STRAIN AT A GNAT, SWALLOW A CAMEL

While “Saving” Money With Your Worker’s Comp Claims

BY CHERYL TINSLEY, ARM, ABC

I recently had a colleague ask if she could quiz me a bit about worker’s compensation. She began her story with, “my husband was injured recently, and we are very worried....”. She went on to tell me that her husband fell from a ladder at work and sustained a low back injury. He had not worked for over twelve weeks because the treating physician would not allow modified duty, despite both her husband (the injured employee) and his physical therapist recommending modified duty work.

Red flag #1: If the treating physician you or your insurance carrier chooses will not assign modified duty without a clear explanation why, change treating physicians. In states where employers get to choose the treating physician (and this is the case for this person), the only party to take the blame for this IS THE EMPLOYER. The employee is ASKING to come back to work within safe restrictions. His supervisor is on board with this plan.

My friend went onto say that her husband’s employer voluntarily paid money beyond the state’s required temporary total disability (TTD) for four weeks, and then paid the statutory amount. During this time, the injured employee was expected to pay his health insurance premium by check to continue coverage, which he had done. However, once twelve weeks had past (the FMLA magic number....) he had been notified that as of January, his employer would no longer be picking up the employer’s share of the premium, so if he would like to continue his health insurance coverage, he would need to pay the full amount of the premium for his family. This amount is close to three thousand dollars, and this notification was given right before Christmas (after another doctor follow-up appointment where he again was denied modified duty work).

GETS CREDIT FOR THE ABOVE SAYING.

Red flag #2: It is acceptable to run FMLA time concurrent with worker’s compensation benefits. Many employers do this. However, what is the end goal? Is the plan to terminate an employee who is actively treating for a work-related injury? Think through how best to use the protection provided by FMLA in a way that is best for all affected parties. Depending on state law, a wrongful termination lawsuit might come into play. And that, my friends, is quite a bit more expensive to defend than a worker’s compensation claim. I’m not saying don’t use FMLA in worker’s compensation cases; I’m saying think things through so more problems aren’t created than solved.

At this point, the injured employee has even more stress on his injured back, as the full amount of the healthcare premium will eat up a large chunk of his total TTD payments. He is contemplating calling an attorney because he does not know what else to do.

Red flag #3: There are times when having an injured employee represented by counsel is a blessing, depending on the complexity of injuries, etc. However, a litigated claim is always more expensive to the employer than a non-litigated one.

I gave my friend two pieces of advice: 1. Ask the employer to request a nurse case manager. Having a nurse might get the treating physician to budge on the issue of modified duty. Alternatively, the nurse might recommend a second opinion to get things moving (there has been no treatment other than physical therapy for over twelve weeks). 2. I gave her the name of a claimant attorney. I recommended trying option one (nurse case manager) first but absent of some movement at his next doctor›s appointment, obtaining counsel is the next logical option.

Update: I spoke with my friend recently. She said her husband had gone to his employer work comp/ HR person and requested a nurse case manager. The HR person agreed that a nurse was a good idea. He was contacted by a nurse case manager within hours. At his next doctor’s appointment, he was allowed to work modified duty. He is also scheduled for surgery soon since conservative treatment failed. The nurse case manager has gotten the case moving forward, and my friend’s husband was able to get back to work at least for a few weeks, to avoid having to pay 100 percent of his healthcare premiums.

If I had an opportunity to speak with his employer, I would ask who advised them to manage their claims in this manner (cutting off employee medical insurance when FMLA time runs). This employee is not new to his company; he’s worked there for ten years. Here’s my rant: do not tell your employees they are “family” and then do this. Families don’t cut off family member’s health insurance, not to mention during the holidays. Not my family, anyway. This is what my colleagues and I used to call “fighting stupid”.

Update: The fact that the work comp contact person immediately agreed to requesting a nurse case manager tells me that the contact person is wearing too many hats to really monitor the injured employee’s progress and status. He was off work (out of sight, out of mind). Because he asked for some assistance, the case is moving again, and an employee is feeling VALUED. Where the claims adjuster was on this case is another article for another time.