South Carolina Workers’ Compensation: Nuts and Bolts Medical Version Sarah S. Alphin.

South Carolina Workers’ Compensation: Nuts and Bolts

Medical Version

Sarah S. Alphin

Claimant alleges a work accident

• Employer investigation:– Statement from Claimant

• Obtain written statement if possible

– Identify witnesses– Document as much as possible in writing

Initial Medical Treatment

• Claimant sent to emergency room or other urgent care, if needed

• Employer or Carrier has right to choose medical provider

• Drug test performed

• Obtain work restrictions

Claim sent to Carrier

• Carrier should review Employer’s investigation reports and physician report

• Carrier conducts further investigation– Recorded statement of Claimant– Obtain prior medical records– Interview witnesses and Employer

representatives

Carrier must determine:• Did the Claimant sustain

– (1) an injury by accident– (2) arising out of and– (3) in the course of employment

• Do any defenses exist?– Notice: 90 days– Statute of Limitations– Intoxication/Willfulness– Fraud in the Application

Accept or Deny?

Reasons to Deny a Claim

• It did not happen!

• Not compensable

• No EE/ER relationship (independent contractor, volunteer)

• Heart attack/stroke/mental-mental only compensable if unusual and extraordinary conditions of employment

Is the injury compensable?

• An injury is only compensable if:– An injury

• Must be unexpected

– By accident• An unlooked for or untoward event

– Arising out of and• Origin/cause of accident (must be caused by employment)

– In the course of employment• Time, place, circumstances

Injuries that are not compensable

• Idiopathic injuries (level floor)

• Fights unrelated to work

• Horseplay

• Going and coming to work– Exceptions: parking lot, ER provided travel,

EE paid for travel, or EE charged with task

If Claim is denied:

• No further medical treatment authorized by carrier

• Initial treatment authorized by carrier still paid for by carrier

• Claim can be denied at anytime

If Claim is accepted:

• Claimant is entitled to 3 types of benefits:– Medical benefits– Temporary compensation– Permanent compensation

Medical Treatment Medical Treatment

• Section 42-15-60 of the South Carolina Workers’ Compensation Act governs what medical benefits are provided under the Act.

• The employer/carrier is required to provide medical care which is causally-related to the work injury.

• The statute states that the employer/carrier shall provide medical treatment that will “affect a cure or give relief.”

Medical Treatment Medical Treatment • Medical care can continue so long as in the opinion of the

Commission it will tend to lessen the period of disability.

• Claimants are entitled to medical treatment after maximum medical improvement if they can establish that the medical care (medications, physical therapy, etc.) will “tend to lessen their period of disability” or maintain their level of functioning.

• You will hear this referred to as “Dodge” medicals because they are based on the Dodge case (Dodge v. Broccoli).

Medical Treatment Medical Treatment

• The employer/carrier is allowed to choose the physicians the employee receives care from.

• Prosthetic devices are covered for repair or replacement for a claimant’s life.

Regulation 67-1307

• Regulation 67-1307 of the South Carolina Workers’ Compensation Commission addresses the role of rehabilitation professionals. (see attached)

• R. 67-1307 (A) reads as follows: “Rehabilitation professionals are coordinators of medical rehabilitation services, including but not limited to state, private, or carrier based, whether on site, telephonic, in or out of state.”

Regulation 67-1307

• R. 67-1307 (B) reads as follows: “The role of a rehabilitation professional is to ensure the primary concern and commitment in each workers’ compensation case is to advance the medical rehabilitation of the injured worker.”

• R. 67-1307 (C) requires rehabilitation professionals to comply with Section 42-15-95 and R. 67-1308.

Obtaining Medical Records and Obtaining Medical Records and Communication with PhysiciansCommunication with Physicians

• Section 42-15-95 (A) – An employee who seeks treatment for an injury or condition for which compensation is sought CONSENTS to the release of medical records related pertaining to workers’ compensation claim

• A request citing Section 42-15-95 as the authority allowing you to obtain the records

• Medical providers must provide records within 14 days

Obtaining Medical Records

• If carrier wants to investigate pre-existing conditions or prior medical conditions, a subpoena can be issued by an attorney

• If Claimant’s attorney wants prior records, the Claimant can sign a written release

• A subpoena/release from Claimant can request any and all records, even records prior to an accident

Communication with Physicians Communication with Physicians

• Section 42-15-95 (B) governs communication with health care providers.

• Issues that may be discussed: - Medical history- Diagnosis- Causation- Course of treatment- Prognosis- Work Restrictions- Impairments

Communication with PhysiciansCommunication with Physicians

• Requirements to have such communication

- Notify employee/claimant or claimant’s attorney in timely fashion, in writing or orally, prior to communication taking place (R. 67-1308 requires 10 day notice).

- Advise employee of the nature of the discussion or communication prior to the discussion or communication

- Allow claimant or claimant’s attorney to attend the meeting or participate in the discussion.

Communication with PhysiciansCommunication with Physicians

• If written questions are used, provide a copy of the questions to the employee/claimant or claimant’s attorney at the same time the questions are submitted to the heath care provider.

• Provide copy of response to questions to employee.

• Any information obtained in violation of these requirements cannot be used at a hearing.

Communication with PhysiciansCommunication with Physicians

• When a Form 14B is sent to a medical provider, a copy of it should also be sent to the Claimant or Claimant’s attorney.

• When a completed Form 14B is returned, a copy of it should be sent to the Claimant or Claimant’s attorney.

Form 14B

- Addresses MMI, permanent impairment, work restrictions and future medical treatment.- Is future medical care needed “to a

reasonable degree of medical certainty?”- Not just that it may be needed in the future- Is the injured body part rated?

Form 14B

• WCC requires a Form 14B in certain cases– 16A settlements– Informal Conference settlements

• Form 14B to be completed by medical provider

• Important to fully complete the Form 14B

Nurse Manager Communication with Interested Parties

- Updates to adjuster and attorneys regarding status of treatment

- Nurse case manager reports

- Request for reports from Claimant’s attorney

- Discussions by phone with adjuster/employer

Who Do Nurse Managers Work For?

- Services are engaged by the carrier

- Request from Claimant, Claimant’s attorney, Claimant’s family regarding specific things they want

Who Directs the Medical Care?

• The employer/carrier has the right to direct medical care under the South Carolina Workers’ Compensation System.– Carrier selects physician– If referrals are made by physician, carrier can still

direct the referral

• If a Claimant attempts to change appointments without letting you know, Nurse Managers should advise the physician’s office not to allow the appointment to be changed unless it is authorized by you.

While a Claimant is treating

• Carriers need copies of medical records following appointments– Needed to authorize additional treatment,

referrals, diagnostic testing, etc.– Many times these things cannot be authorized

with the corresponding medical note

• Carriers need updated work restrictions/status following appointment

While a Claimant is treating

• Light Duty work– Physicians often allow Claimant's to return to

work restricted or light duty while treating– Providing light duty reduces overall cost of

claim– The longer a Claimant is totally out of work,

the harder it may be for them to return later

• Employers are not required to provide light duty work in SC.

Questionnaires from Attorneys

• Why are questionnaires needed?– Causation– Issues not being address in narratives notes

• Practice used by both Defense and Claimant’s attorneys

• Claimant’s attorneys can request questionnaires without notifying carrier/Defense attorney

• Defense attorneys must copy Claimant on questionnaires to comply with communication regulation

Permanent Disability BenefitsPermanent Disability Benefits

• If the matter is heard by a Commissioner, the Commissioner determines the amount of disability.

• The amount of the disability will not normally be the same as the impairment rating.

• There are no exact factors or guides to determine how much the disability award will be and the Commissioners have great discretion in determining the award.

Permanent Disability BenefitsPermanent Disability Benefits

• Different people with the same injuries and ratings could be awarded a different amount of disability- For example, a construction worker who has a

significant back injury and has lifting restrictions because of his injury will most probably receive a disability award that is higher than a person who works in an office environment but is not required to do any significant lifting, even though their injury and medical impairment rating are the same.

Permanent and Total DisabilityPermanent and Total Disability

• A person is entitled to permanent and total (P&T) disability benefits when they are unable to work at their previous job or at any other employment which is reasonably available in the economy.

• Maximum weeks allowed for permanent and total disability is 500 weeks.

Permanent and Total DisabilityPermanent and Total Disability

• A claimant is not entitled to lifetime indemnity benefits for permanent and total disability.

• P&T disability awards do include lifetime medical care for medical conditions causally-related to their injury.

• Cases involving paraplegia, quadriplegia or physical brain damage - no 500 week cap- lifetime weekly benefits- lifetime medical treatment

QUESTIONS?QUESTIONS?