CIC Workers Compensation part 2

What is foreign coverage?

it is designed for US employers with employees working outside the country.

What happens to the limit if the carrier has to hire an attorney for the employer seperate from the claim?

it is paid outside the limit as a supplementary payment.

what is the exception to the working outside us and territories exclusion for EL policy

does not apply if they are temporarily there for a work assignement

what is the most common way premium is calculated?

Premium and class codes

What types of damages are excluded by the employment related practices exclusion

• Excludes damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions

What are dual capacity claims?

• Protects against lawsuits brought by an injured employee, against the employer when the injury arises from the activities of the employer in a capacity other than an employer. In such a case, the employer is liable not only as an employer for workers compensation benefits but also as an entity acting in a different capacity.

What is the rehab benefits category?

- usually included under medical benefits. May have a separate provision a) Physical rehabilitation to restore the injured employee to maximum physical capacity b) Vocational training may or may not be included

What is a third party over claim?

1) Lawsuits filed by a third party seeking indemnity because it was held liable for an employee's injury a) Employers Liability Insurance Part Two i. EL provides coverage if the third party claim is filed on the basis of tort (negligence). Employee sues third party for employee's injury. Third party alleges that the employer is responsible, in whole or in part, for the employee's injury. ii. Has broad exclusion for employmentrelated damages b) CGL Policy "Insured Contract" i. CGL Policy excludes Employers Liability however the exclusion does not apply to liability assumed under an "insured contract" ii. So the CGL Policy provides coverage if the third party claim is filed on the basis of contractual liability triggered by an indemnity agreement that is an "insured contract." (See "Insured Contract" definition paragraph f.)

what is a consequential bodily injury claim?

1) Protects against a lawsuit filed by a family member for an injury or disease suffered as a consequence of the employee's injury 2) Example: The spouse of a severely injured employee suffers a heart attack or a nervous breakdown upon learning of the injury to the employee

what is a care and loss of services claim?

1) Protects against lawsuits filed by an injured employee's spouse and/or children for loss of the services resulting from injury to the employee in the course of employment 2) Services may include sexual relations, companionship, help in performing household chores, etc. 3) Example: Jane, a marketing rep, is severely injured in an auto accident and is in the rehab hospital. John, her spouse, has to hire a housekeeper to take care of the household and their children. John files a claim against Jane's employer to recover for this loss.

What does employers liability apply to?

1. Applies to bodily injury by accident or bodily injury by disease including resulting death a. Must arise out of and in the course of employment b. Employment necessary or incidental to named insured's work in a state or territory listed in Item 3.A. c. Bodily injury by accidental must occur during policy period d. Bodily Injury by disease must be caused or aggravated by work conditions - last day of exposure must occur during the policy period e. Original suit must be brought in the USA, its territories or possessions, or Canada

What are the four general categories of benefits provided in WC law?

1. Medical Benefits 2. Compensation for lost wages (disability benefits) 3. Rehabilitation benefits 4. Death or survivor benefits

What is the compensation for lost wages (disability benefits) category?

1. Temporary partial 2. Temporary total 3. Permanent partial 4. Permanent total

What are the exclusions of the employers liabilitypolicy

1. contractual liability 2. punitive or exemplary damages 3. BI of employee while employed in violation of the law 4. under obligation of any other WC law 5. intentionally injured or aggravated 6. injury outside the US, territories or canada 7. employment related practices 8. subject to long shore or other acts 9. work subject to FELA act 10. BI to master or crew. 11. Fines due to violation of the law 12. Damaged due to MSAWPA

IF there is an injury, what is the duty of the insured?

1. cooperate 2. provide info on the injury 3. send the dude to the doctor 4. do nothing to interfere with subro rights 5. no voluntary payments or incurring expenses (dont hide it)

What is the nonappropriated fund instrumentalites act (NAFIA)

Applies to civilian employees of non‐appropriated fund instrumentalities of the Armed Forces. Examples: military base exchanges and morale, welfare, and recreational facilities. Eligible employees are entitled to similar benefits as in the LHWCA. You can get coverage for them through the Nonappropriated Fund Instrumentalities Act Endorsement WC 00 01 08 A

Give an example of a third party over claim.

An employee is injured using a piece of machinery that the employer had not properly maintained. In addition to the benefits received under the workers compensation program, the employee also sues the manufacturer (third party) of the equipment. In turn, the manufacturer (third party) of the equipment sues the employer for contributory negligence due to poor maintenance.

What is the outer continental shelf lands act OCSLA

Employees who work on fixed platforms (not the same as floating drilling rigs which are considered vessles). for coverage, you would get the outer continental shelf land act WC 00 01 for coverage as this is not covered in WC. Separate coverage is needed.

What does the Foreign WC policy provide for?

IT includes the rules from your state of hire but also provides coverage for endemic diseases and repatriation expenses.

Give an example of a dual capacity claim?

IW works for a ladder manufacturer and gets injured while using a ladder that is manufactured by his employer. The injured worker can sue as both an employee and as a user of a the ladder. employers liability covers the manufacture suit and WC covers the employer suit.

Why is contractual liability excluded in the EL policy

Look for coverage in BAP or CGL

IF you list kansas in 3a and you have colorado listed under 3c with a policy effective date of 4/1. what happens in this situation. 3) A lucrative opportunity presents itself in Wyoming, so Donaldson rents space, hires employees and begins operations in Wyoming on November 1. Will Donaldson's Policy provide coverage for Wyoming benefits for injury to a worker in Wyoming on November 30?

No, Wyoming is a monopolistic state. WC coverage should be purchased directly from Wyoming. Remember to add the Employers Liability Coverage endorsement either to the existing WC Policy or add the Stop Gap endorsement to a CGL Policy.

what is the insurers promise for WC policies?

Pay claim and defend the insured

What is the problem when looking at WC and other states insurance?

Problem: If a state is listed under 3.C. and NOT under 3.A. and there are existing operations at the inception of the policy period, then there is no coverage provided for that state unless the insurer is notified within 30 days of the renewal date.

Summary of WC Insurance

Provides WC benefits according to the WC law in the states listed under 3.A. Provides coverage for known and expected operations in that state but only if listed under 3.A. After the effective date, named insured must notify the insurer at once if named insured begins operations in any state not listed in 3.A. or 3.C. If not listed, then no coverage for that state.

Summary of other states insurance

Provides WC benefits according to the WC law in the states listed under 3.C. Provides coverage for unknown or unexpected operations that develop during the policy period for that state only if listed and if operations begin after the effective date of the policy. Must notify the insurer if named insured begins work in any state listed in 3.C. (Crucial to notify the insurer by the renewal date or at the latest within 30 days of the renewal date.)

If there is an "insured contract" between the third party and employer and the third party is asking to be indemnified in accordance with a contract provision, where is there coverage?

The CGL policy pays due to the plus in lease plus

What happens if there is no contract between the third party and the employer. Who pays?

The employers liability policy would pay then.

What type of claims does the employers liability policy handle?

Third party over Care and loss of services Consequential bodily injury Dual capacity

IF you list kansas in 3a and you have colorado listed under 3c with a policy effective date of 4/1. what happens in this situation. 4) Business is very good, so Donaldson expands again, this time hiring employees and beginning operations in Utah on February 10 of the next year. Will Donaldson's Policy provide coverage for Utah benefits for a worker injured in Utah on March 3?

Utah benefits are not provided since Utah was not listed in 3.A. or in 3.C.

How can the insured waive subro rights in a WC policy?

Waiver of Our Rights to Recover From Others Endorsement - WC 00 03 13

How are limits done on the EL plolicy

a. Limits shown on the Information Page are the most that will be paid b. The insurer will not pay any employers liability claims once the applicable limits of liability are exhausted c. Employers Liability Insurance limits of liability do not apply to workers compensation benefits paid - this is a SEPARATE insurance coverage

IF you list kansas in 3a and you have colorado listed under 3c with a policy effective date of 4/1. what happens in this situation. A work‐related injury happens to a worker in Kansas on May 22. Will your Policy provide coverage for Kansas WC benefits?

Yes, coverage applies automatically since Kansas is already listed in 3.A. WC coverage is state based, not location based. a

IF you list kansas in 3a and you have colorado listed under 3c with a policy effective date of 4/1. what happens in this situation. You begins operations and hires employees in Colorado starting September 12. Will your Policy provide coverage for Colorado WC benefits for a worker injured in Colorado on September 30?

Yes, coverage applies automatically until renewal since Colorado is listed in 3.C. AND the operations started after the effective date of the Policy. Always remember to notify the carrier at once when operations begin and make sure that at renewal Colorado is listed under 3.A. Otherwise coverage is not afforded for that state (Colorado) unless the insurance carrier is notified within 30 days of renewal.

What are endemic diseases?

a disease that is prevalent in a country or region that is not normally located elsewhere. (ebola or malaria)

What is the death or survivorship benefits category?

a) Burial expenses - amount varies statute b) Income benefits to eligible dependents • Dependents as defined in statute • Amount and payment period varies by statute

What is the medical benefits category?

a) May be unlimited - as long as they are restorable or purative b) May be subject to reasonable & necessary

What are the limits of liabilty for ELI

a. Applies only for those states listed under Item 3.A. • When you activate a state in part A, you activate it in part B b. Limits of liability 1) Standard limits BI by Accident - $100,000 each accident BI by Disease - $500,000 policy limit BI by Disease - $100,000 each employee 2) May be increased

What are the rights of the WC carrier to recover from others?

a. Insurer has the rights (subrogation rights) of the named insured, or the person or persons to whom payment is made under the policy, to recover from anyone liable for the injury b. Must protect the subrogation rights of the insurance company c. No waiver allowed before or after a loss without an endorsement Note: An endorsement is required as the policy has no contractual "insured agreement" protection.

What are the problems that could be ran into when dealing with other states and coverage?

a. Only 30 days to notify company of operations existing on effective date in any state not listed in Item 3.A. b. Reliance on Item 3.C. to provide automatic coverage c. Insured should notify company at once if work is begun in any 3.C. state d. Challenge of regional carriers and state specific carriers - not licensed

What type of payments will the carrier not pay for on the WC policy?

a. Serious and willful misconduct b. Employee employed in violation of law c. Failure to comply with health or safety law d. Discharge, coercion, or discrimination in violation of the workers compensation law

How is coverage applied to other states insurance?

a. States listed under Item 3.C. of the Information Page b. Must begin work in that state after the effective date 1) Employees injured in a scheduled 3.C. state will receive the WC benefits prescribed under that state's law if required by application of law or court decision. Thus, the policy pays benefits in listed 3.C. states just as if the state was scheduled under 3.A. (Not listed, no coverage for that state's benefits.) 2) Caution: if work began in a state on or before the effective date, that state should be listed in Item 3.A. c. The insurer will reimburse the named insured if the insurer is not allowed to pay benefits directly to the injured employee d. 30 days to notify insurer of operations existing on effective date in any state not listed in Item 3.A. 1) After the 31st day, there is no more coverage for that state to move it from 3c to 3a.

What is the insurers promise in relation to employer liability claims?

a. Will pay all sums the insured must legally pay as damages b. Because of bodily injury to an employee

what is a final audit in WC?

carrier comes to see if you reported your payroll correctly and they received enough premium for the risk. If you paid too little, you pay them more. If you overpaid, they pay you back.

What are repatriation expenses?

costs to bring a injured or deceased employee back to the US

How can you provide coverage for an out of territory employee?

if it is temporary, this would be covered under WC/EL. if long term you need to get a Foreign Workers Compensation and Employers Liability Endorsement.

What is the maritine laws?

these are not covered by WC or EL due to exclusion. This is for seamen and high seas employees. For coverage you need to get Maritime Coverge endorsements WC 00 02

What is the defense base act?

these type of employees US government contractors working outside the US on public works or military operations. Since these type of employees are excluded due to the exclusion 8. You need an endorsement to pick up coverage. You would get the defense base act endorsement WC 00 01 to pick them up

What is teh federal employers liability act (Fela)

this is for BI from railroad workers. this is not covered under WC or EL. You need to purchase a endorsement called FELA COVERAGE ENDORSEMENT wc 00 01

What is Longshore and arbor act?

this is for employees that work on barges, marina, vessle construction as they do not qualify for WC coverage. You need to buy long shore coverge for this.