Category Archives: Workers’ Compensation

Disclosure Bias In Workers’ Compensation

Dr. Sunita Sah

I read most things through the narrow prism of a lawyer representing injured workers and a Law Professor teaching Workers’ Compensation. I read with fascination Dr. Sunita Sah’s (M.D., MBA, Ph.D., Cornell University Professor) recent article in the New York Times (07/10/16) on “Disclosure Bias,” one of her research interests. Her theory: Although bias disclosure is supposed to act as a warning (to consumers, advisees, clients), it often has the opposite effect, making advisees more likely to follow biased advice.  For example, doctors view their own specialties as delivering more effective treatment than others to recommend treatment options. (chiropractors use hands, surgeons like scalpels, physiatrists prefer needles).

Dr. Sah’s research found that even (and especially) when the doctor discloses her bias, patients are more likely to follow the advice since the disclosure “creates increased pressure to follow the advisor’s recommendation.”  This increased pressure runs the gamut from recommendations on prostate cancer treatment to financial conflict.

In the workers’ compensation world, even though I disclose my lawyer’s preference when I advise clients on  things like choice of venue (Milwaukee or Madison), type of claim (occupational or traumatic), kind of treatment (surgery or pain clinic), or even case tactics (settle or go to trial), Dr. Sah’s research cautions against the unintended consequences of disclosure bias.  Since clients do not want to signal distrust to their advisor, or indicate I may be biased, the disclosure itself may become a burden on clients.  (One more thing to worry about. . . )

Fault: Creeping Back Into Workers’ Compensation

Workers’ Compensation is a compromise. As originally crafted in 1911 and as interpreted, Wisconsin Workers’ Compensation is a compromise in which both employers and employees surrender certain advantages in order to gain others that are deemed more important. Employers give up the immunity that would otherwise apply in cases where they were not at fault and employees surrender their former right to full damages in the few instances when they could recover under tort law and instead accept more modest assured benefits for injuries and deaths (without having to prove fault).

The concept of negligence should play no role whatsoever in the workers’ compensation system. The doctrine of liability without fault is part of the compensation system; the 1911 legislature attempted to guarantee payments by the employer for injuries arising out of and in the course of employment. The economic burden shifted from the employee to the consuming public.  

Traditionally, the only vestiges of fault and negligence that remained in Wisconsin involved penalties involving employer or employee safety violations. If an employee was hurt because of the employer’s safety violation, the benefits to which the worker was entitled were increased by 15% and paid directly by the employer. Similarly, if the employee committed a safety violation causing injury, benefits from the insurance carrier or self-insured employer could be reduced by 15%. 

Recent revisions in the law, effective March 2, 2016, chip away at the “Grand Bargain,” the legislative deal made in 1911 where workers surrendered all rights to sue their employers for negligence in return for which the employer paid for work-related injuries regardless of fault. 

An employee who had sustained a work-related injury and would return to work for an employer has always received the protection of the Workers’ Compensation Statute. Even if the employee was terminated for good cause during a post-injury healing, he was entitled to continued receipt of Temporary Total Disability benefits (2/3 of time-of-injury wages). However, effective March 2, 2016, a new Statute now states that if an employee is discharged or suspended for misconduct or substantial fault, as these terms are defined by the Unemployment Compensation statutes, the employee’s Temporary Total Disability benefits could be suspended. The legal standard for what constitutes “sufficient grounds for termination for misconduct” and “substantial fault” will be defined by the Unemployment Compensation Law (These are employer-friendly changes that were implemented in the UC system in 2014). 

Going forward, administrative hearings in both the Unemployment Compensation and Worker’s Compensation forums will occur. The issue of whether a decision binding on one forum will be binding on another remains to be seen.  A worker could face the “double whammy” of being denied benefits in both the workers’ compensation and unemployment compensation case.

Additionally, the new law indicates that an employee who violates an employer’s drug and alcohol policy at the time of injury (where the violation is causal to the injury) is not entitled to anydisability benefits under the Workers’ Compensation system. This harsh 100% penalty is a substantial change from the now pedestrian 15% diminution that formerly applied to injuries before March 2, 2016.

Lastly, the new law allows apportionment of Permanent Partial Disability in cases of traumatic injuries between that permanency caused by the work injury and that “caused by other factors.” The statute is silent as to the meaning of the term disability, or “other factors,” and the problems raised by the possible interpretations of these terms will be determined in subsequent court decisions.

The net result will clearly be more disputes in the supposedly “no fault” compensation system—likely resulting in more litigation and potentially raising the cost of workers’ compensation for all stakeholders.


1. 2015 Wis. Act 180 (effective March 2, 2016) made significant changes to the workers’ compensation law—for employers and employees.  This blog will explore those changes in a series of upcoming posts.

Getting Workers’ Comp and Social Security Disability–Is it Really “Double-Dipping?”

double dippingAn injured worker’s receipt of Social Security Disability (SSD) benefits can produce an offset from workers’ compensation (WC) payments.  A workers’ compensation recipient who is also collecting SSD cannot receive, in combined benefits, more than 80% of his average current earnings (ACE).  Wisconsin is one of nine “Reverse Offset” states whereby any offsets are taken on WC benefits rather than Social Security benefits.  Under Wisconsin statutes, for each dollar that the total monthly workers’ compensation benefits (excluding attorney fees and costs) plus the monthly benefits payable under the Social Security Act for disability exceed 80% of the employee’s ACE as determined by Social Security, the workers’ compensation benefits shall be reduced by the same amount, so that the total benefits payable do not exceed 80% of the employee’s ACE.

In most states, under Social Security law, a recipient’s SSD benefits are reduced when the total of the recipient’s disability payments plus workers’ compensation (WC) benefits exceed 80% of the ACE.  The reduction is taken against the recipient’s monthly SSD, not WC. In Wisconsin, however, just the reverse is true and the workers’ compensation insurance carrier’s liability is reduced.

In Wisconsin, the maximum age for ending the Social Security offset has been 65 since the offset went into effect in 1980.  However, since Congress amended the Social Security Act in 2013 by the incredibly-titled “Achieving a Better Life Experience (ABLE) Act,” the amendment extends the workers’ compensation Social Security offset to the full retirement age (essentially age 66 for those born between 1943 and 1954, and age 67 for those born after 1960).  The revised law provides that the offset continues until an employee attains full retirement age.  The way this works out practically, for example, for a worker with a $600 monthly Average Weekly Wage ($400 in Temporary Total Disability), or about $30,000 in average current earnings (ACE), 80% ACE would be $24,000 per year or $2,000 per month.  If SSD pays $900 per month, WC would be limited to the 80% ACE figure ($2,000) so the WC carrier liability would be limited to $1,100 instead of its $1,720 ($400 TTD rate x 4.3) monthly liability absent the SSD.

The purposes of the two systems—SSD and WC—differ substantially. WC applies the principle that, irrespective of fault, projected costs of injuries can be secured in advance through insurance. Eligibility for SSD benefits requires an employee to build equity in the program through earning income credits.  The employer has paid a premium for the worker’s injury not based on any offset, and the employee has paid into Social Security for the entirety of his work life.  The rationale for the “offset” is loosely based on a “double dipping” assessment, much the same as the “Moral Hazard” rationale for not providing a full pay check to workers who are injured (in order to reduce the incentive to remain off work).

Wisconsin experimented historically with the percentage of Permanent Partial Disability payable for Temporary Total Disability (from 70% to the current 66.66%), based on the notion that the worker should be no better off disabled than if he were working, the 33% diminution assessed as an amount relatively close to his taxation rate.  This rationale does not, of course, hold for those workers who exceed the maximum (currently $1,380) wage rate.  The “Moral Hazard” rationale for reduction of benefits is based on the theory that an injured worker should not be “better off”  because of his injury.  In over 40 years’ representing injured workers, I’ve yet to see a worker actually better off because of his work injury.

Oklahoma Commission Says Workers’ Comp “Opt Out” Not OK

Today’s post comes from guest author Kristina Brown Thompson, from The Jernigan Law Firm.

Ever since Oklahoma employers were allowed to “opt out” of the workers’ compensation system in 2013, nearly 60 big employers have chosen the “opt out” path. By opting out, these large corporations (like Wal-Mart and Big Lots) are no longer constrained by the requirements of the Oklahoma State workers’ compensation laws. Instead they are allowed to create their own internal workers’ compensation system playing under their rules and definitions.

According to a NPR study these opt out plans “ . . . provide fewer benefits, make it easier for employers to deny benefits, give employers control over medical assessment and treatment, and leave appeals in the hands of employers, and force workers to accept lump-sum settlements.”

However, just last week, the Oklahoma Workers’ Compensation Commission unanimously declared two sections of the “Oklahoma Employee Injury Benefit Act” (a/k/a Oklahoma’s Opt Out law) unconstitutional. According to the Commission, the Opt Out provisions deprived injured workers of equal protection and access to the court. The Oklahoma Workers’ Compensation Commission called the opt out plans “a water mirage on the highway that disappears upon closer inspection.”

Here is a link to the Oklahoma Workers’ Compensation opinion filed 26 February 2016. The ruling will likely be appealed and we can expect to hear much more about these Oklahoma opt-out plans in the near future.

 

 

 

Tips on Your Workers’ Compensation Claim

I just returned from New Orleans where I made a presentation to about 150 workers’ compensation lawyers (both for workers and for employers) on “Case and Client Evaluation In Workers’ Compensation”.

Since many in the audience represented insurance companies and employers, I paid particular attention to their response to my presentation. As one would expect, their best chance to win a case on behalf of the employer and insurance carrier occurs when several items come into play:

  1. When there is no actual report of the injury. [Worker’s Tip: No matter how small the work injury, make sure it is reported in some fashion – cell phone, voice recording, or Accident Report and the worker keeps a copy (BEST).]
  2. Failure to report that a work injury occurred to the first treating practitioner (whether Emergency Room, employer-directed medical facility, hospital, or primary care physician). The single most difficult hurdle in a workers’ compensation claim involving a traumatic injury occurs when no report of the injury is found in the initial medical record.
  3. In “Occupational Exposure” cases, no discussion with the doctor about work duties or prior incidents. (In Wisconsin, a worker can recover for workers’ compensation in one of two ways: 
    1. A traumatic injury where a single incident has caused the disability (lifting a box, falling, etc.)
    2. Occupational Exposure, where the wear and tear of a worker’s job causes the disability over time. In this latter category, workers routinely do not indicate with any kind of specificity the type of work they perform when they see the doctor.

These three tips can help us as workers’ compensation lawyers win claims, more so than any “Clarence Darrow” court room techniques or strategies.

NEW LAW: Wisconsin Enacts Worker’s Compensation Changes

It’s official. The Wisconsin legislature and Governor recently approved amendments to the worker’s compensation system in our state. We have a new law.

The bill arose from the Wisconsin Worker’s Compensation Advisory Council—the historically stabilizing group, consisting of members of labor and management.  The Advisory Council bill produced common sense reforms and improvements to the worker’s compensation system. A competing bill (informally known as the “work comp destruction bill”) never even received a hearing. In stark contrast, the legislature demonstrated support for the Advisory Council recommendations by unanimously passing the bill (Senate vote was 32-0 and Assembly vote was 97-0), and Governor Walker continued that support by swiftly signing the Council recommendations into law.

The new changes are 2015 Wisconsin Act 180. The bill is effective March 2, 2016.

Importantly, the new bill does not alter the underpinnings of the worker’s compensation “grand bargain”, whereby employees gave up the right to sue in court in exchange for scheduled, fixed benefits without having to prove fault.  Additionally, the new law does not affect an employee’s right to choose their own medical doctor and care, nor does the law impose any type of major medical fee schedule.

The Advisory Council bill was a compromise, as per usual, with provisions that benefit workers and employers. Among the major highlights of the new law:

  • Increased PPD Benefits. An injured worker’s maximum weekly benefits for permanent partial disability (PPD) will increase $20 to $342/week for injuries on/after March 2, 2016, and to $362/week for injuries in 2017.
  • Greater Access to Retraining Benefits. Injured workers with permanent limitations that do not allow a return to the time-of-injury employer can pursue academic retraining benefits (weekly maintenance benefits while in school, along with tuition, books, meals, and mileage). Traditionally, a hearing could not be held until the worker actually was enrolled and taking classes, which could be financially prohibitive when a worker is off work with no income. The new law allows a Judge the authority to issue prospective orders for future retraining benefits before the worker is in school.
  • Allowance for Working while in School. A worker pursuing an academic retraining program will be allowed to work up to 24 hours/week without those wages reducing any weekly worker’s compensation maintenance benefits.
  • Statute of Limitations Reduction for Traumas.  The statute of limitations, running from the date of injury or date of last compensation payment, for traumatic injuries only is reduced from 12 years to six (6) years. The statute of limitations for occupational exposure claims is not changed—remaining at 12 years.
    We anticipate that the traumatic injury statute of limitations change does not apply retroactively, meaning the new 6 year statute of limitations applies to traumatic injuries beginning March 2, 2016.
    The impact of this change will play out in the future. The potential for increased litigation exists as workers file hearing applications to protect their medical treatment expense benefits. For example, if a worker has a knee injury in April 2016 with arthroscopic surgery one month later, all disability benefits paid by the end of 2016, and that worker continues to have periodic difficulties ultimately resulting in a proposed knee replacement in 2023, they may be time-barred if no hearing application was filed within 6 years (or the end of 2022). If barred, those expenses are shifted to the worker, group health insurance, or the government.
  • PPD Apportionment. If a worker suffers a traumatic injury resulting in permanent partial disability (PPD), a physician’s report on PPD shall include a determination of the approximate percentage of PPD caused by the work injury along with the percentage attributable to “other factors” before or after the work injury. A worker, upon request, shall disclose any/all previous findings of permanent disability or impairments that are relevant to the work injury. The provision does not apply to occupational exposure injuries and does not mandate that a physician must find some percentage attributable to other factors (i.e., the entire functional PPD percentage can be attributable to the traumatic work event).Heavy litigation is likely given the provision’s ambiguity. By intent, it appears the language is restricted to functional PPD. The provision should not upset the “as is” rules on legal causation of an injury itself. Additionally, it does not appear the provision would affect liability for temporary total disability, medical expenses, retraining benefits, or potential loss of earning capacity or permanent total disability benefits.Litigation likely will occur over the type of competent evidence necessary to constitute “other factors” apportioning a PPD award. With the worker disclosure requirement, one could argue that only documented, ratable disability findings can be used, as opposed to a doctor’s speculation regarding pre-existing condition (e.g., a worker’s complaint of pre-existing sporadic low back pain is different than a pre-injury accident that resulted in a lumbar fusion procedure with a paid 10% PPD).
  • Lost Time Benefit Denial for Misconduct Terminations. Previous law, under the Brakebush case doctrine, allowed a worker to receive lost time benefits (Temporary Total Disability, or TTD) during a healing period even if they had been terminated for misconduct or allegedly valid reasons by the employer. The new law effectively puts an end to components of the Brakebush doctrine.Temporary disability benefits can be suspended when an employee is released to limited duty post-injury and subsequently is suspended/terminated for “misconduct” or “substantial fault,” as defined under the unemployment insurance law (Chapter 108). Based on the statutory language, TTD benefits, however, are still payable if a worker is completely off work in the healing period, per their physician.These terms “misconduct” and “substantial fault” were recently included in the unemployment laws with specific statutory definitions:
    • “Misconduct” is conduct evincing such willful or wanton disregard of an employer’s interests as is found in (1) deliberate violation or disregard of standards of behavior that an employer has a right to expect of his or her employees; or (2) carelessness or negligence of such degree or recurrence as to manifest culpability, wrongful intent, or evil design in disregard of the employer’s interests or to show an intentional and substantial disregard of an employer’s interests or of an employee’s duties and obligations to his or her employer.
    • “Substantial Fault” equals acts or omissions of an employee over which the employee exercised reasonable control that violate reasonable requirements of the employee’s employer, but not including minor infractions, inadvertent errors, or failure to perform work due to insufficient skill, ability, or equipment.
    With the worker’s compensation act now referring to the unemployment rules for the definitions of both terms, the possibility exists for the worker’s termination to result in the cessation of both worker’s compensation and unemployment benefits.
    The exact interpretation of these terms and the legitimacy of terminations will play out through litigation—and presumably a significant amount of litigation.
  • Benefit Denial for Alcohol/Drug Violation. All indemnity benefits are precluded if an employee violates an employer’s consistently enforced drug policy concerning alcohol or drug use when there is a direct causation between the violation and the worker’s injury. The worker, however, can still recovery/pursue medical treatment expenses.Previous law allowed a potential reduction of a worker’s benefits by 15% if an injury was the result of intoxication or the use of controlled substances.Notably, the new provision is a large injection of “fault” concepts into the otherwise no fault system undergirding the grand bargain of worker’s compensation.
  • Fraud Prevention. Worker’s Compensation Department (at DWD) will fund one Department of Justice position to assist in investigating and prosecuting any “fraudulent” claim or “fraudulent activity” on the part of any player in the worker’s compensation system (insurance carrier, employer, employee, or health care provider)
  • Electronic Medical Records. The cost for certified medical records in “electronic format” is fixed at a maximum of $26 per request.
  • Physician Drug Dispensing. Prescription drug dispensing outside of a licensed pharmacy (i.e., physician dispensing) are limited to the existing pharmacy fee schedule and pharmacist dispensing fee.
  • Review of Minimum PPD Ratings. The new law requires the Department to create a medical advisory committee, consisting of various areas of medical specialization, to review and revise the minimum functional PPD ratings found in the Administrative Code every eight years.

Change can mean uncertainty. A number of the statutory enactments and effects will be seen over time and through the litigation process. The key is that the Advisory Council process worked, continuing its vital role in Wisconsin’s beneficial and efficient worker’s compensation system.

Why Care About Comp?

Charlie Domer has a recent article in the Wisconsin Law Journal. Why Care About Comp? addresses the status of the worker’s compensation system in our state, as well as the recent legislative machinations. In short order, we should have a signed worker’s compensation bill that modifies and improves on our first-in-the nation worker’s compensation system.

Status of Workers’ Compensation in the United States

For all those concerned about worker’s compensation in our country—which really is all citizens—take a look at this important report on the current status of worker’s compensation systems.  The report, from the Worker’s Injury Law & Advocacy Group (WILG) highlights the scary place where some legislators and big businesses want to take worker’s compensation.

 

WILG - The State of Workers' Compensation In The United States

Click Here For The Report (PDF)