Workers' Compensation 101

Workers' Compensation 101

Objectives:

  • Explain how basic workers' compensation works.

  • Direct injured workers and employers to Bureau resources.

Basic Elements of Workers' Comp:

  • Medical Care

  • Temporary disability benefits (Temp)

  • Permanent disability benefits (Perm)

  • NA

Injury and Reporting

  • What must happen first? An Injury

  • Report of Injury

  • Report Need for Medical Treatment

  • It costs money when something is done wrong.

  • Example: 6,5006,500 in plaintiff attorney fees and $222.20 in costs. In Grissom v UPS, the Court of Workers’ Compensation Claims ordered the employer to pay $27,353.63 in plaintiff attorney fees and expenses.

  • Other consequences of not reporting correctly or on time.

Reporting a Work Injury

  • How does one report their work injury?

  • How long to report an injury?

  • What happens if they wait too long?

  • February 2, 2024, CWCC Blog, Arlene Ernstes v. Printpack Inc.

    • Key Questions:

      • Did the employee provide timely written notice of the alleged work-related injury?

      • If not, did the employer have actual knowledge of the alleged work-related accident or injury?

      • If no to both, did the employee show a reasonable excuse for the failure to give proper notice to the employer?

      • If no to all of the above, the claim should be denied and dismissed.

      • If written notice was given but the employer asserts a defect, the burden of proof shifts to the employer to prove actual prejudice.

Medical Care

  • How does one get medical care?

  • Who schedules the appointment?

Authorized Treating Physician (ATP)

  • What is an Authorized Treating Physician?

  • What three presumptions does an ATP have?

Medications

  • How does one get their medications?

  • Who chooses the pharmacist?

Bills

  • How does one pay their bills?

Disability Benefits

  • Can one collect disability benefits and work a 2nd job?

Claim End

  • How does one's claim end?

  • Why would an injured worker be entitled to temporary disability benefits after Maximum Medical Improvement (MMI)?

  • Questions?

  • That's WC 101

Workers' Compensation 201

Burden of Proof & Standard of Proof

  • What is the difference?

  • Who has the burden in TN Workers' Comp?

  • What standards apply in TN Workers' Comp?

Standards of Proof

  • Beyond a Reasonable Doubt

    • Requires elimination of every reasonable doubt.

  • Clear and Convincing Evidence

    • Firm belief or conviction.

  • Preponderance

    • More likely than not.

    • Likely to prevail at a hearing on its merits.

  • Probable Cause

    • Facts and circumstances lead an ordinary person to believe.

    • Specific and articulable facts.

  • Reasonable Suspicion

  • Pyramid: As the level of proof required rises, the fewer number of cases meet the level of proof.

Arising Out of Employment (AOE) and Course & Scope (C&S)

  • Arising out of and within the course and scope of employment.

  • AOE or C & S

  • Examples:

    • Fell from Roof

    • Driving a car

    • Hit by car

    • Using the exfiltration machine

  • What does "arise out of the employment" mean?

  • What does "course and scope" mean?

  • Fell from Roof while repairing shingles.

  • Impact injury from accident while driving a car.

  • Hit by car while crossing the street.

  • Sleeve caught in conveyor while using the exfiltration machine.

Common Errors

  • 1+1=31+1=3

  • Not using a physician to answer an AOE question.

  • Using a physician to answer a C&S question.

Aggravation or Exacerbation of a Pre-Existing Condition

  • What is a pre-existing condition?

  • What is the difference between aggravation and exacerbation?

  • What is an aggravation or exacerbation?

  • What does return to baseline mean?

Common Errors

  • 1+1=31+1=3

  • Employer take them as they are.

  • Fail to ask the doctor about causation.

  • Current complaints and conditions, not overall condition.

Idiopathic Injuries

  • What is an idiopathic injury?

  • Does an idiopathic injury arise out of the employment?

  • Does an idiopathic injury occur within the course and scope of employment?

  • What is a hazard incident to the employment?

Common Errors

  • 1+1=31+1=3

  • Steps

  • Not distinguishing between the personal condition and the work injury.

Coming and Going Rule

  • What is the coming and going rule?

  • How many exceptions can you name?

Common Errors

  • 1+1=31+1=3

  • Decision not based upon C & S

Workplace Assault

  • How many classes of assault can you name?

  • Which are compensable?

Common Errors

  • 1+1=31+1=3

  • Applying workplace rule violations

  • Not considering expected risks

Intervening Causes

  • What is an intervening cause?

  • Does negligence matter?

  • What is direct and natural consequences rule?

Common Errors

  • 1+1=31+1=3

  • Not considering physician direction

  • Severing too quickly

Injuries Not Covered

  • What are the six types of injuries that are not covered?

  • What does affirmative defense mean?

Common Errors

  • 1+1=31+1=3

  • Not considering physician causation.

  • Not getting help from an attorney to put the defense together.

Petition for Benefit Determination

  • If the PBD is the lawsuit, can an adjuster respond to it?

  • What is a Dispute Certification Notice?

  • Do I have to hire an attorney?

  • How long will the lawsuit be pending in the Court?