- Administrative Policy 2-03 Workers Compensation Program
Administrative Policy 2-03 Workers Compensation Program
DATE: May 2, 2005
SUBJECT: Workers’ Compensation Program
PURPOSE: To provide Workers’ Compensation and injury management for employees claiming job related injury or illness. Included are procedures for obtaining medical treatment, injury reporting, contested and uncontested claims, returning employees to work, monitoring employees in “On-the-Job Injury” leave status and processing of medical bills. The provisions of Title 85 Oklahoma Statutes and the Lawton City Code shall apply in addition to the provisions of this policy.
BACKGROUND: The City of Lawton desires to standardize the various aspects of its Workers’ Compensation Program. In the past, departments may not have been consistent in the application of procedures for obtaining medical treatment for injured employees, charging lost work time due to an employee’ s injury or preparation for a court hearing, contesting a claim, returning an employee to work on full or light (limited) duty. Further, employees needed a source of information that would answer their questions concerning their benefits, rights and responsibilities under the Oklahoma Workers’ Compensation Act and the City’ s program.
DEFINITIONS: Claim - A request for benefits under the Workers’ Compensation Act.
Compensable Injury - An injury for which benefits are payable under provisions of the Oklahoma Workers’ Compensation Act.
Contested Claim - A claim the employer considers to be not compensable under the Workers’ Compensation Act. Generally, benefits, including On-the-Job Injury leave, will not be paid on a contested claim unless the or until the Workers’ Compensation Court finds the claim to be compensable.
Court - The Oklahoma Workers’ Compensation Court.
Division Supervisor - Division Superintendent, Deputy Fire Chief, Police Major, or similar level supervisory personnel.
Form 2 - Entitled “Employer’ s First Notice of Injury”, this is the document that employer must file with the Workers’ Compensation Court and the third party administrator when an employee is injured, contracts an occupational disease in the course of his employment for which medical treatment is obtained away from the work site or dies as the result of a compensable injury or illness.
Form 3 - The document an injured employee may file with the court to request workers’ compensation benefits due to an accidental injury. The Form 3 is also called the “Employee’ s First Notice of Accidental Injury and Claim for Compensation”.
Form 3A - The document that a dependent of a deceased worker may file to request workers’ compensation death benefits. The Form 3A is also called the “Claimant’ s First Notice of Death and Claim for Compensation”.
Form 3B - The document that an injured employee may file with the court to request benefits due to an occupational disease. The Form 3B is also called the “Employee’ s First Notice of Occupational Disease and Claim for Compensation”.
Functional Capacity Evaluation (FCE) - A medical evaluation conducted by a qualified physician or occupational therapist designed to quantitatively measure and record an employee’ s physical abilities to perform job activities required in a specified position or job.
Immediate Supervisor - The Field Supervisor, Lieutenant, or other supervisor responsible for directly overseeing the day-to-day job related activities of the employee.
Light (Limited) Duty - Jobs or tasks that can be safely performed by an employee who is restricted from performing all tasks associated with the employee’ s permanently assigned job due to physical restrictions imposed by a qualified physician for a compensable injury. Also referred to as “limited” or “restricted” duty. See Administrative Policy 3-19.
Maximum Medical Improvement (MMI) - No further material medical improvement would reasonably be expected with additional medical treatment or the passage of time.
Occupational Illness - A disease or illness which is due to causes and conditions characteristic of or peculiar to the particular trade, occupation, process or employment in which the employee is exposed to such disease. As used herein the term injury or illness are interchangeable unless otherwise indicated.
On-the-Job Injury (OJI) - As used in this policy, means a compensable injury.
Supervisor - Either the immediate or division supervisor who may be designated by the department director to carry out the responsibilities of the “Supervisor” as indicated in this policy.
Workers’ Compensation Claims Administrator - A firm under contract with the City of Lawton to provide third party administration of the City’ s own-risk Workers’ Compensation Program. The administrator is responsible for processing claims and issuing checks in payment of workers’ compensation benefits.
PROCEDURES: A. Employee Rights - Notification Required.
1. Employees must be notified of their rights and benefits prescribed by the Workers’ Compensation Act. If they have not received such notice, the time limits imposed by the law may be tolled. Thus, an employee lacking such notice may be able to file a claim and collect benefits without regard to the statute of limitations. NOTICE will be done by posting in each department, in conspicuous locations, Workers’ Compensation Form 1A “Workers’ Compensation Notice and Instructions to Employers and Employees”. Form 1A must be posted so that all employees will have access to it. Department directors and division supervisors must ensure that the Form 1A is posted and accessible to all employees.
2. The reverse side of the City’ s “Report of Injury” form also contains notification to injured employees of their rights and responsibilities under the Workers’ Compensation Act.
B. Obtaining Medical Treatment for Injured Employees.
1. The primary consideration whenever an employee is injured is to obtain the appropriate medical treatment for the employee as soon as possible. The injured employee should be provided a signed medical treatment authorization form by his/her supervisor and seek treatment from a provider chosen by the employee. If emergency treatment is required for an injury which is threatening to life or limb, the injured employee should be transported to the nearest medical facility than can provide the required treatment unless the injured employee specifies an alternate provider. If an injured employee does not choose a provider, the employee’ s supervisor must refer the employee to an appropriate source for treatment of the employee’ s injuries.
2. If medical progress of the injured employee becomes unsatisfactory to management personnel, the employee will be referred to a physician selected by the Legal Services Department Administrator in consultation with the City’ s Workers’ Compensation Administrator, as appropriate, for a second opinion. Should the employee refuse to report to this additional physician for evaluation or treatment as directed, payment of workers’ compensation benefits may be suspended.
C. Accident Investigation. After ensuring that the injured employee receives medical care, the supervisor will immediately begin investigating the situation that caused the injury. The result of this investigation will be documented in the appropriate sections of the City’ s “Report of Injury” form. Additional documentation may be generated as warranted. If, after investigating, the supervisor doubts that the injury is compensable, he/she should so indicate on the form and inform the Legal Services Department Administrator that the validity of the claim is in doubt. The Legal Services Department Administrator will notify the third party administrator to further investigate the claim and contest it if appropriate.
D. Injury Reporting Requirements.
1. The Legal Services Department Administrator will be notified as soon as possible by phone of any injury involving a City employee by the employee’ s immediate supervisor, assistant department director or department director. If the injury occurs on other than a normal business day the injury will be reported on the next business day. If the injury results in the death of the employee the City Manager will be notified immediately. The notice will include the injured employee’ s name, the nature of the injury and the severity of the injury. The Authorization to Treat form signed by a supervisor should be sufficient authorization for an employee to receive treatment. However, many providers will still call the Legal Services Department Administrator to verify that an injury is covered by workers’ compensation.
2. Upon being notified of an injury potentially compensable under the Workers’ Compensation Program the immediate supervisor will complete a “Report of Injury” form. The immediate supervisor will complete the form based on investigation, statements by the injured employee and witnesses and any other source of information. The form will be forwarded to the Legal Services Department Administrator NO LATER THAN THE NEXT BUSINESS DAY FOLLOWING THE INJURY. The second copy of the form including all documentation required for review by the Injury Review Board will be submitted to the Human Resources Department within five (5) working days.
E. Workers’ Compensation Claim Processing.
1. As soon as practical after a compensable injury or illness occurs (normally at the time the “Report of Injury” is initiated) the injured employee shall be informed by his/her supervisor of the rights, responsibilities and benefits as set out in paragraph A.1. or A.2. of this policy. This information is printed on the reverse side of the “Report of Injury” form. The injured employee will be provided a copy of the “Report of Injury”. The injured employee does not have to file a claim form in order to have relevant medical expenses paid and to receive temporary compensation for lost work days incurred due to the injury. These will be provided voluntarily unless it is determined by the City that the injury did not arise out of and in the course of employment. See contested claims paragraph F.
2. A Workers’ Compensation Court Form 2, Émployer’ s First Notice of Injury”, will be filed by the City Attorney’ s office with the Workers’ Compensation Court and the City’ s Workers’ Compensation Administrator for each injury. The Form 2 is generated based upon the information contained in the “Report of Injury”. Submission of the Form 2 is required whether or not the claim is thought to be valid.
3. The Form 2 is the Workers’ Compensation Administrator’ s authorization to provide medical benefits to the injured employee unless the administrator is notified at the time of filing of the Form 2 or at some later date that the claim is contested. The injured employee has the right to file a claim using Workers’ Compensation Court Form 3 or Form 3B. The forms are available in the City Attorney’ s office.
4. Under no circumstances are Group Health Plan claim forms to be used to claim benefits that are payable under the City’ s Workers’ Compensation Program.
F. Contested Claims.
1. Injuries or illnesses must arise out of and be in the course of employment in order to be compensable. Injuries or illnesses that are not work-related are not covered. This means that an injury must occur at work and while the employee is performing activities that the employee was hired to perform or which benefit the employer.
2. The City will conduct an inquiry to determine if the injury or illness is compensable. If the results of the inquiry indicate that a particular injury or illness is not compensable, the City Manager, after consulting with the employee’ s department director and the City Attorney, will determine if the claim should be contested. If contested:
a. The Legal Services Department Administrator will notify the employee that the claim has been contested. If the injury or illness is determined not to be a compensable job-related injury or illness the claim will be referred to the City’ s health insurance program or if the employee has chosen not to be covered by the City’ s health insurance program the employee will be responsible for all costs and he/she will not be eligible for “On-the-Job Injury Leave” or “Temporary Total Disability” benefits.
b. The Legal Services Department Administrator will notify the Workers’ Compensation Administrator that the claim is contested. However, as required by law, a Form 2 will be filed with the Workers’ Compensation Court.
c. Once a claim is determined not to be work-related and is contested workers’ compensation benefits will not be paid unless the Workers’ Compensation Court determines that the claim is compensable. However, a claim previously contested may at any time be reconsidered and accepted as a valid claim. Reconsideration will only be approved at the direction of the City Attorney after approval by the City Manager. The Legal Services Department Administrator will inform the claimant and the claimant’ s department director of any change in the status of the claim.
d. If the claim is later determined by the City or the Court to be compensable, the employee is entitled to be placed on on-the-job injury leave or temporary total disability and receive benefits from either the City or by Court order. If the employee used sick leave, vacation leave or flexible holiday hours, all payments received by the employee for these hours from the City will be reimbursed to the City. After the employee reimburses the City for these hours they will be restored to the employee’ s appropriate leave accounts.
G. Payment of Benefits.
1. Medical benefits:
a. Information for Medical Services Provider: An injured employee who feels his/her injuries are compensable will provide a signed Authorization to Treat form to the provider.
b. Payment Process for Medical Treatment: All statements or invoices (“bills”) will be processed for payment by the City’ s Workers’ Compensation Administrator. These may be sent through the Legal Services Department Administrator or sent directly to the workers’ compensation claims administrator by the physician or the medical facility providing treatment. However, if sent in error to the injured employee, the employee is to immediately forward them to the Legal Services Department Administrator. (Note: Some physicians and medical facilities send information or courtesy statements to the injured; these statements do not demand payment and are to be retained by the employee.) If an employee becomes aware that medical bills that should have been processed by the Workers’ Compensation Claims Administrator have been processed by the Group Health Plan Claims Administrator, the employee must immediately report the error to the Human Resources Department and the City Attorney’ s office.
c. Reimbursement of Employees for Expenses Paid: If the injured employee pays for any portion of expenses for treatment, prescription drugs, medical supplies, or equipment necessitated by a compensable injury, he/she will be reimbursed by the City’ s Workers’ Compensation Claims Administrator. Any receipts for such payment must be turned in to the Legal Services Department Administrator in order for the employee to be reimbursed. Employees should mark all such receipts indicating “job injury” and the date of the injury.
d. Unauthorized “Second Opinions”: Treatment provided from sources to which the injured employee was not properly referred by the initial treating physician are not covered expenses. Second opinions are not covered unless they are directed or authorized by the City. Injured employees not satisfied with the treatment they are being provided should seek authorization for a change in physicians from the Legal Services Department Administrator.
2. Temporary Total Disability (TTD) Benefits:
a. In general, all regular employees will be provided their full salary through the City’ s payroll system during the first twenty six (26) weeks an employee is required to miss work because of a compensable injury or illness. This benefit will be paid from the first day of lost time for up to twenty six (26) weeks unless the employee is authorized to return to work earlier.
b. After twenty six (26) weeks, payment of salary through the City’ s payroll system will cease. Any additional time off will be considered as Temporary Total Disability benefits and will be paid through the Workers’ Compensation Administrator at the rate mandated by law. The City’ s payroll system will carry the employee in Leave Without Pay status.
c. Employees will not be allowed to use their accrued leave (vacation, sick, flex or comp time) to augment TTD benefit payments or in lieu of TTD while on leave without pay as a result of an on-the-job injury.
d. If an employee should return to work in a light duty status any subsequent doctor or physical therapy appointments will be considered as on-the-job injury leave, however the total number of on-the-job injury leave hours shall not exceed four (4) hours in any one work day unless the appointment is not in Lawton, in which case the injury leave shall not exceed travel time to and from the appointment location plus four (4) hours.
e. An employee who terminates employment with the City while temporarily totally disabled will continue to received TTD benefits for as long as and at the rate required by law.
3. Determination of Employee Fitness for Duty after Injury: An employee who is released to return to full duty by his/her treating physician will be returned to full duty as soon as possible. When an employee has reached maximum medical improvement but is released by the treating physician with limitations the Legal Services Department Administrator will refer the employee to the Human Resources Director who will arrange for the employee to be evaluated by another physician or arrange for a Functional Capacity Evaluation (FCE) to determine if the employee is able to return to his/her position. Should the employee be determined to be physically unfit to continue in his/her assigned position due to permanent physical restriction they will meet with their department director and the Human Resources Director to discuss the possibility of allowing the employee to continue to work in the position. If this is unfeasible, the Human Resources Director will work with the employee in trying to find a vacant City position consistent with the employee’ s permanent restrictions and for which the employee may be qualified. After a physician has determined that the employee has achieved maximum medical improvement from treatment for a compensable injury the employee is no longer eligible for any additional TTD benefits including On-the-Job Injury leave.
4. Permanent Partial Disability (PPD) Benefits: PPD benefits are paid only upon order by the Workers’ Compensation Court based upon the percent of permanent partial disability sustained by the employee as a result of a compensable injury.
H. Preparation for Workers’ Compensation Court. Charging lost work time due to preparation for Workers’ Compensation Court hearing:
If the employee has returned to work in either a full duty or light duty status any:
1. Time lost while the employee is undergoing an Independent Medical Examination conducted by a physician selected by the employee or the employee’ s attorney is to be charged against the employee’ s accrued leave balance (vacation, flex or comp time) or leave without pay.
2. Time lost while the employee is undergoing an Independent Medical Examination conducted by a physician selected by the City’ s Workers’ Compensation Administrator or attorney is to be considered normal work duty for the employee and is not to be charged to any type of leave.
3. Time lost due to the court hearing itself is to be charged to the employee’ s accrued leave or leave without pay.
I. Monitoring Disabled Employees.
1. Information Systems (IS) will provide the Legal Services Department Administrator and the Human Resources Director a report listing employees who are losing time from work due to an on-the-job injury and are on “On-the-Job Injury Leave” or leave without pay status.
2. When an employee is listed on the report as missing more than eight (8) hours of work because of an on-the-job injury, the Legal Services Department Administrator will send a letter to the injured employee explaining the employee’ s rights, responsibilities and reporting requirements. Copies of the letter will be forwarded to the director of the department to which the employee is assigned.
3. The injured employee will be required to contact his/her immediate or division supervisor no less than once each week during the period of temporary total disability to report his/her status.
4. The injured employee, if physically able, will report to his/her immediate supervisor or division supervisor immediately after each doctor’ s appointment. The injured employee will provide a doctor’ s written excuse keeping him/her off work or a written authorization allowing the employee to return to work with or without restrictions. The injured employee will also report to the supervisor the date and time of the next scheduled medical appointment, if any. If the injured employee is not physically able to report in person to the supervisor, the employee will provide the above information by telephone, mail or messenger. Failure to comply with these requirements will result in disciplinary action be taken which may include termination from employment for a third or subsequent violation. ON RECEIPT OF THE INFORMATION THE DEPARTMENT WILL IMMEDIATELY FORWARD THE INFORMATION TO THE LEGAL SERVICES DEPARTMENT ADMINISTRATOR.
5. The supervisor will monitor to ensure that the injured employee does not miss any scheduled appointments. Benefits may be discontinued for missed appointments with the medical care provider. In addition disciplinary action will be taken which may include termination for a third or subsequent violation.
6. The supervisor, in coordination with the Legal Services Department Administrator, will maintain communication with the medical care provider to encourage release of the injured employee to full or restricted duty as soon as it is prudent to do so.
J. Workers’ Compensation Claims Administrator’ s Responsibilities. The administrator will:
1. Set up a file for each Form 2 submitted by the City. This file must be established before any expenses related to a claim can be paid. All documentation from the injured employee, the employer, medical care providers, attorney’ s representing the employee or the City and any other relevant information will be maintained in the file.
2. Arrange for services, such as medical case management, second opinions, claims investigation, vocational evaluations and vocational rehabilitation, directed or authorized by the City Attorney’ s office or as ordered by the Workers’ Compensation Court.
3. Provide expert advice to the City concerning validity of claims, appropriateness of medical treatment and costs, appropriate settlement methods and amounts and other workers’ compensation matters.
4. Coordinate with and assist the City’ s workers’ compensation attorney in defending litigated claims.
5. Respond to inquiries from employees concerning claims, benefits or workers’ compensation rules or procedures.
6. Negotiate and arrange permanent disability settlements with employees not represented by attorneys to the limits provided in the agreement between the administrator and the City. All other will be referred as directed by the City Attorney.
7. Pay all workers’ compensation expenses from a checking account maintained by the City and provide weekly listings of all checks written against the account.
8. Provide monthly listing of all claims filed in the various claim years and summarize all workers’ compensation costs by expense category, i.e. medical, indemnity, legal and other.
L. Inquiries. Any questions concerning the status of a particular claim or any aspect of the claims procedure should be directed to the Legal Services Department Administrator or the Workers’ Compensation Administrator.
REFERENCES: Title 85, Oklahoma Statutes and the Lawton City Code
RESCISSION: This policy becomes effective May 2, 2005 and supersedes Administrative Policy 3-16, dated October 1, 1998. This policy will remain in effect until rescinded.
DEPARTMENT: Legal Services
May 2, 2005