SECTION 6.20 WORKERS’ COMPENSATION
Last Update: 8/08
Workers’ Compensation is a mandated benefit that provides medical and lost time benefits for employees injured in the course of and arising out of their employment. These benefits may include:
·
Payment of wage replacement
benefits beginning the fourth day off work (excluding the day of injury).
·
Payment of medical bills.
In addition, state employees can elect to supplement their temporary disability benefits with sick leave, vacation, or compensatory time.
6.20.01 Roles and Responsibilities
The
DAS-HRE
Its primary role is program oversight, including financial management,
legal management, and loss prevention and control services. DAS-HRE is responsible to assure that the
program meets regulatory requirements, assessments to the employing departments
for premiums to fund the program, and facilitate informational needs of the
agencies. DAS-HRE is represented by the
Office of the Attorney General on litigated claims.
SCMS
SCMS is responsible for claims intake, evaluation, authorization of
medical care, and payment of benefits to claimants. They will be in frequent contact with the
injured worker, the employers’ designated representatives, and the treating
physician (three-point contact).
The Employing Agency
The Departments are requested to help in the process by:
·
Establishing policies and procedures
that encourage prompt and accurate reporting of all accidents and illnesses
alleged to be work-related, regardless of fault or suspicion.
·
Working directly with the
Sedgwick CMS claims adjudicator assigned to the department to provide and
request information about the claim to assure that return to work and payroll
needs are met.
·
Developing, maintaining, and
communicating agency early return to work policies and procedures with own
employees and Sedgwick CMS.
·
Providing for restricted duty
work assignments.
6.20.02 Filing Claims
The time to file a First Report of Injury is when the employer first
becomes aware of the injury or illness, and reasonably believes that the injury
or illness is work-related. It is the
goal to report all injuries that require medical treatment within 24 hours of
knowledge of the accident. The
consequences of delayed reporting include:
·
Delay in the delivery of
benefits to the employee, which can cause financial hardship.
·
Medical Care may not be
initiated early or appropriately, which can affect the medical outcome of the
claim, prolonging and/or increasing the disability.
·
The cost of the claim will be
higher.
The normal method of notification is by faxing to SCMS the First Report
of Injury or Illness (IAIABC FORM 1.2, 12/98).
This form is supplied by the Workers’ Compensation Commissioner’s office
of the Department of Workforce Development.
This report will be referred to as the First Report. No on-line reporting is available or
necessary.
Outside of normal working hours (8:00 a.m. to 4:30 p.m., Monday through
Friday), an SCMS call center in
It is most effective if the employee and the employee’s supervisor both
provide input on the claim. Fill out the
form as completely as possible. It is
especially important that the following information be provided:
·
Employee name, social security
number, and home address
·
Date and time of the incident
·
Accident description (how,
where, why)
·
Type of injury (cut, scrape,
sprain, etc.)
·
Exact part of body injured
·
Name and address of physician
or hospital
·
Work status (did employee
return to work?)
6.20.03 Investigations
Sedgwick CMS will evaluate the claim to establish its compensable
status (accepted or denied) based upon information forwarded and/or resulting
from an additional investigation. Areas
evaluated include:
·
Presence of an
employer/employee relationship at time of incident
·
Work-relatedness of the injury
·
Past medical treatment or
claims for the same condition
·
Fraud
If the employer is suspicious about the claim, this should be
communicated to SCMS. It is not the
employer’s responsibility to investigate workers’ compensation fraud.
6.20.04 Disputes
The filing of a first report is neither a guarantee of benefits, nor an
admission of liability on the part of the employer. Sedgwick CMS will evaluate and investigate as
needed to decide if a claim is compensable according to the Workers’
Compensation laws of the State of
If the employee is not satisfied with the decision, the Division of
Workers’ Compensation of the Department of Workforce Development,
6.20.05 Medical Care
Sedgwick CMS will be responsible for the direction
of medical care as allowed under Iowa Code 85.27 for work-related
injuries. Sedgwick CMS provides agencies
a list of preferred providers for initial evaluation and treatment of
injuries. Subsequent care will be
coordinated by Sedgwick CMS. Sedgwick
CMS will work with the injured employee and the employee’s medical provider to
obtain information and maintain proper communication and control. The employee has the responsibility to
present documentation from the provider supporting absence from work, return to
restricted duty, or release to full duty.
Sedgwick CMS should be contacted in all cases where this information is
not presented or where clarification is needed.
Requests for alternate medical care and reports of missed medical
appointments must be reported to Sedgwick CMS.
Employees who change medical providers without the authorization of
Sedgwick CMS, or fail to comply with appointments, physical therapy, or other
aspects of medical treatment risk a suspension of lost time benefits. Sedgwick CMS will be responsible for
informing the employee of such decisions and the employee’s right of appeal, as
required.
Contact the Sedgwick CMS claims representative assigned to your agency
for further clarification and assistance.
6.20.06 Emergencies
In all cases, if a life-threatening situation arises, access the
emergency 911 system to get immediate help.
If it appears that the situation might be work-related, contact Sedgwick
CMS as soon as possible after emergency
help has been summoned. If the
situation occurs after normal working hours, contact the After Hour New Report
Call Center (1-866-222-8768). This is a
toll-free number.
6.20.07 Waiting Period and Healing Period
Employees injured on the job may or may not be able to return to
work. If the medical provider determines
that the employee must remain off work due to the injury, healing period (HP),
benefits will be paid beginning on the fourth day of disability until a return
to full or restricted duty has occurred.
A three-day waiting period for the commencement of benefits is required
under
The waiting period will be picked up by workers’ compensation after 14
days of disability (unless otherwise stipulated by collective bargaining
agreements). The final determination on
return to work issues is based upon the approval of the treating physician to
allow the injured employee to perform tasks or jobs that the employer has
identified as being available, either the same job or special assignment. The treating physician may also return the
employee back to work part time on a temporary basis, known as temporary
partial disability (TPD). In this
situation, the employee will be paid their workers’ compensation rate for hours
not worked.
6.20.08 Time Lost for Medical Appointments
Once the employee has returned to work (restricted or full duty) after
sustaining a work-related injury, and requires additional medical appointments,
time lost from scheduled work for these appointments will be paid at the
regular rate of pay, subject to normal and customary payroll deductions. These payments are not considered weekly
benefits and will be paid by the employing agency through normal payroll as
regular work time pay and not sick or vacation time.
6.20.09 Maximum Point of Recovery
The employer needs to be aware of when the “Maximum Point of Recovery”
has been reached. This information is
available from Sedgwick CMS. Once the
maximum point of recovery has been reached, the employee may be eligible for
permanent partial disability benefits (PPD).
The key issue to be addressed at this time is whether the employee will
be able to perform the essential functions of his/her previous position. The employer may need to address this
question in writing directly to the physician.
Note: Disability as defined under
workers’ compensation may not meet the same definition as the “Americans With
Disabilities Act” (
6.20.10 Managing Return to Work
DAS-HRE administrative rule 11-59.3(5) provides that agencies shall
provide restricted duty work assignments without change to an employee’s class
and regular rate of pay for employees who have a medical release to return to
restricted duty following a job-related illness or injury. This is a benefit to both the injured worker
and the agency. Recovery from a
job-related injury can be enhanced by providing the injured employee positive
work activities. This program is not
available to temporary and probationary employees. Restricted duty is not intended as an
accommodation for permanent restrictions.
The employee should be asked to request reasonable accommodations at the
point the restrictions become permanent.
To make a restricted duty program successful, the
department must:
·
Notify employees of the
restricted duty program and the expectation to participate.
·
Develop and maintain job
descriptions that include the physical demands of the job.
·
Identify tasks suitable for
restricted duty, including physical demands that are consistent with knowledge,
ability, and skills, to establish restricted duty suitable for the employee.
·
Inform employees that refusal
to accept a temporary restricted duty assignment may result in the loss of
workers’ compensation benefits.
Providing restricted duty requires:
·
A Patient Status Report completed by the treating physician, outlining
the physical restrictions that an employee must adhere to upon return to work
in a restricted duty assignment.
·
Placing the employee in a restricted duty assignment consistent with the
information provided by the physician on the Patient Status Report.
·
Tracking of the duration of
restricted duty. Under Federal
Occupational Health and Safety Administration (OSHA) recordkeeping guidelines,
all restricted duty time worked must be logged on the OSHA 200 log. See the
Occupational Safety and Health Standards for General Industry (29CFR, part
1904).
The DAS-HRE rule 11 59.3(5) provides that an appointing authority shall
provide restricted duty work assignments.
The original period of restricted duty shall be the hourly equivalent of
20 workdays (pro-rated for part-time employees), or until the employee is
medically released to full duty, whichever is less. However, extensions may be granted. The most important factor is the treating
physician’s view of anticipated medical improvement.
6.20.11 Supplementing Workers’ Compensation Benefits
An employee may elect to use available sick leave, vacation and/or
compensatory leave to supplement workers’ compensation benefits at any time
during the period benefits are received.
Once the employee has elected to receive supplementary payments, the
supplement shall continue until the leave(s) selected is exhausted or the employee
is no longer eligible for workers’ compensation benefits, whichever comes
first.
When more than three days have been missed, a Benefit of Election form
must be filled out and provided to the Liaison, who will inform Sedgwick CMS of
their choice. The first three days
missed from work are paid from sick leave.
A copy of this document must be sent to the employee as a verification
of their selection.
Employees may elect not to supplement initially and supplement later
on. However, once a decision to supplement has been made, an employee must
supplement until the selected paid leave is depleted.
Note:
For employees covered under the State Police Officers Council (SPOC)
collective bargaining agreement, special provisions under that agreement apply.
The State’s share for health insurance coverage will be paid for
employees who supplement workers’ compensation benefits with sick leave,
vacation, or compensatory leave until all paid leave is exhausted, plus
coverage for an additional four months.
The State’s share for health insurance coverage will be paid for four
months for employees who do not elect to supplement benefits. The employee must submit a personal check for
the employee’s share of the premium (made out to the State Treasurer if Blue
Cross and Blue Shield; to the carrier if a health maintenance organization
[HMO]) to be forwarded to the DAS-HRE Benefits Section. At the end of the four-month period,
employees may continue health insurance coverage by paying the entire premium
(both the State share and the employee share).
When the date of injury is prior to the 16th day of the
month, that month will count as the first month of the four-month period.
6.20.12 Termination and Recall
In some cases employees will be unable to return to their previous
position because they are unable to perform the essential functions of their
position. Termination of employment
would be an option at that point. However, the employing agency and the injured
worker are encouraged to pursue the mutually beneficial goal of continued
employment.
Employees who have been terminated or who have permanent restrictions
that cannot be accommodated in their previous position will be eligible for
recall. Recall will be in accordance
with Iowa Administrative Code.
6.20.13 Leave of Absences and Workers’ Compensation
Receiving workers’ compensation benefits alone does not maintain
employment status. Employees must be on
some form of leave at all times to maintain their employment status. Under workers’ compensation, this means the
employee must supplement workers’ compensation benefits, as described above, or
request leave without pay. The employee
off on workers’ compensation should consider these factors when deciding
whether or not to supplement. General
guidelines to follow include:
·
All leave without pay (LWOP) must be consistent with contractual and
DAS-HRE rule provisions, including withholding approval until sick leave is
exhausted.
·
After 90 days of LWOP, an evaluation will be made to determine the
potential to return to work. Employees
who receive an indefinite prognosis, or are not reasonably expected to return
to work will need to consider recall and/or long-term disability.
6.20.14 Family and Medical leave Act (FMLA)
FMLA provides 12 weeks of leave to take care of
personal or family medical needs, along with some other related issues, such as
adoption. Therefore, lost time due to
workers’ compensation may also qualify as FMLA leave. Refer to the FMLA policy in effect for your
department.
6.20.15
Handling Medical Information
The employer needs to know the nature of the injury and how the injury
affects the employee’s ability to perform their job. Detailed clinical notes, treatment plans, or
other information that might be received by the employer should be treated as
confidential, and should be forwarded to Sedgwick CMS as soon as possible. Any
medical information deemed necessary to maintain by the employer must be kept
separate from personnel files in a manner to protect the confidentiality of the
information.
6.20.16 Instructions for Submitting Claims
Information to Sedgwick CMS
The First Report of Injury or Illness is a form prescribed by the
Workers’ Compensation Division of the Iowa Department of Workforce Development. You can visit their web site at http://www.iowaworkforce.org/wc/ to obtain this form and learn more about their role and function as
the regulatory body for workers’ compensation in
Detailed instructions are provided at the end of this chapter. Note
that the Claim Administrator Name will always be Sedgwick Claims Management
Services using the
Under the Accident/Injury fields of the form, the specific agency or
department name will appear. Sedgwick
CMS will have the organizational structure of the State pre-defined in their
system and will be able to provide assistance to assure that the correct
reporting requirements are met.
DAS-HRE has requested Sedgwick CMS collect the payroll number of an
injured employee by placing it at the top of the first report. This information can be useful as a tracking
tool but only if it is consistently and accurately provided to Sedgwick CMS.
Wage Statement
For all injuries resulting in lost time, a verification of the 13 weeks
prior to the injury date is required.
Please use the following guidelines for wage verification:
·
If paid hourly, show the hourly
rate paid, number of hours worked at straight time, number of overtime hours
worked, and gross pay.
·
If the employee is salaried,
advise of the salary rate.
·
If the employee is paid a shift
differential, note the base hourly rate and provide the amount of the shift
differential.
This form
can be accessed by going to the Forms Referenced in This Chapter area of
the index to this chapter.
Election of Benefit Form
This document must be forwarded to Sedgwick CMS within three days of
the date of injury to assure that the Department of Revenue and Finance can
determine what accrued benefit, if any, has been authorized by the employee to
supplement their workers’ compensation.
Please fax due to time sensitivity.
This form
can be accessed by going to the Forms Referenced in This Chapter area of
the index to this chapter.
Travel Reimbursements
All requests for mileage, lodging, meals or other reimbursements must
be submitted to Sedgwick CMS for payment.
They may be faxed or mailed.
This form can be accessed by going
to the Forms Referenced in This Chapter area of the index to this
chapter.
Original Notice and Petition
Employees may make an appeal relating to various issues of their
workers’ compensation claim. In some
cases, an Original Notice and Petition may be filed by an employee or their
legal representative. These petitions
are time-sensitive and should be forwarded immediately to Sedgwick CMS. Please fax the document to SCMS and send the
original to them by mail. It is appropriate
and advisable to keep a copy at the agency for backup.
Please use this same procedure for all other legal notices or requests
for information relating to workers’ compensation. However, be aware that some requests or
portions of a request for information involving personnel records and payroll
information will need to be handled at the agency.
6.20.17 Contact
Information
For all claims related inquiries, please contact:
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Sedgwick CMS
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Main
Phone: |
515-327-4888 |
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Toll
Free: |
866-342-3920 |
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Fax: |
515-327-4899 |
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After
Hours New |
866-222-8768 |
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(use
only for new claims requiring medical treatment) |
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For all claims documentation, please send to:
Sedgwick
CMS
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The Iowa Department of Administrative Services – Human Resources
Enterprise is responsible for the overall administration of the program. Questions or comments about the program
should be directed to:
Iowa
Department of Administrative Services –
Human
Resources
Attn: Workers’
Compensation Bureau
1305
East Walnut |
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Phone: |
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515-281-4513 |
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Fax: |
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515-242-5157 |
6.20.18 Instructions
for Filling Out the First Report of Injury or Illness
The First Report of Injury or
Illness (IAIABC Form 1.2) is the prescribed form used by the State of
CLAIM ADMIN Section
Claim Administrator Name:
Sedgwick Claims Management Services
Claim Rep. Bus. Phone:
515-327-4888
Insurer Name:
IA - - STATE OF
Mailing Address, City, State & Postal Code:
Claim Admin. Claim Number:
Leave Blank
Insurer FEIN:
421590141
Claim Admin. FEIN:
362685608
Claim Type Code:
Leave Blank
Leave all other fields in this section blank.
EMPLOYER Section
Employer Name:
Iowa – State of
Physical Address, City, State & Postal Code:
1305 East Walnut,
Nature of Business:
Government
Employer FEIN:
421590141
Employer Type Code:
Put a check mark before Employer (E)
Mailing Address, City, State & Postal Code:
DAS-HRE, 1305 East Walnut,
Employer UI Number:
Use the Unemployment Insurance
Number for your agency, not DAS-HRE.
Contact your business office to obtain this information.
Employer Contact Name and Business Phone Number:
Jeff Johnson, 515-281-4513
POLICY Section
Please ignore and leave blank the Policy section.
EMPLOYEE Section
Enter employee’s name, home address, and home phone number
in appropriate boxes.
Enter employee’s date of birth.
Put a check mark in front of the employee’s gender.
Leave Tax Filing Status blank.
Enter the date the employee started with the State.
Leave Educational Level blank.
Put a check mark in front of the employee’s marital status.
Use the DAS-HRE job classification title for the Occupation
Description.
Leave Manual Classification Code blank.
Enter the office, bureau or section name of the employee.
Enter a check mark in front of the correct employment status
type.
For Employee ID Number, enter the employee’s social security
number.
Leave Employee’s Authorization blank.
WAGE Section
Enter the employee’s bi-weekly wage and check the
appropriate frequency of pay option.
Note: A Wage
Statement is required on all lost time claims.
See section 6.20.16 of this chapter.
Salary Continued in Lieu of Compensation:
This box will normally be checked
“No” in most situations, but SPOC contract-covered employees are eligible for
salary continuation for 60 days. Check
“Yes” if this is the case.
Full Wages Paid for Date of Injury:
Indicate “Yes” if full pay was granted for day of injury.
Discontinued Fringe Benefits:
Leave blank.
Enter number of Dependents. Note that the actual number of dependents
should be reported, not W-2 information.
Employee number of Exemptions:
Enter a check mark in front of Entitled
Put in the amount of days an employee works per a week
Leave blank
ACCIDENT/INJURY Section
Fill in all pertinent dates
Enter the time of injury or
illness and the time the employee’s workday begins. This must be in military format.
Pre-Existing Disability Code:
Leave blank.
Accident Premises Code:
Leave blank.
Accident Site Organization Name:
Enter the name of your agency,
department, or main organizational division, such as Department of Human
Services, Regents, Department of Transportation, Department of Justice, etc.
Accident
Enter the employer’s address where the employee normally
reports.
Accident Location Narrative (if no street address):
Enter the address or other
location description (highway marker x, front steps of client’s home and give
client’s address, etc.).
Accident Site County/Parish:
Provide the name of the county where the injury occurred.
If injury is due to auto accident, complete and attach a
copy of the accident report.
Leave blank
For Nature of
Injury, Part(s) of body, event, object or substance, and specific activity:
Provide
complete but concise detail. Additional
sheets may be attached as needed.
Have all
witnesses complete a statement as to what happened.
MEDICAL
Section
Initial Treatment Code:
Select one of the six choices
listed on the form. The choice should indicate initial treatment only that the
employee received immediately after the injury.
Provide Initial Medical Provider information as available.
Managed Care Organization and ICD Primary Diagnostic
information:
Leave blank.
Preparer’s Name & Title:
Provide the name of the person filling out the form.
Preparer’s Company Name: