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CLAIMS TIPS

Timely Reporting of Information

Effective and efficient claims management involves many aspects, but one of the most important is - and always will be - timely communication of pertinent information between the employer and the insurer's claims administrator. Only then can you be assured of the immediate and proficient servicing of all claims, which ultimately results in lower associated claims costs. Claims costs have a direct bearing on the amount of workers' compensation premiums paid by you and all employers.

Once an employee makes a claim, you assume certain responsibilities which you must handle promptly. First, you should immediately report the claim, especially if it is serious or questionable. Prompt reporting ensures the timely payment of benefits legally due to an injured worker. Even if you question an employee's credibility or the validity of his claim, you must notify Stonetrust. Immediate reporting allows us to more effectively investigate a questionable claim. Mediation notices, lawsuits, or other legal documents relating to the claim should also be reported to us upon receipt. 

The timely reporting of all recommended treatment and diagnostic tests is also essential. This enables your insurer to review, authorize, and pre-certify where treatment is medically necessary. As you may know, Louisiana Workers' Compensation claims are subject to a fee schedule. Regardless of the amount billed, the doctors, hospitals, therapists, etc. can only collect the allowed fee for a specific procedure. It is important that your claims administrator authorize and pay all bills direct as this is the only way to guarantee the lowest possible payment.

Providing Light Duty Work

Employers can help reduce claims related expenses by providing light duty employment once the injured employee has been cleared for work. If the job pays 90% or more of the claimant's pre-accident average weekly wage, then weekly indemnity payments will cease. If the job pays less than 90%, the claimant's weekly compensation rate will be reduced to two-thirds of the difference between the pre-accident and post-accident average weekly wage. Also, if the claimant does not accept a physician-approved light duty job, the employer/insurer can still terminate benefits. The earlier an employee is offered and returns to gainful employment, the less the claim will cost. Also, the chances of the claim being handed over to an attorney are decreased, thereby eliminating future litigation costs.

Use of the Second Injury Fund

The purpose of the Louisiana Second Injury Fund, as provided by Section 23:1371 of the Louisiana Workers' Compensation Statute, is to encourage the hiring of individuals who have a permanent, partial disability. In return, if an employee has a subsequent serious injury which merges with the pre-existing condition to cause a greater disability than what would have resulted from the subsequent injury alone, the employer/insurer will be limited in the amount he is required to pay for the new claim. The pre-existing condition can be congenital and does not have to arise from a prior job accident.

The first requirement for a successful second injury claim is the employer's knowledge (i.e., knowledge by an owner or supervisor authorized to hire or fire) of a permanent partial disability as defined in section 23:1378(F), such as a ruptured disc, partial loss or use of a body part, epilepsy, diabetes, arthritis, and many others. The next requirement is the employer's awareness of the condition prior to the job accident; it is not necessary to have knowledge at the time of hiring. The final requirement is to establish a merger of the job accident (second injury) with the pre-existing permanent disability. Specifically, it must be shown that the merger of the two conditions has caused a greater disability and/or higher associated medical costs than that which would have occurred had there not been a pre-existing condition. If these requirements can be satisfied, the employer's responsibility is generally limited to 130 weeks of compensation and a $25,000 medical deductible.

Personnel records which include prior medical histories – to be completed after an offer of employment has been made - are extremely helpful in assessing eligibility of Second Injury Fund claims. A post-hire questionnaire is an easy, convenient way for employers to inquire about pre-existing conditions, whether congenital in nature or not, and could potentially save tens of thousands of dollars. You may download a Second Injury Fund Questionnaire and other helpful employment documents in the “Downloads” section. |