WC claim, the employer needs to be actively involved in managing that claim and if circumstances dictate, talking to the employee's doctor. I once had an employee already working the lightest job in the plant who claimed to have a back strain whose doctor put her off work. That just didn't make a whole lot of sense to me so I called the doctor up. Here's how the conversation went:

Me: "Doctor, why have you decided Mary is completely restricted from working right now?"
Doc: "Because her job is so physically demanding."
Me: "Um, what did she tell you she did?"
Doc: "She said she had to lift 100 pounds."
Me: "That's true - but she lifts items weighing 1 pound approximately 100 times a day."
Doc: Long pause. "I'll be releasing her for work immediately."
Me: "Thanks, Doc."

Most employees with a work related injury aren't trying to work the system but if you get a whif of someone who is, you need to get involved immediately, including talking directly to the employee's doctor.

Beth is correct that HIPAA does not apply. http://www.dol.ks.gov/wc/html/wchipaa_ALL.html

I also agree that it sounds like the employee might be "gaming" you.

Given your overall unfamiliarity with this entire process, it might be a good idea to spend a couple K sending one of your employees for training on how to deal with worker's comp claims.

I will be very happy to assist you please contact me via private e-mail at LMay4111@aol.com or you can call me at 217/390-4299 Linda ie LMay