The Basics of Idaho Workers’ Compensation

PRESENTER: Kim Takagi,

Idaho Industrial Commission Compensation Consultant

Who is the Industrial Commission, and what do they do?

The Industrial Commission is the state regulatory agency that administers the workers’ compensation law in Idaho.

The Commission has exclusive jurisdiction over claims involving work

related injuries.

Forms referred to in this presentation can be found on the Commissions website at www.iic.idaho.gov under find a form.

Functions of the Industrial Commission

Approve carriers & self-insured employers

Ensure adequate security deposits Enforce coverage requirements Regulate benefit payments Resolve disputes Provide rehabilitation services Provide compensation to victims of

crime

History of Idaho Workers’ Compensation Prior to the introduction of workers' compensation, workers injured on the job were compensated under a system of negligence liability. The employer was no longer liable, respectively, if the worker knew of the danger and assumed the risk of the danger when accepting the job, or if a fellow worker caused the accident, or if the worker's own negligence contributed to the accident.

What is covered by workers’ compensation?

All medical treatment related to an on the job injury is paid in accordance with the Idaho Fee Schedule. The medical provider is prohibited from billing an employee for any balances remaining.

What is covered by workers’ compensation?

(67%) of the employee’s wages are covered while the employee remains in the period of recovery and has a decrease in wage earning capacity or is totally off work.

(Pain and suffering is not covered under workers compensation)

Coverage requirements An employer with one or more employees

is required to secure workers’ compensation insurance coverage, even if the employee is a part-time worker.

Coverage requirements, cont.

The employee pays no portion of the employer’s workers’ compensation coverage premium

No agreement by an employee to waive his rights to workers’ compensation benefits will be valid. This includes the employee agreeing to use vacation or sick leave pay in lieu of workers’ compensation income benefits.

Injury reporting requirements for the employee The employee shall report

his injury to the employer within 60 days of the injury.

Delay in giving notice shall not be a bar to proceedings under this law if it is shown that the employer had knowledge of the injury, or that the employer was not prejudiced in their investigation of the claim by the delay in giving notice.

Injury reporting requirements for the employer For injuries requiring medical treatment or one or

more days from work, the employer must complete and file a First Report of Injury form (IC form 101) within 10 days after the occurrence of an injury.

Filing of a claim by the employer is not admission of liability and is not conclusive evidence of any fact stated therein.

The employer must maintain record of every injury reported to him, either by filing a First Report of Injury, or for minor injury, completing an incident report as a permanent record of the injury.

Injury reporting requirements for the employer If the employer has knowledge of an injury, and

willfully fails or refuses to file a report of injury, the time limitations that apply to the employee’s filing of a request for hearing within one year will not begin to run until the report of injury is filed.

Compensability—is it covered or not? This doesn’t look

safe. Would an electrocution injury be covered or not?

Compensability—is it covered or not? Idaho Workers’

Compensation is a “no fault” system, which means ignorance is covered.

Injuries occurring on an employer’s premises Injuries that occur

on the employer’s premises, including the employer’s parking lot are generally covered.

However, there are some exceptions to the premises rule:

Exceptions Domestic

violence

Fights

Horseplay

Assaults

Coming and going (generally not covered Exceptions

(may be covered):› Peculiar risk› Employer’s premises:

Coming and going exceptions Employer

provided Transportation:

Ingress and Egress:

Employer requested trip:

Repetitive injuriesRepetitive injuries are generally rapidly developing conditions that are compensable, if a physician has deemed them caused by work related activities. They are distinctively separate from occupational diseases due to their rapid and acute development.

Aggravation of pre-existing condition by injury Previous findings state that the employer takes

the employee as he finds him. The current employer’s responsibility would be to return the injured employee to his pre-injury condition, not to fix the pre-existing condition.

72-208 Willful Intention (1) No

compensation shall be allowed to an employee for injury proximately caused by the employee's willful intention to injure himself or to injure another.

Intoxication on the job If intoxication is a

reasonable and substantial cause of an injury, no income benefits shall be paid.

Exception: If the intoxicants were furnished by the employer or if the employer permits the employee to remain at work knowing the employee is intoxicated.

Heart attacks If it can be proven

that the employees work was a substantial contributing cause of the heart attack, it may be compensable.

Occupational diseases 72-102 (22) "Occupational diseases."

› (a)  "Occupational disease" means a disease due to the nature of an employment in which the hazards of such disease actually exist, are characteristic of, and peculiar to the trade, occupation, process, or employment.

Manifestation 72-102 (19) "Manifestation" means the time

when an employee knows that he has an occupational disease, or whenever a qualified physician shall inform the injured worker that he has an occupational disease.

72-439 Actually incurred/non acute occupation disease (1) The employer is not responsible if the

occupational disease was not incurred in the employer’s employment.

(2) Employee must be exposed to the hazard of such disease for a period of 60 days for the same employer in order for that employer to be liable for a non-acute occupational disease.

Reporting requirements for occupational diseases 72-448 (1)

› The employee must give written notice to the employer within 60 days of the manifestation date, or to the Industrial Commission within 90 days of the manifestation, if the employer cannot be located.

› A claim for workers’ compensation for an occupational disease must be filed within 1 year of its first manifestation, or will forever be barred.

Psychological accidents and injuries

72-432: Medical services, appliances and supplies—reports (1) Reasonable

medical treatment.› Designated

Company Physician (2) Appliances and

prostheses. (3) Attendant care

benefits.

72-432: Medical services, appliances and supplies—reports (4) Change of

Physician › 1. By treating

physician referral› 2. Upon approval by

the employer/surety› 3. Approval by

Industrial Commission

(IC form “Petition for Change of Physician”)

72-432: Medical services, appliances and supplies—reports (5) Employee not entitled to

reimbursement of medical care if sought in a manner other than listed in #4

(6) No provider shall engage in balance billing.

(7) Employee not responsible for charges from medical providers related to treatment of an industrial injury.

(9) Treatment by an accredited Christian Science practitioner shall be covered.

72-432: Medical services, appliances and supplies—reports 11) Medical records related to the treatment

of an industrial injury shall not be considered confidential, and shall be provided to the employer, surety, their attorneys, ISIF, the claimant, and/or the claimant’s attorney, and the Industrial Commission.

(12) Physicians or others providing services under this section shall assist and cooperate with the Industrial Commission Rehabilitation staff.

72-432: Medical services, appliances and supplies—reports (13) Employee shall be reimbursed

their expense of necessary travel while obtaining medical care. › Travel is reimbursable at the current state

travel reimbursement rate. The first 15 miles is not covered.

› Claimant requests travel reimbursement on IC Form 432. Surety pays travel reimbursement every 30 days.

72-432: Medical services, appliances and supplies—reports (14) An employee who moves out of the area

must give timely notice to the employer and surety of their intent to leave their locality. The employer/surety can request an examination by the treating physician prior to the employee leaving the locality, or if this is not practical, may assist in arranging an evaluation in the new locality.

The employer/surety shall have the same responsibility to furnish care after the employee’s relocation.

72-433 Submission of injured employee to medical examination Employee shall submit to an

Independent Medical Exam (IME) if requested. The employee will be reimbursed for travel expense and current wage rate if working.

The employee has a right to have a physician of his choice present during the IME exam and/or obtain an audio recording of the exam.

Average weekly wage Wages are defined as the employee’s

money payments for services. Wages also include board, rent, housing,

lodging, fuel, gratuities (tips), and other advantages, which can be estimated in money, received from the employer.

Gross wages are used, for a maximum of 1 year prior to the injury through the day before the injury occurred, including bonuses and fringe benefits.

Average weekly wage Bonuses must be an amount the

claimant can make demand for payment on, such as commissions, bonuses related to increased physical effort, or bonuses related increased efficiency.

Overtime pay and Premium pay (shift differential) are not included in the gross wages. Overtime hours should be included at straight-time pay.

Average weekly wage “Wages” shall not include sums that

the employer has paid to the employee to cover any special expenses entailed on him by the nature of his employment. Per Diem would be considered a special expense in most cases.

Compensation benefits are based on the employee’s average weekly wage at the time the injury occurred.

Average weekly wage Idaho Code 72-419 sections (1) through

(11) provide the method of calculations for establishing the average weekly wage in different wage situations.

Income benefits 72-402 Waiting Period: 5-day waiting

period unless disability exceeds 14 days, or the employee is hospitalized as an in-patient.

Income benefits Per 72-408, income benefits are paid at

67% of the employee’s own average weekly wage, subject to the maximum and minimum limits in 72-409.

Income benefits The maximum and minimum limits set

forth in 72-409 are based on a percentage of the Average Weekly State Wage established by The Department of Labor every January 1st.

Income benefit examples For an employee who earns $600 per

week, income benefits would be paid at 67% of their own average weekly wage, or $402.00 per week.

For an employee who earns $1,000 per week, income benefits would be paid at 90% of the currently applicable Average State Wage, or a maximum of $572.40 per week in 2009.

Income benefit examples An employee earning $50.00 per week

would receive the minimum of 15% of the currently applicable Average State Wage, or $95.40 per week for 2009

Income benefit are payable as long as the injured employee is in the period of recovery, and under medical work restrictions.

Income benefits If on restricted work duties and the

employer provides work at pre-injury wages, the employee will not be entitled to income benefits as there is no wage loss. If the employer provides work at a lesser pay or fewer hours, the employee would be entitled to 67% of the difference between his/her pre-injury wages and the wages earned while working light duty, no to exceed off-work income benefits.

Permanent total disability If an employee is injured so severely that they

cannot return to any type of work on a permanent basis, the employee shall be entitled to lifetime income benefits as described previously under Income Benefits.

Permanent partial impairment An injury, which results

in a permanent physical functional loss, may be eligible for a monetary award. The treating physician assigns a percentage of impairment to the injured body part, and the insurance carrier pays a monetary award based on the work comp statutes.

Permanent partial impairment

The physician should not address permanent partial impairment until the employee has become medically stationary from the injury.

Permanent Partial Disability A decrease in wage-earning capacity

based on medical and non-medical factors related to a work related injury.

Death benefits If death occurs

within 4 years from the date of accident or manifestation of an occupational disease, the employer shall pay weekly death benefits to the employee’s dependents

Death benefits Death benefits are subject to annual

adjustments as the Average State Wage increases or decreases on January 1st of each year.

Percentage of weekly benefits are as follows:1) Dependent widow, or widower with no

dependent children until death or remarriage, but not to exceed 500 weeks: › 45% of the currently applicable average state

wage. For the year 2009, 45% of the average state wage is $286.20.

Death benefits2) A widow with children:

› 45% of the currently applicable average state wage with an additional 5% of the currently applicable average state wage per child ($31.80), to a maximum of 3 children, or 60% of the current ASW. For the year 2009 60% of the average state wage is $381.60 per week.

Death benefits Children are eligible for death benefits until the age of 18

years, or marriage or death if either occurs prior to the age of 18 years.

Children enrolled as a full-time student in any accredited educational institution, or accredited vocational training program, are eligible until the child reaches the age of 23 or ceases to be enrolled.

Death benefits3) If there is no dependent widow or

widower but a dependent child or children: › 30% of the currently applicable average

state wage ($190.80) for the first child, plus 10% average state wage for each additional child to a maximum of 60% of the current average state wage. For the year 2009, 60% of the average state wage is $381.60.

Third party liability In cases where a

third party is responsible for the accident causing the employee’s injury, the employee can pursue the third party for recovery of benefits related to the injury, including pain and suffering.

Third party liability The employee cannot

collect and keep both workers’ compensation benefits and a third party settlement. The employer/surety is entitled to reimbursement of the workers’ compensation benefits paid as a result of the accident

Lump sum settlements Whenever the commission determines

that it is for the best interest of all parties, the liability of the employer for compensation may, on application to the commission by any party interested, be discharged in whole or in part by the payment of one or more lump sums to be determined, with the approval of the commission.

Attorney fees-Work Comp Compensation paid or not disputed

would not be considered available funds to apply attorney fees against.› It must be shown to the Commission that

the services of the attorney operated primarily or substantially to secure the fund out of which the attorney seeks to be paid.

Attorney fees-Work Comp Reasonable attorney fees are consistent

with the attorney’s fee agreement with the claimant subject to the element of reasonableness as follows:› 25% of available funds if no hearing is held› 30% of funds awarded after a hearing is held› Permanent total disability: 25% or 30% of

weekly benefits for the first 10 years, then 15% thereafter

72-706 Time limit to apply for hearing 1 Year if no benefits

paid 5 Years from date of

injury if benefits paid› 4 Year exception› Payment of medical

bills after 5 years-no affect

› No limitation on medical benefits

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