Workers Compensation

Advantages to purchasing private insurance WC policy

- "Employers Liability" coverage is included, with certain limits for damages - "Other States Insurance" is included if the "other states" are listed on the Declarations page of the policy - Insurer bears all costs of investigations and claims payments - DISADVANTAGE IS HIGH DEDUCTIBLES

Foreign Coverage Endorsement

- Adds foreign voluntary compensation insurance for employees hired w/in the US while they are traveling or temporarily residing outside the US for a period no longer than 90 days

Medical Benefits

- Does not include dollar or time limit on covered medical expenses - employer is responsible for all medical costs until the "maximum medical recovery" is reached, or some similar measure, depending on state law

Self-Insurance

- Employer is legally obligated to pay for all WC benefits required by state law - required to demonstrate to their state gov their financial responsibility to pay their claims: can do so by posting a surety bond, or depositing funds with the state treasury

Managed Care

- Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) were originally introduced to reduce the costs of health care - Traditional Indemnity (fee-for-service) plans permit insureds to select their own physician, choose the number of visits they feel is necessary, and the treatment received is not restricted - Managed care plans limit the choice of physicians, attempt to reduce unnecessary treatments, and tightly control the amount that can be charged for services

Compensation not provided for following injuries

- Injuries caused solely by the injured employee's intoxication from alcohol or controlled substance while on duty - injuries resulting from the willful intention of the injured employee to injure or kill him/herself or someone else - injuries sustained in the voluntary participation in an off-duty athletic activity not constituting part of the employee's work-related duties. This exclusion does not apply if the employer requires the employee to participate in the activity and compensates them for doing so

Work-related Travel

- Injuries occurring during commutes are NOT compensable - if overnight travel is required as a condition of employment, the employee is covered for 24 hrs a day, until the business trip ends

Experience period

- NCCI has collected a large amount of data from millions of insureds, over a long period of time, making their estimates of expected losses highly credible; insurer's actual losses that are plugged into the formula are those experienced during the "experience period", which is the previous four years, excluding the most recent year. Claims occurring in the most current year are not fully developed and would not be credible

Worker Classification

- NCCI separates all work performed into more than 500 hundred different "classifications" and assigns each one a four-digit code to each. This information is published in a manual with a detailed description of each classification - the NCCI also files historical premium and loss information for each work classification, organized by state. This information is used to develop different rates for each classification and state

Part one - What additional expenses will be paid?

- Reasonable expenses incurred by the insured at the request of the insurance company, but not loss of earnings - premiums for bonds to release attachments and appeal bonds in amounts up to the amount payable under this insurance - litigation cots taxed against the employer - interest on a judgement as required by law, until we offer the amount due under this insurance - expenses incurred by the insurance company

Employers Liability 3 limits of liability

- a limit for all claims in one accident - a limit "per employee" for bodily injury by disease - a limit for all bodily injury by disease claims - basic limits are $100,000/$100,000/$500,000

Part Five - Premium

- addresses the methods used to determine the WC premium. also includes the provisions about the insurer's manuals of rates and classifications, payroll estimation, and how final premiums are determined by an audit of actual premiums. The insurer retains the right to examine an insured's relevant records for three years after the policy expires, and adjust final premiums accordingly

State Funds

- all state's provide methods for employer's to obtain WC in states where it is required, and employers cannot find coverage in the standard markets

Death Benefits

- benefits to be paid to an injured worker's beneficiaries when a work-related injury or occupational disease results in death. Those entitled to receive indemnity death benefits include the surviving spouse or children. If there are no surviving dependents who are entitled to receive these benefits, NY law provides for the sum of $50,000 be paid to the surviving parents or the deceased worker's estate - if there is a solely surviving spouse with no minor children and no children who are either blind or physically disabled, the surviving spouse will receive indemnity death benefits equal to 66.6667% of the deceased worker's average weekly wage up to the statutory maximum rate scheduled at the time of the worker's death - if there are minor children in addition to the surviving spouse, there is no increase in the overall amount of the indemnity benefit. instead, the benefit amount is divided amongst the surviving spouse and all minor children. When there is more than one surviving child, the spouse receives 36.6667% of the weekly benefit and the children divide the remaining benefits equally - Generally, the surviving spouse received indemnity death benefits for the remainder of their life, unless they remarry. When a surviving spouse remarries, they will receive a lump sum equal to two years of death benefits. Surviving children's benefits will cease once they reach the age of 18, or if they are full-time students, the benefits cease at age 23. In addition to the indemnity death benefits paid to beneficiaries, the employer is responsible to pay the injured worker's funeral expenses in an amount up to $6,000

NCCI Part One: WC

- bodily injury by ACCIDENT, DISEASE, RESULTS IN DEATH - also specifies that bodily injury by accident must occur during the policy period - bodily injury by disease must include evidence that the disease was caused by or aggravated by the conditions of employment. The employee's last day, of last exposure to the conditions that caused or aggravated the bodily injury by disease, must occur during the policy period

Indemnity - Waiting Period

- can be anywhere form 2-7 days, depending on state. Income benefits earned during the waiting period may be recoverable later, if the disability persists beyond a "retroactive period' which also varies from state to state

Excluded employees

- clergy and members of religious orders - people engaged in a teaching or non-manual labor capacity for a religious, charitable or educational institution - people employed in certain maritime trades, interstate railroad employed, federal government employees and others covered by fed WC laws - people, including minors, doing yard work or casual chores in and about a one-family owner-occupied residence. "Casual" means occasionally, w/out regularity, w/out foresight, plan or method. coverage is required if the minor handles power-driven machinery, including a power lawnmower - certain employees of foreign govs - NYC police officers, firefighters, and sanitation workers. Uniformed police officers and firefighters in other municipalities may also be excluded - certain real estate salespersons who sign a contract with a broker stating that they are independent contractors

Longshore and Harbor WC Act (LHWCA)

- covers maritime workers who are disabled from injuries sustained on the navigable waters of the US, or in adjoining areas used in loading, unloading, repairing, or building a vessel - also required that benefits are offered to the dependents of the injured worker, if the injury results in the employee's death

- Damages the insurer will pay where recovery is permitted by law:

- damages for which the employer is legally liable to pay, that are won from a third party by an injured worker. "Third-party-over-action", and occurs when an injured worker sues a third party for the injuries sustained on the job. Then, 3rd party sues the employer to recoup the damages paid to the injured worker - loss of care and services - for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee, provided that these damages are the direct consequence of bodily injury that arises out of and in the course of, the injured worker's employment by the insured - bodily injury to the worker that arises out of and in the course of the employment, claimed against the employer, who was acting in a capacity other than as "an employer" at the time of the injury. "dual capacity claim" - employer's failure to provide WC coverage - fellow worker doctrine

Grave injury

- death - permanent and total lose of use, or amputation of, a limb or member - paraplegia or quadriplegia - total and permanent blindness or deafness - loss of nose or ear - permanent and severe facial disfigurement - an acquired injury to the brain caused by an external physical force resulting in permanent total disability

Occupational Illness & Disease

- disease resulting from the nature of employment and contracted due to the employment. NY statues list certain occupational dieses that will be handled for compensation on the same basis as accidental injuries - because occupational diseases may be slow in developing and are not as immediately identifiable as accidental injuries, there is a specified period of time to file occupational disease claims. the time period is provided so that an employee has a reasonable opportunity to discover the disease and its cause. Claims must be filed w/in 2 years after disablement or death, or w/in 2 years after the claimant knows or reasonable should have known that the disease was related to their employment

Temporary Total Disability (TTD)

- employee can, for a period of time perform no work at all, but is expected to recover and resume the same duties

Temporary Partial Disability (TPD)

- employee cannot immediately return to the same work, but can perform other "light duty" work while recovering

Permanent Partial Disability (PPD)

- employee has suffered a permanent impairment, such as the loss of a limb, leaving the injured worker unable to continue in the same line of work, but they could possible be retrained to work in another field

Breach of Duty

- if the injured worker can prove one or more of the common law duties was breached, and that the breach caused or contributed to their injury or illness, the injured employee can recover damages

Contributory Negligence

- if the injured worker contributed to her own injury in any way, they cannot collect for damages - very few states continue to use the contributory negligence rule because it would be almost impossible for an injured worker to prove that the employer was 100% responsible for her work-related injury

Comparative Negligence

- if the injured worker contributed to his own injury, damages will be reduced by the percentage the employee contributed to her/her own injuries - state may use the pure comparative negligence rule or the modified comparative negligence rule with regard to WC claims

Assumption of Risk

- if the injured worker was aware of the dangers, but voluntarily exposed him/herself anyway - injured worker cannot recover damages, even though the injuries were sustained through no fault of their own, but through the fault of someone else

Final Premium

- insurer has up to three years after the policy period ends to audit the insured's actual payroll and work classifications - this information is used to compute the final premium, which may result in an additional premium charge or a return of premium

Part two excludes

- liability assumed under a contract - punitive or exemplary damages because of bodily injury to an employee who was hired in an illegal employment - bodily injury to an illegally employed worker, hired with the knowledge of the employer or executive officers of the company - any obligation imposed by any WC, occupational disease, unemployment compensation, or disability benefits law - bodily injury intentionally caused or aggravated by the covered employer - bodily injury occurring outside the US 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 - bodily injury to any worker who is already covered under any federal WC program or any other WC plan - injury to the master or member of the crew of any vessel - fines and penalties imposed for violations of federal or state law

Medical Billing Audits errors

- many times the treatment indicated by the CPT code was not performed. The audit may also show that the treatment was billed at a higher rate than is permitted by the RVU for that treatment code - Additionally, health care providers are not permitted to 'unbundle" treatments that are normally billed together under a single code. When treatments are "unbundled" providers can bill them separately, charging more for the separate treatments than would have been charged if the treatment was billed as a single treatment. These are considered "billing error" that may be determined by a medical billing audit, that when corrected can save the insurer on benefit payments - An intrinsic weakness of medical bill audits is that an analysis of the medical bills after treatment is complete, will not prevent unnecessary treatments from being performed or over-billing from occurring

Designated Providers

- more often used with employer sponsored group health insurance plans and WC policies - providers that may be designated by the employer or insurer include physicians, physician assistants, occupational therapists, physical therapists, and other health care providers - these "designated providers" have agreed to accept payment for services according to the fee schedule outlined by the insurer. Many times with workers' compensation insurance, an HMO itself, is the designated provider

Benefits and Employments Covered by State Law

- non of the state laws place dollar limitations on medical expense benefits, there are considerable differences between state laws in how disability income (indemnity) benefits are calculated and paid. - states differ in whether they offer vocational counseling and retraining, physical rehabilitation benefits, and how death benefits are paid to the dependents of workers in case of death

Every employer must annually submit to WCB

- number of employees w/in ADR program - number of claims filed w/in ADR program - total amount of lost wages (Indemnity) benies paid w/in program - total amount of medical payments made w/in the program - number of decisions rendered, settlements made and appeals taken

Covered Injuries

- only for accidental injuries arising out of, and in the course of, employment and any disease of infection that may naturally an unavoidably result from those injuries. Compensation is not provided for an injury that is solely mental and that is based on work-related stress if the mental injury is a direct consequence of a lawful personnel decision made in good faith by the employer involving a: - disciplinary action - work evaluation - job transfer - demotion - termination

Death/Burial/Funeral benefits

- paid to the surviving spouse and children: for death (indemnity) benefits, most states pay a percentage of the deceased workers wages, subject to maximum and minimum limits - however, flat amount is usually provided for a burial/funeral allowance

Disability income (indemnity) benefits

- paid when an injury is so severe that the injured worker is unable to return to work for a period of time

Indemnity waiting period

- payable only after a 7-day waiting period. however, the benefits will be payable retroactively if the disability continues beyond a period of 2 weeks. Whether the disability is permanent or temporary, the benefit amount is calculated at 66 2/3% of the employee's AWW prior to disability. There are also "scheduled" benefits paid for certain permanent partial disabilities such as the loss of limb, sight, hearing - the income benefit amount is also subject to the maximum and minimum dollar amounts per week, scheduled by state statute every year. Payments continue for the duration of the disability. Any benefit already being received from Social Security will be deducted from WC income benefit payments

Estimated Annual Premiums

- premium discount, based on the amount of the manual premium - schedule rating factor, which is a modification of manual rates to either a higher (debit) rate or a lower (credit) rate, based on the insurer's view of the safety, quality, and desirability of the insrued, relative to the perceived average - the experience modification factor, which is a number calculated by the NCCI annually

Premium Rate Computation

- premium rates are expressed in terms of dollars. Rates are multiplied by the estimated annual payroll for the classification, and the rate applied per $100 of payroll

5 common law duties

- provide a safe place to work - provide an adequate number of fellow competent workers - provide safe tools and equipment - warn of inherent dangers - make and enforce rules for the safety of all workers Injured employee can sue employer if these standards are not met

Rehabilitation benefits

- provided in case of disability: each state provides some level of necessary physical, mental, and vocational rehab; including institutional care, maintenance costs, travel and incidental expenses

Voluntary Compensation Endorsement

- provides coverage to workers or volunteers who are exempt from statutory WC benefits. The applicable state and work classifications are listed on the endorsement

Methods employers can use to obtain WC coverage

- purchasing insurance form private or state-run insurance companies - self-insurance - purchasing insurance from the state WC funds (residual markets)

Additional Expenses Paid

- reasonable expenses incurred in defense of a claim, but not loss of earnings - premiums for bonds to release attachments and appeal bonds in amount up to the limit of liability - litigation costs taxed against insured - interest on a judgment as required by law

Exempt for WC law

- some states do not require small businesses with fewer than 3 employees to provide WC coverage - employers still bound by "common law" duties to use "reasonable care" to keep their employees safe

State Marketplace for Purchasing WC Insurance

- state's WC law is considered "monopolistic", "private", or "competitive" - Monopolistic: state gov is sole provider of WC insurance - Private state: private insurance carriers write all the WC policies - Competitive state: private insurance companies write WC coverage, but the state also writes coverage that competes with the coverage that the private carrier offer

For employers coverage to apply

- the bodily injury must arise out of and in the course of the injured worker's employment - the employment must be necessary or incidental to the employer's work in a state or territory listed on the information page of the policy - bodily injury by accident must occur during the policy period - bodily injury by disease must be caused or aggravated by the conditions of employment - if the employer is sued, the original suit and any related legal actions to recover damages for bodily injury by accident or disease, must be brought in the USA territories or possessions Canada

Part one - how will the insurance company defend the employer against claims?

- the insurance company has the right and duty to defend, at the expense of the insurer, any proceeding or suit filed against the employer, for benefits payable under WC policy

Part one- how will "other insurance" be handled?

- the insurance company will not pay more than their share of benefits and costs as indicated w/in the policy. The method specified in the standardized policy for paying claims when more than one policy applies is the "contribution by equal shares" method - using this method, each insurer pays an equal amount of the loss until the loss is covered, or the policy limit of any one policy is reached. If one or more of the polci8y limits are reached, the "equal shares principle" applies to the remaining insurers until all policy limits are reached

Manual Premiums

- the premium computation we just reviewed is used for each classification of work that the employer has indicated in the underwriting information. the total of these computations is known as the standard or manual premium - after the manual premium has been calculated it is subjected to other factors, including state workers compensation laws and practices, by the insurer writing the coverage before the actual manual premium amount is reached

Negligence of a Fellow Worker

- this defense is only applicable if one worker was negligent and caused the injury of a fellow worker of the same employment rank - narrowly interpreted and not commonly accepted by the courts; additionally it may be specifically barred from use as a defense by some state laws

Medical Billing Audits

- thorough review of med bills submitted to an insurer to contain health care costs - 30-40% of hospital bills submitted to insurance carriers contained errors; many hospitals and physician's offices submit a "uniform bill" to insurers that provides a summary of the services provided and the charges for those services; when adjusters requested an "itemized bill", they were able to find discrepancies in the treatment codes listed on the bill and the actual treatment provided

Disability Income Indemnity Benefits

- usually calculated as a percentage of the injured employee's average weekly wage, average monthly wage, or the prevailing wage in the state, subject to specified maximums and minimums

Prospective Review

- utilization review conducted prior to a hospital admission, a health care procedure, or course of treatment that required "preapproval" before the services are provided. This is known as "preauthorization" and the insurer may use this type of review to identify potentially large claims before they are actually filed

Ambulatory Review

- utilization review of health care services performed or provided in an outpatient setting

Permanent Total Disability (PTD)

- worker is permanently, and totally, disabled and will no longer be able to work from the date of the injury, going forward

Employments Covered by law

- workers in all employment conducted for profit. Part-time employees, family members, and volunteers are all covered by the law - employees of counties and municipalities engaged in work defined by law as "hazardous" - public school teachers, excluding those employed by NYC, and public school aides, including those working in NYC - employees of the state, including some volunteer workers - domestic workers employed 40 or more hours per week by the same employer (including full-time sitters or companions, and live-in maids) - farm workers whose employer paid $1,200 or more for farm labor in the preceding calendar year - any other worker determined by the WC board to be an "employee" - all corporate officers if the corporation has more than 2 officers - officers of one-or-two person corporations if there are other individuals in employment. These officers may choose to exempt themselves from coverage

Utilization Review

= set of formal techniques designed to monitor the use of health care treatment. The review also monitors the medical necessity, appropriateness, efficacy, or efficiency of the health care services provided. The procedures used to deliver the services and the setting in which they were delivered is also reviewed. There are several different methods that may be employed to conduct a "utilization review"

EMF

A number above or below 1.0. An EMF above 1.0 indicates that the insured's actual claims during the experience period were higher than expected. An EMF below 1.0 indicates that the insured's actual claims during the experience period were lower than expected

Medical Billing Audits example

A physician performed 30 minutes of treatment code 00100 at its corresponding rate on the schedule of $34.25 per 15 minutes. The RVU for CPT code 00100 is 5.00. How much would the physician receive in compensation for the treatment performed? - first, multiply $34.25 by 2 because 30 minutes of treatment was performed instead of 15 minutes. The result of this multiplication is &68.50. Then, we would multiply $68.50 by the RVU of 5.00 which would result in the compensation for the provider. The result of $68.50 multiplied by 5.00 is $342.50 which is the amount the provider would receive in compensation for the treatment

Retrospective Review

A review of the claim (request for benefits) after patient treatment has concluded. Reviewing the medical bills provided w/in the claim file may help in finding areas to reduce those bills

Preferred Provider Organizations

A selected group of hospitals and medical practitioners in a given area who sign a contract with an insurance company to provide health care services at a prearranged cost - HMOS provide care in facilities created for the HMO; with PPOs, health care providers sign a contract to provide their services in their own facilities; PPOs will also pay for emergency care if provided outside of the PPO

Concurrent Review

A utilization review conducted during a patient's stay or course of treatment in a health care facility

Part Four - Insured's Duties if injury occurs

Addresses the obligations of the insured in the event that once of its employees is injured on the job, insured employer: - must report the employee's injury to the insurer immediately. the insurance company is considered to have notice when the employer has notice - must provide for the immediate medical care and other services for the injured worker as required by WC law - must provide the insurer with the names and addresses of all injured parties, witnesses, or other information necessary to investigate the claim - must provide the insurer with all notices, demands, and legal papers related to the injury, claim, proceeding or lawsuit

ADR Reporting Requirements

Alternative Dispute Resolution (ADR) system, the employer is responsible for filing the required form (ADR-2) with the WC Board. This form must be filed w/in 30 days of the final disposition or settlement of the disputed claim - also must promptly comply with the collection requests of the NY State School of Industrial and Labor Relations

Health Maintenance Organizations

An HMO provides comprehensive health care to its members for a prepaid fixed fee, similar to an insurance premium. Services are provided through employed physicians that provide a broad range of health care services with few exclusions and very small deductibles and co-pays if any at all

Second Opinion

An opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making the recommendation for a particular health care service. The second provider will assess the medical necessity and appropriateness of the treatment proposed by the first provider

Fundamental tradeoff

Benefits provided by employer in exchange for their employees relinquishing their right to sue their employer for the tort of negligence

Cost Containment

Business practice used by all types of businesses to maintain expense levels - can be accomplished through curtailing unnecessary expenses to improve profitability w/out risking the quality of the product or service delivered to customers

NCCI General Section

Clarifies the terminology that is contained within the policy - "The Policy" means the Information page and all endorsements and schedules listed there - "Who is insured" refers to the "insured", who is the employer named in "Item 1" of the information page - "Workers Compensation Law" refers to the WC laws of each state or territory named on the information page - "State" means any state of the US and DC - "locations" means all the workplaces listed on the info page

Requirements to Provide WC Coverage

Compulsory vs. elective - Compulsory: employers are required to provide WC coverage to all employees, unless the employer and/or the employments are exempt per law - Elective: employers who choose to provide WC coverage to their employees are granted immunity from lawsuits from injured employees, but employers choosing not to provide coverage, lose the civil immunity from being sued by their injured employees

NCCI

Governing body for WC instates that allow private insurers to issue policies

Utilization review organizations

Hired by insurers to conduct utilization reviews - must be licensed by the insurance department of the state in which they are working. These organizations will conduct their reviews according to the written standard procedures provided to them by the insurer - if a reviewer determines, after completing a utilization review, that the health care services or procedures meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness, the reviewer will "certify" the request for benefits (the claim) - if the reviewer finds that the health care services or procedures provided do not meet those standards, they will make an "adverse determination" and the benefits will be denied

Income Benefits

Indemnity; paid to an eligible worker who is "disabled" because of job-related accidental injury or occupational disease - Disability in NY means the state of being disabled for meaning full wages at the work at which the employee was last employed

In the course of

Injury occurred: - during working hours - on the employer's premises - while the worker was engaged in an activity that he/she was authorized to perform - the activity "directly" or "indirectly" promotes the employer's business - concerns the CIRCUMSTANCES of the occurrence that led to injury

Experience Rating

Insureds that have premiums above a certain amount are eligible to receive an "experience rating" by the NCCI. Individual state laws set the minimum policy premium amount that allows an insurer to become eligible for an experience rating - NCCI uses a complex mathematical formula that compares the insured's actual losses, to the losses that are expected for companies of similar size, that are engaged in the same type of work (EMF OR E-MOD) - Purpose is to reward insureds with a good loss experience with lower premiums and to penalize those with a bad loss experience. This provides insureds with a financial incentive to prioritize safety and control hazards in the workplace

Part six - conditoins

Lists the various conditions that apply to the policy, including cancellation and subrogation rights, and the insurer's right to inspect an insured's workplace at any time

Part Two - Employers liability

Necessary because there are situations in which an employer may be sued outside of the WC laws of their state. For ex - small business where the employer is exempt from purchasing WC coverage; other instances may include an injured worker who was employed illegally or a worker whose injury is considered "noncompensable" under the WC state statutes

Cause

Never includes "proximate cause" - WC coverage is no-fault coverage and is only concerned w/ whether or not the injury or illness arose out of and in the course of employment

Current Procedural Terminology (CPT)

Not only used to identify a particular treatment, but each of the CPT codes are associated with "Relative Value Unit" (RVU). The RVU's provide a narrow range of compensation that a physician or hospital should be compensated for the treatment or procedure indicated by the CPT code. The American Association (AMA) produces the schedule containing the CPT codes with their corresponding RVUs. A conversion factor is included in the schedule to calculate the compensation rate. this conversion factor is updated every few years as necessary

Case Management

Patient care and treatment coordination of serious, complicated, or protracted medical conditions. This coordination is performed for individual patients, reducing the cost by omitting unnecessary treatment, even if that treatment may be recommended generally for patients with the same condition

Volunteer FireFighters or Ambulance Workers Benefits Law

Provides cash benefits and/or medical payments benefits for volunteer firefighters or ambulance workers who are injured in the line of duty. The local political subdivision pays the premium for this coverage and cannot require the volunteer member to contribute. The amount of the benefits to be paid by the subdivision's insurance carrier is determined yearly by state statute. - as with WC benies, no one party is determined to be at fault for benefits to be payable. the amount a claimant received is not decreased by his/her carelessness, nor increased by the company's fault. a volunteer member loses his/her right to benefits if the injury resulted solely from his/her intoxication from alcohol or drugs, or from intent to injure him/herself or someone else

Other States Insurance

Provision applies to provide automatinc coverage in states not listed for Part ONe coverage. However, the state must be listed for Part Three coverage - if the employer begins work in any of the states not listed for Part One coverage, but listed in Part Three, all provisions of the policy will apply automatically - the employer must notify the insurer "at once" if it begins work in any of the "other states" listed in part three of the policy

NCCI Information Page

Same as Declaration's page of other insurance policies - a list of named insureds - mailing address of the first named insured - policy period - limits of the "Employer's Liability" section of the policy - a list of the endorsements attached - premium information

Second Injury Law

Some states have implemented laws to create "second injury funds" (sometimes known as "subsequent injury funds") to encourage employers to hire disabled workers. The law protects these employers from disproportionate liability in the event that a second workplace injury occurs to the disabled worker

Part one - What payments must be made by the employer in excess of the WC benefits paid by the policy?

The employer is responsible for any necessary payments in excess of the benefits regularly provided by the WC law if the employer has engaged in serious and willful misconduct such as - knowingly employing a worker in violation of the law - failing to comply with a health or safety law or regulation - discharging, coercing, or otherwise discriminating against any employee in violation of the WC law

Discharge Planning

The formal process for planning the coordination and management of the patient's care following their discharge from a health care facility

Insured is covered by "employers liability"

Under two or more policies, claims will be settled using the "contribution by equal shares" method. The insurer will not pay any claims for damages after they have paid the applicable limit of liability under the policy

Exclusive Remedy

WC in NY is mandatory, making the WC laws compulsory. Employers are required to post a notice of WC in the workplace - lawsuits may be brought against those employers who fail to secure WC coverage for their employees

WC Board

Was established to administer the WC laws and regulations and responsible for: - adjudication of claims and ensuring that employers provide the required coverage - administering the WC program and its laws in a fair and equitable fashion - receiving and processing claims - seeking to facilitate expedient agreements between injured workers and their employers

Jones Act

also known as Merchant Marine act of 1920, allows maritime workers to sue their employers for negligence that results in injury or death - Act uses the comparative negligence standard and allows the personal representative of a deceased crew member to claim damages on behalf of the survivors

Federal Employers Liability Act (FELA)

applies to railroads and their employees. Not considered WC Act because employees are required to prove negligence on behalf of their employer, in order to collect on a claim. If the negligence cannot be proved, the employer is not liable for the claim. Damages are awarded using the comparative negligence standard

Medical Payments

emplr will pay for the immediate health care costs of an injured employee - includes medical, dental, surgical, optometric or other attendance or treatment, nurse and hospital service, medicine, optometric services, crutches, eye-glasses, false teeth, artificial eyes, orthotics, prosthetic devices, functional assistive an adoptive devices and apparatus for such period as the nature of the injury of the process of recovery may require

WC laws

in effect in all 50 states; state laws determines WC benies and how they are calculated

Federal Employees' Compensation Act (FECA)

provides no-fault WC coverage to three million federal and postal workers, including wage replacement, medical and vocational rehabilitation benefits for work-related injury and occupational disease - self-insured by fed gov

Arising out of

the injury occurred because of a condition or risk created by the job - Concerns the CAUSE of injury

Part one - how will benefits be paid?

the insurer will promptly pay the benefits due to the insured's employees as required by the WC laws of the state

Wokers Compensation

type of insurance that provides wage replacement, medical, rehabilitative and death benefits to injured employees or their beneficiaries

Exclusive/sole remedy

when employee's receive compensation for work-related injury