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WC covering employee illness not related to an onthe-job injury??? New Jersey

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  • #16
    Yea right, that's a different story.
    Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around. Leo Buscaglia

    Live in peace with animals. Animals bring love to our hearts and warmth to our souls.

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    • #17
      . I don't want all the staff to get the idea to report every illness at work via the WC reporting system.
      In most states, the law requires the EE to file a claim if the injury requires more than minor first aid. Unless you are a legally self insured ER, and with a HR dept or TPA specific to WC claims, you would have no input to the validity of a claim. That's why you have a WC carrier, to investigate, and mitigate your financial exposure.

      In some, a provider is precluded from even billing an EE who presents and claims industrial causation to the injury/illness. (yup, ''illness'', even cold or flu in some cases). A provider must bill an ER or IC if known, for any services provided. And, file the necessary claim form if the injury is suspected as industrial.

      Also in most states, the ER/IC has a specific timeframe for investigating a claim. In Calif ie, it's 90 days. The IW is entitled to reasonable medical care, that meets the ACOEM/MTUS adopted treatment guides, up to 10K during that first 90 days.
      Not all states provide for a "swift" dispute resolution process. It can take months sometimes for a disputed medical issue to reach a moderator/judge.

      There may be, and certainly are at times those claims that appear frivilous. As long as the injury/illness meets the AOE/COE standard...the claim is generally compensable.
      ...all of our employees, even office staff who don't do direct care,...
      They could get the idea in their head to make their cold or flu a WC issue, and take time off on WC rather than using their sick time.
      The "direct care" reference here indicates a 'hands on'' approach to another 'human being' or patient in a health care facility (?) A cold/flu could very well be an industrial injury/illness.
      EE's who claim for comp benefits are subject to a waiting period, from 3 to 7 days. Are you paying sick time from the first day of time loss ? Most ER's require a Dr release if an EE is out more than 3 days, even for cold/flu.
      Because if she had reason to believe that she had contracted it (STD) at work, then both she and her partner had been engaging in activity while on work time that could get both of them fired.
      Was this 'business/profession', somewhere in the desert outside Las Vegas ? Could be a "compensable injury/illness" (just kidding cbg... )

      IW's across the country suffer harrassment and discrimination from ER's and co-workers every day due to injury/illness that is not always apparent on the surface.
      I could be catastrophizing, I guess, but in my risk mgmt role, I'm supposed to.
      Watch those desk/file drawers...you could well find yourself on the opposite end of this equation.
      hopefully it won't happen......

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      • #18
        [QUOTE=CAIW;1156824]
        The "direct care" reference here indicates a 'hands on'' approach to another 'human being' or patient in a health care facility (?) A cold/flu could very well be an industrial injury/illness.
        [QUOTE]

        In our sites, "direct care" refers to staff who provide residential counseling services to our residents. They don't do "hands on" medical care. They are teaching residents to cook, clean, make doctor appointments, manage their meds, budget their money, find support groups in the community, learn anxiety mgmt techniques, learn to more effectively cope with hearing voices,etc. We are under the umbrella of "healthcare" but it's behavioral health.
        So if a direct care employee catches a cold from a resident, it "could very well be" a WC issue?
        How do you prove they caught the cold/flu at work and not at home or elsewhere?
        Sounds like a huge slippery slope we don't want to go down or even go near.

        So they are out sick for a cold or flu, and instead of it costing the company by it coming out of sick time, and our health coverage (we're self-insured for health coverage), it will come out of our WC costs, and make those costs soar?

        Incidentally, the people who have been vocal about their colds & flus being the company's responsibility are people here at the corporate office, where they rarely if ever even see a client/resident.
        Last edited by TSCompliance; 02-16-2011, 07:24 AM. Reason: darn, that quote thing didn't work

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        • #19
          So if a direct care employee catches a cold from a resident, it "could very well be" a WC issue?
          How do you prove they caught the cold/flu at work and not at home or elsewhere?
          Sounds like a huge slippery slope we don't want to go down or even go near.
          A cold/flu probably wouldn't be a industrial injury in itself. But regardless, it would not be the ER option to file a claim, or make the decision to compensability of the claim.

          Everything in WC is based on medical evidence, as provided by the treating physician.
          AOE/COE, Arising Out of Employment....the fact the person/EE is there, on the premises is often sufficient to show AOE,
          COE/in the Course Of Employment... performing the job functions, or other activities as assigned.
          And, as WC is a no fault system, the IW does not have to prove they are injured/ill, that is assumed. Nor do you have to prove there is no fault on the part of the ER.
          Based on the IW information, and Dr opinion, the claim is compensable until/or if you wish to dispute, you go through the dispute resolution process as defined in your state WC statutes. Could require a hearing in comp court. Judges/comp courts are prone to find for the IW more often than not. (there's a word for that... I just can't bring it to mind right now...lol)
          Incidentally, the people who have been vocal about their colds & flus being the company's responsibility are people here at the corporate office, where they rarely if ever even see a client/resident.
          Doesn't really matter, I was just picking up on different scenario and the work place.

          The biggest issue you would concern yourself here...IMHO, would be....It is illegal in nearly all states for the employer (whether it's the supervisor, owner, co-worker etc.) to make statements intended to dissuade an employee from filing a claim for WC benefits.
          If the EE/IW presents requesting the claim form...you must provide it. It would not be in your best interests to ever say "I don't believe your claim is valid, or this is due to your job".

          I'm curious though, if you are (large enough) self insured for GHP/Group Health Plan benefits, why not for industrial injury/illness ? Depending on your payroll $$$, those WC premiums could approach the cost of GHP.

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          • #20
            Sheeesh, that's a lot to digest. No one has dissuaded employees from calling HR for injuries/illnesses (the way we make WC reports here); I was just considering the worst case scenarios, which as I see now can be much worse than I'd thought. The thing with the colds & flus is a just a bunch of people mouthing-off (for now) but I'm sure they can get ideas...

            We somehow do a good job with self-insuring for medical care (even more impressive because we're non-profit, and the benefits are really good). We apparently also self-insure our Unimployment, which I had no idea could even be done, until recently.

            I'm sure if self-insuring WC were cost-effective, our CFO would be all over it. It might have to do with the rates in NJ, our industry, or I don't know what. But we do pay a lot for the premiums.

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            • #21
              Sheeesh, that's a lot to digest. No one has dissuaded employees from calling HR for injuries/illnesses (the way we make WC reports here); I was just considering the worst case scenarios, which as I see now can be much worse than I'd thought.
              Just as an FYI, in NJ, from what I can acertain... once a WC claim is finally resolved, your statutes do not provide for FMC/Future Medical Care for this EE/IW.
              If there is additional medical treatment needed... the EE may use the GHP/Group Health Plan coverage to treat the industrial injury... don't like that, but that's what NJ provides.

              It's not unusual for people who don't deal with comp claims on a regular basis to be overwhelmed when finally delving into the statutes, what benefits are provided in WC, and maybe more importantly what benefits comp does not provide.

              The WC laws are state specific though, and vary widely.

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