South%20Carolina%20Workers

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South Carolina Workers Compensation Nuts and
Bolts Medical Version
Sarah S. Alphin
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Claimant alleges a work accident

• Employer investigation
• Statement from Claimant
• Obtain written statement if possible
• Identify witnesses
• Document as much as possible in writing

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Initial Medical Treatment

• Claimant sent to emergency room or other urgent
  care, if needed
• Employer or Carrier has right to choose medical
  provider
• Drug test performed
• Obtain work restrictions

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Claim sent to Carrier

• Carrier should review Employers investigation
  reports and physician report
• Carrier conducts further investigation
• Recorded statement of Claimant
• Obtain prior medical records
• Interview witnesses and Employer representatives

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Carrier must determine

• Did the Claimant sustain
• (1) an injury by accident
• (2) arising out of and
• (3) in the course of employment
• Do any defenses exist?
• Notice 90 days
• Statute of Limitations
• Intoxication/Willfulness
• Fraud in the Application

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Accept or Deny?
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Reasons to Deny a Claim

• It did not happen!
• Not compensable
• No EE/ER relationship (independent contractor,
  volunteer)
• Heart attack/stroke/mental-mental only
  compensable if unusual and extraordinary
  conditions of employment

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Is the injury compensable?

• An injury is only compensable if
• An injury
• Must be unexpected
• By accident
• An unlooked for or untoward event
• Arising out of and
• Origin/cause of accident (must be caused by
  employment)
• In the course of employment
• Time, place, circumstances

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Injuries that are not compensable

• Idiopathic injuries (level floor)
• Fights unrelated to work
• Horseplay
• Going and coming to work
• Exceptions parking lot, ER provided travel, EE
  paid for travel, or EE charged with task

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If Claim is denied

• No further medical treatment authorized by
  carrier
• Initial treatment authorized by carrier still
  paid for by carrier
• Claim can be denied at anytime

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If Claim is accepted

• Claimant is entitled to 3 types of benefits
• Medical benefits
• Temporary compensation
• Permanent compensation

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Medical Treatment

• Section 42-15-60 of the South Carolina Workers
  Compensation Act governs what medical benefits
  are provided under the Act.
• The employer/carrier is required to provide
  medical care which is causally-related to the
  work injury.
• The statute states that the employer/carrier
  shall provide medical treatment that will affect
  a cure or give relief.

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Medical Treatment

• Medical care can continue so long as in the
  opinion of the Commission it will tend to lessen
  the period of disability.
• Claimants are entitled to medical treatment after
  maximum medical improvement if they can establish
  that the medical care (medications, physical
  therapy, etc.) will tend to lessen their period
  of disability or maintain their level of
  functioning.
• You will hear this referred to as Dodge
  medicals because they are based on the Dodge case
  (Dodge v. Broccoli).

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Medical Treatment

• The employer/carrier is allowed to choose the
  physicians the employee receives care from.
• Prosthetic devices are covered for repair or
  replacement for a claimants life.

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Regulation 67-1307

• Regulation 67-1307 of the South Carolina Workers
  Compensation Commission addresses the role of
  rehabilitation professionals. (see attached)
• R. 67-1307 (A) reads as follows Rehabilitation
  professionals are coordinators of medical
  rehabilitation services, including but not
  limited to state, private, or carrier based,
  whether on site, telephonic, in or out of state.

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Regulation 67-1307

• R. 67-1307 (B) reads as follows The role of a
  rehabilitation professional is to ensure the
  primary concern and commitment in each workers
  compensation case is to advance the medical
  rehabilitation of the injured worker.
• R. 67-1307 (C) requires rehabilitation
  professionals to comply with Section 42-15-95 and
  R. 67-1308.

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Obtaining Medical Records and Communication with
Physicians

• Section 42-15-95 (A) An employee who seeks
  treatment for an injury or condition for which
  compensation is sought CONSENTS to the release of
  medical records related pertaining to workers
  compensation claim
• A request citing Section 42-15-95 as the
  authority allowing you to obtain the records
• Medical providers must provide records within 14
  days

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Obtaining Medical Records

• If carrier wants to investigate pre-existing
  conditions or prior medical conditions, a
  subpoena can be issued by an attorney
• If Claimants attorney wants prior records, the
  Claimant can sign a written release
• A subpoena/release from Claimant can request any
  and all records, even records prior to an accident

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Communication with Physicians

• Section 42-15-95 (B) governs communication with
  health care providers.
• Issues that may be discussed
• Medical history
• Diagnosis
• Causation
• Course of treatment
• Prognosis
• Work Restrictions
• Impairments

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Communication with Physicians

• Requirements to have such communication
• Notify employee/claimant or claimants attorney
  in timely fashion, in writing or orally, prior to
  communication taking place (R. 67-1308 requires
  10 day notice).
• Advise employee of the nature of the discussion
  or communication prior to the discussion or
  communication
• Allow claimant or claimants attorney to attend
  the meeting or participate in the discussion.

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Communication with Physicians

• If written questions are used, provide a copy of
  the questions to the employee/claimant or
  claimants attorney at the same time the
  questions are submitted to the heath care
  provider.
• Provide copy of response to questions to
  employee.
• Any information obtained in violation of these
  requirements cannot be used at a hearing.

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Communication with Physicians

• When a Form 14B is sent to a medical provider, a
  copy of it should also be sent to the Claimant or
  Claimants attorney.
• When a completed Form 14B is returned, a copy of
  it should be sent to the Claimant or Claimants
  attorney.

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Form 14B

• Addresses MMI, permanent impairment, work
  restrictions and future medical treatment.
• Is future medical care needed to a reasonable
  degree of medical certainty?
• Not just that it may be needed in the future
• Is the injured body part rated?

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Form 14B

• WCC requires a Form 14B in certain cases
• 16A settlements
• Informal Conference settlements
• Form 14B to be completed by medical provider
• Important to fully complete the Form 14B

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Nurse Manager Communication with Interested
Parties

• Updates to adjuster and attorneys regarding
  status of treatment
• Nurse case manager reports
• Request for reports from Claimants attorney
• Discussions by phone with adjuster/employer

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Who Do Nurse Managers Work For?

• Services are engaged by the carrier
• Request from Claimant, Claimants attorney,
  Claimants family regarding specific things they
  want

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Who Directs the Medical Care?

• The employer/carrier has the right to direct
  medical care under the South Carolina Workers
  Compensation System.
• Carrier selects physician
• If referrals are made by physician, carrier can
  still direct the referral
• If a Claimant attempts to change appointments
  without letting you know, Nurse Managers should
  advise the physicians office not to allow the
  appointment to be changed unless it is authorized
  by you.

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While a Claimant is treating

• Carriers need copies of medical records following
  appointments
• Needed to authorize additional treatment,
  referrals, diagnostic testing, etc.
• Many times these things cannot be authorized with
  the corresponding medical note
• Carriers need updated work restrictions/status
  following appointment

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While a Claimant is treating

• Light Duty work
• Physicians often allow Claimant's to return to
  work restricted or light duty while treating
• Providing light duty reduces overall cost of
  claim
• The longer a Claimant is totally out of work, the
  harder it may be for them to return later
• Employers are not required to provide light duty
  work in SC.

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Questionnaires from Attorneys

• Why are questionnaires needed?
• Causation
• Issues not being address in narratives notes
• Practice used by both Defense and Claimants
  attorneys
• Claimants attorneys can request questionnaires
  without notifying carrier/Defense attorney
• Defense attorneys must copy Claimant on
  questionnaires to comply with communication
  regulation

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Permanent Disability Benefits

• If the matter is heard by a Commissioner, the
  Commissioner determines the amount of disability.
  
• The amount of the disability will not normally be
  the same as the impairment rating.
• There are no exact factors or guides to determine
  how much the disability award will be and the
  Commissioners have great discretion in
  determining the award.

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Permanent Disability Benefits

• Different people with the same injuries and
  ratings could be awarded a different amount of
  disability
• For example, a construction worker who has a
  significant back injury and has lifting
  restrictions because of his injury will most
  probably receive a disability award that is
  higher than a person who works in an office
  environment but is not required to do any
  significant lifting, even though their injury and
  medical impairment rating are the same.

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Permanent and Total Disability

• A person is entitled to permanent and total (PT)
  disability benefits when they are unable to work
  at their previous job or at any other employment
  which is reasonably available in the economy.
• Maximum weeks allowed for permanent and total
  disability is 500 weeks.

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Permanent and Total Disability

• A claimant is not entitled to lifetime indemnity
  benefits for permanent and total disability.
• PT disability awards do include lifetime medical
  care for medical conditions causally-related to
  their injury.
• Cases involving paraplegia, quadriplegia or
  physical brain damage
• no 500 week cap
• lifetime weekly benefits
• lifetime medical treatment

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QUESTIONS?