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

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

    I've never heard of this, but if an employee has a "sudden illness" while at work, is this covered by Worker's Comp? I'm going through our loss runs and found an employee who fainted due to an existing medical condition listed (and then had evaluation & testing at the ER), plus an employee who had a heart attack at work.

    Both are okay now, but now I'm wondering why they are in our WC data, making our losses go up? I figured something like this is covered by medical insurance. We provide our employees with very good medical coverage.

    One of my own employees had a misscarriage at work once, and was taken by ambulance to the ER. Nobody ever labeled this a WC issue, and her health insurance covered it. but I think in these other depts, someone decided "it has to be reported to HR." Were they wrong in doing this, or is is common for these things to go under WC?
    Last edited by TSCompliance; 02-14-2011, 11:52 AM.

  • #2
    I would think someone who have had to have reported these two situations in question to the WC carrier; otherwise, how would they have known about them?
    I don't respond to Private Messages unless the moderator specifically refers you to me for that purpose. Thank you.


    • #3
      I realize some employee or supervisor must have reported this to HR, who then recorded it as a WC incident. No one contacts the WC carrier but HR. I'm sure I have very concrete-thinking employees who think "an ambulance came to work to take away my co-worker; therefore I must call that HR number about workplace injuries"

      Since I posted this, I did find out more info.

      The WC rep told me that employers "usually" report employee sudden illnesses to them, and they then deny the case. But reporting it somehow "protects" us, in case that employee later turns around and says the illness (heart attack, etc) was caused by the job. He said that eventually, cases like this get removed from our loss runs, but I don't like that these two are currently sitting there, looking like $45,000 in WC losses.

      I'm not just going to take his word for it; I need to find out more. I know that as long as it remains a "ding" on our record, the carrier can benefit if it factors into our experience mod. They can make more money off of us. So he might be motivated to tell us to report every employee sudden illness at work to them.

      Anyone else have knowledge about this?
      Last edited by TSCompliance; 02-14-2011, 01:26 PM. Reason: typos


      • #4
        What the WC rep told you is the way I have always understood it. If there's even the slightest chance that the employee might claim "work related" you report it and let the w/c carrier be the bad guy and deny it. That protects the employer and does not harm the employee.
        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.


        • #5
          That's what I learned too. So, what is the status of these cases? Has the carrier done anything?
          I don't respond to Private Messages unless the moderator specifically refers you to me for that purpose. Thank you.


          • #6
            They are both still in "open" status with lots of money listed in Reserve." That means our CFO will have to yell at the carrier to make them delete them. Otherwise they keep huge amounts listed in reserve "just in case" and it makes our losses go up.


            • #7
              What cbg and Patty said is exactly the process.
              Any EE suffering "injury/illness" on the job should be reported to your HR dept. Filing the claim with your WC carrier would be SOP....
              Just because the claims are "open" and carrying reserves, doesn't always mean your x-mod will increase.
              There are lots of variables in writing comp/liability coverage. And the reps take into consideration all of those, including your concerns.

              IMO...discuss your concerns with the WC rep, again, and memorialize that conversation in writing, to the rep, and cc the EE files. It takes time for claims to affect your x-mod, not likely in the next quarterly audit of your payroll records, could the one after.


              • #8
                Thanks all, at least I now know that these reports are on there for a reason. The one incident was just last month (the heart attack), so I'll wait on that. But the fainting one was almost 5 months ago now, so I'm asking them to remove it and close it out.

                Sheesh, learn something new every day. Guess next time I get sick from my lunch and puke in the bathroom, I'll have to call the HR reporting line


                • #9
                  Generally our WC carrier says they will cover one exam to determine if it is a WC issue or not. If I dont think it is, I notify them that we have doubts and they check into it.

                  I had an employee go to the Dr because he "hurt his shoulder." It turned out to be a boil..obvioulsy not WC. We are contesting it and we will not be paying for it.
                  Work with your WC carrier so they know when you have doubts. That helps them and you.
                  I find that the harder I work, the more luck I seem to have.
                  Thomas Jefferson


                  • #10
                    Thanks again

                    I'm always worried about the worse-case scenario. I don't want all the staff to get the idea to report every illness at work via the WC reporting system. Many of our staff who catch colds or flu frequently like to loudly blame "sick building syndrome." They have the idea that if co-workers have a cold or the flu, and they catch it, the company is somehow responsible. No matter that our building is 2 years old, and no matter that all of our employees, even office staff who don't do direct care, get training at hire on universal precautions.

                    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.

                    I could be catastrophizing, I guess, but in my risk mgmt role, I'm supposed to.

                    hopefully it won't happen......


                    • #11
                      I once had an employee who contracted an STD and tried to convince me that it was a workers comp issue and that she had gotten it from a toilet seat at work.

                      I provided her with some literature about how that particular STD was REALLY contracted and asked her if she was sure she wanted to put it through workers comp? Because if she had reason to believe that she had contracted it at work, then both she and her partner had been engaging in activity while on work time that could get both of them fired.

                      She decided that maybe she hadn't gotten it at work after all.
                      The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.


                      • #12
                        Now THAT is freaking hilarious!


                        • #13
                          I had a former employee claim athletes foot as WC. He worked in the sanitation dept, wearing rubber boots and using hot water. The carrier told him it was not industrial, just bad personal hygeine.


                          • #14
                            Can't blame the employees for trying!
                            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.


                            • #15
                              If they could only show that level of creativity & industriousness on the job!


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