Tag Archives: Workers Compensation

Private Investigators in Workers’ Compensation

Today’s post comes from guest author Leonard Jernigan from The Jernigan Law Firm.

As a workers’ compensation attorney I find it interesting that many people in the public question the disability status of injured workers. Let’s assume for the moment that you have sustained an injury on the job and you’ve been out of work for 5 months after back surgery. When you are unable to return to work quickly, the insurance industry has a lot of tools at its disposal to verify your disability status. They can pour over your medical records, pre- and post-injury, looking for any piece of evidence to deny your claim. They can send your file to lawyers who review medical records and recorded statements to potentially attack your credibility and honesty. They can hire a nurse to attend your appointments and speak with the physician and the staff, as well as obtain information directly from you. They can do background searches on you to see if you have a criminal or civil record. Obviously they will check to see if you ever filed a workers’ compensation claim before. They will also do social media and Internet searches on you and your family members (Facebook, Twitter, LinkedIn, etc.). They also can hire private investigators to follow you and your family around and take video recordings of your activities. With all these resources at the disposal of the insurance company, it’s hard to believe that many cases of employee fraud slip through the system.

A private investigator pretended to be a potential buyer and spent an hour or more going through the house.

We have one client recently who was followed by several private detectives for more than a year. They not only followed him around, but also followed his wife and son, who have no workers’ compensation claim. Another client had to sell his house because of his disability. A private investigator pretended to be a potential buyer and spent an hour or more going through the house. Does the concept of “Big Brother” come to mind? Are you concerned about invasion of privacy, particularly for family members, friends, and others who may be seen in such videos? We always tell our clients such activity may occur so don’t be alarmed by it, but that isn’t too comforting to people who are struggling through health issues, who have depression and anxiety problems, and who are sensitive to privacy concerns.

It would be interesting if the roles were reversed and employers who underpay premiums by misclassifying the status of their employees, who fail to purchase insurance required to protect their workers, and who don’t follow proper safety regulations that cause injury, were followed this closely by employees or regulators who administer the workers’ compensation program. I have no doubt that these employers and insurance representatives would be outraged.

 

 

Injuries to In-Home Care Providers: Compensable?

Home care providers may or may not be considered to be employees of the person they are caring for.

A growing segment of the workforce involves individuals providing in-home medical care and assistance to private individuals. The assistance can range from a few hours per day, to 24/7 medical and domestic care for incapacitated individuals.

If the in-home care provider gets hurt while performing work duties, does this entitle the care provider to worker’s compensation benefits?

In a previous blog post, we discussed nannies, baby-sitters and domestic servants. “Home care providers” are treated differently (though an argument could be made that the care recipients from a nanny or from an in-home care provider are equally dependent — a baby and an elderly individual often have similar needs). The Commission held that persons providing personal/medical care to an “invalid” are not domestic servants (and thus, not statutorily exempt from the Act’s coverage). (Ambrose v. Harley Vandeveer Family Trust, WC Claim No. 86-39393 (LIRC Feb. 28, 1989); Winkler v. Vivian Smith, WC. Claim No. 1998059089 (LIRC Jun 29, 2000))

The Department generally considers that persons hired in a private home to give primary care to an individual whose duties involve assisting  in walking, bathing, preparing meals and special diets, supervising use of medications and exercise therapy and other duties commonly associated with the meaning of primary-care giver, meet the definition of home-care provider.

 If the domestic servant exemption does not apply, the question is: are home care providers to be considered as employees of the cared-for individual?

Interestingly, another statutory exception which may apply involves that of the cared-for individuals enterprise, as the person providing personal/medical care does not perform these services as part of the trade, business, occupation or profession of the cared-for individual (102.07(4)(a)2). Since the cared-for individual is not in the business of providing in-home care, there would be no worker’s compensation coverage, unless the cared-for individual elects to award these. Thus, the Department, based on this statutory exception, suggests that no employer-employee relationship exists under the Act.

As the Commission has left this issue largely undecided in the case of a private cared-for individual hiring their care provider, arguments exist both for and against coverage. Alternatively, if a county referred the home care provider to the individual and the county set the provider’s rate of pay, the county is the employer for worker’s compensation purposes. (See Cobb v. County of Barron, WC Claim No. 2006-043003 (LIRC Dec. 11, 2008); Nickell v. Kewaunee County, WC Claim No. 94064155 (LIRC Sept. 24, 1996)).

 

How does Wisconsin “Rank” in Workers' Comp?

Wisconsin scored a B for Workers' Comp, but only because the study did not consider benefit level and ease of obtaining legitimate claims.

 

On a scale of A to F, Wisconsin scored a B on a list of 2011 State report cards released by the Work Loss Date Institute (WLDI).  For the last ten years , the Institute has tracked trends and gives each of the states a grade and a tier ranking based on their performance.

The State report cards are based on data from OSHA forms 300 and 200, on which employers report incidents of injury and illnesses.  The OSHA reports form the basis for state by state rating of workers’ compensation performance, which help employers, insurance carriers, State governments, and workers’ compensation departments to assess and analyze their own programs.

The State report cards emphasize one primary measure of outcome: whether workers get better and go back to work.   One shortcoming of the report is that it does not track medical costs.  Five different outcomes  are measured and compared among the states for each year.

  1. Incidents rates;
  2. Cases missing work;
  3. Median disability durations;
  4. Delayed recovery rate; and
  5. A key condition, or Low back strain

With over ten years of data, the WLDI has enough information over a long enough time frame to differentiate states adequately.  The best performing states were Utah, Arkansas, and Minnesota (graded A).  The worst: Kentucky and New York, with a grade of F.  Wisconsin ranks in the middle tier, graded a B.  States surrounding  Wisconsin include Iowa with a B, Minnesota with an A, Michigan with a B, and Illinois with D.  State ranking can be viewed here.

 

Note: The study is limited in that it does not grade by benefit level or by the difficulty or ease of obtaining workers’ compensation benefits. On this criteria Wisconsin ranks fairly high.  It provides benefits for injuries and illnesses using a “more probably than not”  medical causation standard..  It also provides for mental injuries and does not deny benefits for injuries involving alcohol or drug use, both of which are denied in many states.

 

 

Photo Credit: Maggie Smith / FreeDigitalPhotos.net

 

 

More surgeries = More benefits (Part 2)

In Part 1, we discussed how to determine the PPD (Permanent Partial Disability) value for certain body parts and surgical procedures. In this article, we continue the discussion on applicable PPD values for cumulative or multiple surgeries.

For multiple surgeries on the same work-related injury, permanent disabilities are "stacked"-- after all, having two surgeries rather than one means that you have to recuperate twice.

What about multiple surgeries?

“Redo” or cumulative surgeries can be problematic, but recent court decisions clarified the issue.

For background information, the Wisconsin Supreme Court (DaimlerChrysler v. LIRC, 2007 WI 15, 299 Wis. 2d 1, 727 N.W.2d 311 (2007))held that any additional invasive surgery resulting from the same work injury carries an additional, additive PPD rating under section 80.32. In effect, the minimum percentages of disability are “stacked” on each other, based on each performed procedure listed in the Code section.

For example, if an injured worker has an initial ACL repair to his knee (minimum 10% under the Code section), followed by a second ACL repair later (minimum 10%), the PPD is stacked for a cumulative 20% minimum PPD—even if the treating physician assigned a lower percentage.

The general policy behind this “stacking” of the disability percentages listed for surgical procedures is that “repeat or multiple surgeries have a cumulative, negative effect on the function of the body part upon which they are performed” (DaimlerChrysler, 2007 WI 15, ¶ 32, n.14).

Some confusion exists when a joint replacement occurs after prior surgical procedures, all stemming from the same work injury. In the introduction to Code section 80.32, an appropriate reduction can be made for any preexisting disability.  Accordingly, applicant and defense attorneys have argued about whether the PPD attributable to a joint replacement can be reduced from prior surgical procedures to the same body part when the surgeries are all after and relate to one work injury.

 

 For example, if a worker has an initial knee ACL repair (10% minimum), followed by a total knee replacement (50% minimum), is the PPD a cumulative 60%, just 50% for the total knee, or 40% based on a reduction?

 

This issue was resolved in favor of “stacking” the PPD percentages for a cumulative number (60% in the above example).  The Wisconsin Court of Appeals recently held that the Commission has consistently interpreted the DaimlerChrysler rule to allow for cumulative minimum PPD ratings where successive surgeries are necessitated by the same work injury; there was no reason to apply the rule differently when one of the surgeries was a total joint replacement.  (MG&E v. LIRC, 2011 WI App 110, Ct. App. June 16, 2011).

The Wisconsin Supreme Court recently declined review of the case, which keeps the Court of Appeals ruling in place.  Therefore, under the current law, each additional surgery listed in Code Section 80.32 that a worker has after an injury carries a separate and additive PPD percentage under the law—a significant benefit to Wisconsin’s injured workers.

 

 

 

Photo Credit: Apple’s Eyes Studio / FreeDigitalPhotos.net

WCRI: Wisconsin Injured Workers Motivated to Return to Work (Part 2)

Last week, we began a discussion about a recent study by the WCRI which found that Wisconsin injured workers have better return-to-work outcomes compared to other states (see Part 1 of this article). In today’s post, we continue on said topic.

Letting workers choose their own doctors meant that there was less doubt about whose side they were really on.

Significance of Worker’s Choice of Treating Doctor

Worker’s compensation administrators and experts who were interviewed indicated that worker choice of provider was the foundation for the Wisconsin system,  and that it was central to establishing injured workers’ trust in their treating doctor’s recommendations about treatment and return to work.  (Although Wisconsin worker’s compensation insurance carriers have regularly attempted to limit employee choice, those efforts have been stopped in the advisory council, a group of labor and employer representatives who meet to recommend changes in the law.)

Since Wisconsin workers have a choice of practitioners, workers can have greater confidence in their treating doctor’s recommendation regarding the ability to return to work.  Significantly, the study found that workers’ choice of providers did not lead to longer absences from work.  In fact, survey results among injured workers specifically indicated that Wisconsin injured workers returned to substantial employment faster than workers in ten other states included in the study.

 

The “85% Rule”

Lastly, the study found that Wisconsin’s workers’ compensation system encourages employers to accommodate injured workers with permanent restrictions, and for the worker to accept these offers.

The most prominent feature is the “85% Rule” which bars an employee from making a claim for a Loss of Earning Capacity if the employer rehires the employee 85% of his pre-injury wage.  On the other hand, if the employer cannot or does not accommodate the employee’s permanent restrictions, Loss of Earning Capacity benefits can be four to seven times higher than functional impairment benefits alone.  Workers who refuse legitimate job offers can lose their right to Loss of Earning Capacity benefits.

And since Permanent Partial Disability benefits are paid at  only 35% of the temporary disability benefit maximum, there is a substantial financial incentive for workers to accept the job when shifting from temporary to permanent disability benefits.  All this is good news for Wisconsin’s system and Wisconsin workers.

However, during the economic downturn, employers are finding it more difficult to offer light transitional or modified duty.  Quite simply, the employer may not have a job available or one that meets the employee’s restrictions, especially in these hard economic times.

 

 

Photo Credit: Ambro/Freedigitalphotos.net

WCRI: Wisconsin Injured Workers Motivated to Return to Work (Part 1)

Injured workers in Wisconsin are more motivated to return to work-- thanks to the state's workers' compensation system.

With unemployment numbers high, injured workers face increasing challenges in returning to work.  A study by the Workers’ Compensation Research Institute (WCRI) titled “Factors Influencing Return to Work for Injured Workers: Lessons From Pennsylvania and Wisconsin” indicates that those two states have reported better return- to- work outcomes compared to other states, even during economic downturn.

This study focuses on “long term unemployed injured workers” (defined as workers who have been out of work for three months or more). These workers, unlike the vast majority of injured workers highly motivated to return to work after an injury, face particular challenges in returning to work – challenges that are even greater considering economic hard times.

The study tried to identify which worker’s compensation systems features facilitated return to work for long-term unemployed injured workers, and which features serve as barriers to return to work for these workers.

 

The Wisconsin Scenario

Earlier research done by WCRI indicated that workers in Wisconsin have higher rates of return to work, and workers tend to return to work sooner than in other states.  The reason: Employer and injured worker motivation to return to work, as well as multiple Wisconsin workers’ compensation system features.

One of the features which encourages return to work  in Wisconsin is the transition between temporary disability and Permanent Partial Disability benefits. Wisconsin encourages incentives for both the worker and the employer to return workers with permanent restrictions to work, and for injured workers to accept offers of legitimate employment.

 

“The Healing Plateau”

 Unlike many other states, Wisconsin’s clear standards for terminating temporary disability benefits encourages return to work.  As they are effectively communicated by employers and insurers, and well understood by injured Continue reading

Telling your supervisor about an injury is not enough. Here's what else you need to do.

injured workerToday’s post comes to us from our colleague Matthew Funk of New York and is part of an ongoing series of questions and answers about workers compensation.

QUESTION: I TOLD MY SUPERVISOR ABOUT THE ACCIDENT BUT I DID NOT SUBMIT AN ACCIDENT REPORT. AM I GOOD TO GO WITH THE VERBAL NOTICE?

ANSWER: ALWAYS REPORT AN INJURY IN WRITING

Joe was working a construction job when Mike accidentally beaned Joe on the head with a 2X4. After seeing a couple of Tweety Birds and a whole bunch of stars, Joe went down to his supervisor’s station and told him he had just had an accident. Then he went off to the ER to make sure he was not seriously injured, relieved he had taken care of business at the job site. All he had to do now was get better.

No, Joe! No!

Yes, Joe satisfied the notice requirement. However, Joe was NOT good to go.

Supervisors sometimes have a funny habit of forgetting Continue reading

Reflections on 100 Years of Workers' Compensation in Wisconsin

My first lecture each semester in the Workers’ Compensation course at Marquette University Law School in Milwaukee centers on the “great trade-off” between workers and employers that forged the nation’s first constitutional worker’s compensation system in 1911: Workers gave up the right to sue employers for workplace injuries in return for a “no fault” compensation system with assurance of timely but limited benefit payments, adequate and competent medical services, and prompt and sufficient rehabilitation.

The system was designed to provide a means of “guaranteed” compensation for a legitimate injury and disability.

Employers received immunity from tort suits in return for compulsory provision of a scheduled benefit.  Continue reading