Coverage
Compensable
Injury..
Benefits.
Medical
Compensation for Missed Work Time.
Death Benefits.
Average Weekly Wage.
Waiting Period.
Responsibility
of Employee.
Notice to Supervisor
Obtaining Medical Care.
Return to Work (Same Day)
Return to Work (After Workers' Compensation Leave)
Other Responsibilities of Employee.
Third
Party Administrator Services.
Key Risk Management Services.
Acceptence
or Denial of Claim for Workers' Compensation.
Coordination
of Workers' Compensation Disability with Sick and Vacation Leave.
Day of Accident
Period of Disability.
After Return to Work.
Continuation
of Other Employment Benefits.
Hospitalization Insurance.
Retirement Service Credit.
Vacation and Sick Leave.
Legislative and Performance Increases.
Longevity.
Return
to Work.
All University employees are covered under the North
Carolina Workers' Compensation Act, including full-time faculty, staff (EPA and
SPA), senior administrative officers, part-time employees, and temporary
employees. Any employee who suffers an accidental injury or contracts an
occupation disease within meaning of the Workers' Compensation Act is entitled
to benefits provided by the Act.
An injury is compensable under Workers' Compensation if
it meets the following criteria:
1.
The injury was caused by an accident.
(In case of hernia or injury to the back, the injury is compensable only
if the result of a specific traumatic incident of the work assigned.)
2.
The injury arose out of the employment.
3.
The injury was sustained in the course of employment.
The cost of all medical and surgical services
necessary to effect a cure is covered (includes hospital charges, physician and
nursing fees, sick travel, prescription drugs, and prescribed rehabilitation).
Medical services are subject to the maximum fees set by the North
Carolina Industrial Commission.
During temporary total disability, the injured
employee is entitled to receive two-thirds of the average weekly earnings at the
time of the accident subject to a minimum and maximum.
The Industrial Commission at the beginning of each calendar year sets the
minimum and maximum TPD amounts. The
Department of Human Resources can provide the current maximum weekly benefit.
The maximum benefit can be supplemented by using
earned sick leave and vacation leave up to a maximum number of hours set by the
State Personnel Commission according to the employee's annual salary.
(For the period beginning January 1, 1998, the maximum weekly benefit is
$532.00 and the maximum sick/vacation leave per week begins at 5 hours for
salaries of $10,000 - $41,999 going to a total of 25 hours for higher salaries.)
If, following a period of temporary total disability,
an employee is released by the physician to return to light work, the employee
is entitled to two-thirds of the difference between the average weekly wage on
the date of injury and wages the employee is able to earn upon return to light
work.
If the injury results in permanent total or partial
loss of use of a part of the body, the employee is entitled to compensation in
accord with the disability rating given by the treating physician and the
payment schedule set forth in the Workers' Compensation Act.
Employees are eligible to receive this compensation for permanent partial
disability even though they have returned to work and are earning wages.
If the injury leaves serious facial or head
disfigurement, or causes the loss of or permanent injury to an important organ
of the body, the Industrial Commission, within its discretion, may award
additional compensation of up to $20,000. No
compensation is allowed for scars where the employee is paid for loss or partial
loss of use of the same member. The
employee is also entitled to payment for the loss of permanent teeth.
In the event of death resulting from an injury
arising out of and in the course of employment, compensation is paid to the
surviving spouse for 400 weeks at 66b
percent of the deceased employee's average weekly wage at the time of the
accident. If there is no surviving
spouse, compensation payments due to a dependent child are paid for 400 weeks or
until the child reaches the 18th birthday, whichever is later.
There is a $2,000 allowance for funeral expense.
Compensation is based on the average weekly wage
earned by the employee. The average
weekly wage is computed by adding all wages earned in the employment in which
the employee was injured, including any special allowances during the 52-week
period prior to the
injury. This total is divided by 52
to arrive at the average weekly wage.
There is a waiting period before an employee can
begin to receive compensation for time lost from work due to the injury.
An employee is not entitled to compensation for the first seven calendar
days of disability unless the disability continues more that 21 days.
These 21 days do not have to be consecutive and any workday in which the
injured employee does not earn full wages because of the injury is counted as a
day of disability. After disability
has continued more than 21 days, the employee is entitled to receive
compensation for the first 7 days.
The employee must notify the supervisor immediately
in writing using North Carolina Industrial Commission Form 18 (Employee's Notice
to Employer State, Office of State Personnel SGWCP Form and Supervisor's
Accident Investigation Report). His/her
supervisor will then submit both Forms 19 (Employer's Report of Injury)
to the Department of Human Resources Safety Office. The written notice may be handwritten or typed and should
indicate the date of the accident (or approximate date when occupational illness
was contracted), how the accident occurred (cause of illness), and the nature
and extent of injury (illness). It
should also note whether or not the employee had to missed work because of the
accident and, if so, the expected or actual return-to-work date.
Forms may be obtained by contacting the Safety Office of the Department
of Human Resources.
The Workers'
Compensation Act requires that an employee give written notice to the employer
within 30 days of an accident or within 30 days of being diagnosed as having a
disease associated with employment. After
30 days no compensation is payable without a ruling by the Industrial
Commission.
An employee who is injured on the job or who
contracts an occupational disease must go to the Department of Human Resources
to receive written authorization for medical care. If the Department of Human
Resources is not operating at the time of the injury, the employee may go to
Cape Fear Medical Center or to Highsmith-Rainey Hospital Emergency Room.
An employee who must use medical services other than the Doctor’s
Urgent Care Center for treatment must secure approval of the Worker’s
Compensation Administrator in the Department of Human Resources before
submitting to lengthy treatment and/or surgery unless the surgery is required
under emergency conditions. Employees
may not choose their own doctor.
Please refer to the University's Quick Reference Guide for further
clarification and step-by-step procedures.
The university authorized treating physician may
refer the employee to other medical providers.
In this case the university authorized treating physician will notify the
WCA that an outside referral has been made, and the employee may proceed to
secure treatment from the referred source without further approval by the WCA.
However, anytime there is a change in the level of treatment planned, for
example, from normal office visits to surgery, the employee must notify and seek
approval from the WCA before proceeding.
The employee's responsibility includes accepting
medical treatment provided by the university authorized treating physician or
its referees. The employee must
follow as directed all prescribed treatment, including any medical, hospital,
surgical, and other treatment or rehabilitation procedure when ordered by the
treating physician. Refusal to
accept treatment bars the employee from further compensation.
After treatment by a physician following a
work-related accident, the employee is expected to return to work unless the
treating physician indicates the employee must go home for the day.
The employee is responsible for obtaining from the treating physician a
written statement certifying the need to go home instead of returning to work.
An employee who has been released by the treating
physician to return to work has the obligation to accept any suitable employment
provided by the employer that is in keeping with the employee's capability.
Refusal to accept suitable employment will result in termination of
compensation and may result in dismissal. (A
description of the process of re-assimilating the employee into the University
is described in the section titled Return to Work.)
An employee who must go on workers' compensation
leave automatically continues enrollment in the state health insurance program
without personal cost. However, if
the employee carries coverage for dependents, he/she must contact the Department
of Human Resources and University's Payroll Office to arrange direct payment for
the additional coverage.
Key Risk Management Services have been awarded the
contract to administer the Workers’ Compensation Program for the all state
agencies and universities.
Key Risk Management Services is responsible for the
following:
Claim Management
Medical Case Management
Disability Management
Fiscal Management
Loss Control Management
Litigation Management
Information Management
Claim management entails providing a dedicated
claim adjuster for the university. Claim files will be established and
maintained by the third party administrator. If an employee is injured on the
job, subsequent to the Safety Director and WCA completion of the Form 19, the
third party administrator will communicate with the employee.
Accident investigation will be done in conjunction with
the safety director and the workers’ compensation administrator. After an
investigation of accident has been completed the TPA will make the liability
determination and notify the employee.
The TPA will complete all North Carolina Industrial
Commission forms.
When
questions or issues arise relative to claims TPA will follow the claim review
process. If the employee disagree with any determination made by the TPA, he/she
can exercise his/her appeal rights using the Internal Appeal Process.
Medical Case Management – The TPA has provided a
network of Medical care providers. These providers are part of the Compcare
Network.
Compcare Network is a credentialed group of medical
providers contracted with Key Risk Management Services to provide services to
our employees.
The university will direct the injured employee to the
Compare Network provider. Compcare
will treat the injured employee at a cost, which is less than the medical fee as
established by the North Carolina Industrial Commission.
Key Risk Management Services will evaluate usual and
customary treatment. Key Risk Management Services will provide medical bill
auditing, employee/physician communication coordination, treatment action plans,
pre-certification process/hospital utilization review and independent medical
examination referrals/coordination.
Disability Management – Key Risk Management
Services will manage all rehabilitation services, recovery tracking and updates,
disability rating process and authorization of compensation payment.
Fiscal Management- Key Risk Management will make
medical payment in a timely manner; coordinate indemnity payments, medical
payment by provider, and refund subrogation recoveries.
Loss Control- Key Risk Management Services will
provide trending reports of the university’s claim activity for the quarter.
Litigation Management- the Attorney General Office
will be used in practically all cases in litigation. Key Risk Management will be
responsible for the following:
Communication
The TPA
will communicate with the AG’s office on all issues, with the exception of
interrogatories. The AG’s office will communicate directly with the university
for completion of interrogatories during discovery. Any correspondence generated from the AG will be copied to
TPA. The TPA will complete the Form 24 and file it directly with the NCIC.
The informal hearing will be handled by TPA. The AG will be advised by
the TPA if their representation is required.
The TPA
will send copies of the Form 33/33R and the complete claim file to the AG.
The TPA will ensure all claim files are complete and fully detail the
basis of the denial. This documentation should be sent to Attorney’s General
office in a timely manner with the 45 days filing requirement.
Mediation
TPA will
attend all mediations. If claim is in litigation, the AG’s office will
represent and attend the mediations. Prior to the mediation, TPA will obtain
authority of settlement from the university and inform the AG’s office if
their representation is required.
The Worker’s Compensation Administrator in the
Department of Human Resources in conjunction with Key Risk Management Services
has the responsibility for determining whether or not the University is liable
for the claim for workers' compensation benefits. The decision is made on the basis of all the facts presented
on the employee's notice (Form 18) and in discussions with the supervisor and
the University Safety Director. Payment
of medical bills by the University is not an indication of the University's
acceptance of liability for the claim.
If the claim is denied, the employee will be notified
as soon as possible, pending receipt of medical documentation if necessary.
To petition further, the employee must file a written notice of claim by
writing to the North Carolina Industrial Commission (430 N. Salisbury Street,
Dobbs Building, Raleigh, NC 27611). The
notice should include the employee's name, address, Social Security number, the
Employer's name, the date and nature of the injury.
The employee may provide all this information on Form 18, provided by the
Industrial Commission, which is available by calling the WCA in the Department
of Human Resources.
The employee is not charged leave for time lost work
on the day of the injury. In
situations where the employee cannot return to work after treatment by the
medical provider, the employee is paid full salary for normal working hours on
the day of the injury.
If the injury results in additional time away from
work, the employee must go on workers' compensation leave and receive the
workers' compensation weekly benefit after the required waiting period.
During the waiting period, the employee may elect to take sick or
vacation leave without pay. If the injury results in disability of more that 21 days, the
workers' compensation weekly benefit begins and will cover, as well, the first 7
days of disability. However, if the
employee has elected to use sick or vacation leave for the first 7 days, no
adjustment will be made.
After the employee has gone on workers' compensation
leave, the weekly benefit may be supplemented by the use of partial earned sick
or vacation leave in accordance with a schedule set by the State Personnel
Commission that relates to the employee's annual salary.
Compensatory time may be substituted for sick or vacation leave within
the time frames provided under federal and state law.
Earned leave and compensatory time are paid on temporary payroll at the
employee's hourly rate of pay. It
is subject to state and federal withholding taxes and Social Security, but it is
not subject to retirement.
For more detail on how these leave periods correlate
with workers' compensation benefits, the employee should consult the WCA in the
Department of Human Resources.
An injured employee who has returned to work but
continues to require medical or therapy visits to reach maximum medical
improvement is not charged for reasonable time lost from work for required
medical or therapy treatment.
While on workers' compensation leave, an employee is
eligible for continuation of the following benefits:
While on workers' compensation leave, an employee
continues coverage under his/her state health insurance program.
The employer's monthly contribution for the employee will continue to be
paid by the University. It is the employee's responsibility to continue his/her
monthly contribution as well as the premium for any dependent coverage that must
be paid directly by the employee.
While on workers' compensation leave, an employee
does not receive retirement credit. An
employee who is a member of the Retirement System may purchase credit for the
period of time on an approved leave absence.
While on workers' compensation leave, the employee
continues to accumulate vacation and sick leave to be credited for use upon
return to work. If the employee
does not return, vacation and sick leave accumulated during the first 12 months
of leave will be paid in a lump sum along with other unused vacation.
Special provisions apply when the employee accrues more vacation time
than can normally be carried forward.
For SPA employees the salary will be computed based
on the last salary plus any legislative increase to which the employee would
have been entitled. Any performance
increase which would have been given, had the employee been at work may also be
included in the reinstatement salary, or it may be given on any pay date
following reinstatement.
While on workers' compensation leave, an employee is
in pay status and will continue to receive longevity credit.
Employees who are eligible for longevity pay shall receive their annual
payments.
When an employee has been released to return to work
by the treating physician, there are three possible return-to-work situations.
The physician will be asked to make a determination as to the employee's
"maximum medical improvement," a term which signifies the point at
which no substantial further improvement expected. The physician will also be
asked to make an evaluation of the employee's suitability for return to work on
the basis of the employee's current job description.
Employee has reached maximum medical improvement and
can return to same job:
The University will place the employee in the
original position or one of like seniority, status, and pay held prior to
workers' compensation leave.
Employee has reached maximum medical improvement with
a disability that prevents return to the former job:
The University will attempt to place the employee in
another position suitable to the employee's capacity. This work placement may be a permanent assignment or either
part-time or temporary assignment until a permanent assignment is found.
If a position is not available for work placement,
the university shall appoint the employee to the first suitable vacancy, which
occurs. During the interim period
if a suitable vacancy is not available, the employee shall be referred to the
Office of State Personnel for re-employment assistance and a possible return to
work in another agency.
Work Placement efforts will continue for a period not to
exceed 12 months, except with the approval of the Director of Human Resources
Services.
Employee has not reached maximum medical improvement
and is ready to return to limited work duty with approval of the treating
physician:
The University will provide work reassignment suitable to the employee’s
capacity. This work assignment will
be temporary, normally not to exceed 90 days.
The University's Return to Work Council may be consulted if the
department cannot accommodate prescribed restrictions.
When the employee reaches maximum medical improvement, the employee will
then return to the original position or one of like seniority, status, and pay
held prior to workers' compensation leave or to another suitable position.
In making reassignment of an employee, the University
may work with other state agencies, such as the Office of State Personnel and
North Carolina Division of Vocational Rehabilitation.
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