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Showing posts with label Medicine. Show all posts
Showing posts with label Medicine. Show all posts

Thursday, September 1, 2011

Who Is Paying the Premiums for Workers Compensation Anyway

Employes have been subject to "give backs" and "add on" costs for decades, but now employers want to shift the cost of workers compensation insurance to employees. The intent of the workers' compensation act was to shift the costs of workers' compensation coverage to the consumer of the product and/or user of the service and not the employee.


A recent Massachusetts Judge reiterated that principle, but left open the question as to whether the employee could consensually contract to accept the costs of workers' compensation coverage. If this occurs, it is ultimately a "deal breaker."


Cost shifting of workers' compensation coverage is a dangerous precedent going to the heart of the initial promise made to workers in creating the system. Is is against  "public policy," and defeats the Legislative intent of the act. While the economy is soft and the workers' compensation system in a weakened condition it is not time to abandon ship unless a more creative approach for reform of the entire system comes into play. As jobs remain scarce, the process would not be consensual, but merely coercion. Shifting the cost would ultimately remove the deterrent effect for unsafe workplaces, and yet is another reason why employers and ultimately consumers should remain responsible for workers compensation  costs.


See: Awuah v. Coverall North America, Inc.,--- N.E.2d ----, Mass. , 2011 WL 3805255, Mass., August 31, 2011 (NO. SJC-10829)

For over 3 decades the Law Offices of Jon L. Gelman  1.973.696.7900  jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.

Tuesday, August 30, 2011

What Hurricane Relief Volunteers Need to Know About Workers Compensation

Hurricane relief volunteers are entitled to workers compensation benefits for injuries and illnesses that occurred as a result of their participation in relief efforts. In order to claim those benefits injured volunteers need to make sure that they follow some simple steps.

1. Make sure that they establish an employment relationship for the agency or company conducting the relief work. In other words, the volunteer, even if earning no money, must be an employee of the the company conducting the rescue and/or relief effort. The best evidence would be a written agreement that the worker is to be considered an employee of the company. 

2. Report to the report if an accident or injury occurs arising out of and in the course of the employment. This report should be made as quickly as possible following the event or manifestation of illness. This should be followed up immediate with a written communication to the employer advising that an injury or illness occurred and that medical treatment, if necessary, is being sought.

3. Record the names and addresses witnesses to the even or exposure.

4. Seek medical care if required. If it is an emergency and you are unable to first notify your employer, seek medical attention first and then report the event. Most emergency rooms will record your event history and notify your employer, but that is not always the case. Therefore, advise your employer where and when you sought emergency medical care as soon as possible.

5. If you are advised by a medical profession to stay out of work, then obtain that information in writing. Make a copy of the lost time order and give the copy to your employer.

6. See the advice of an attorney at law familiar with workers' compensation matters since volunteer work in emergency situations produced a lot of complication issues. Those issue are inherited from the chaos and complications that occur in the wake of a major natural disaster such as a hurricane.

Volunteering for the hurricane relief effort is a noble gesture. Workers, in the emotional haste to assist, must also insure that they remain insured for workers' compensation benefits.

Monday, August 29, 2011

Pensions, Workers Compensation and Medical Benefits

The State of New Jersey has taken assertive action to guarantee medical benefits to injured workers for their lifetimes even though they are receiving accidental injury pensions. The Director has issued an Administrative Directive requiring language to literally toll the statute of limitations and permit the Division of Workers' Compensation to retain jurisdiction over such matters where the injured worker has accepted the continuing medical benefit option.

"Petitioner has been awarded and accepted an accidental disability pension effective _(date)_. To resolve the workers' compensation case, petitioner and respondent have agreed to provide petitioner with reasonable and necessary medical treatment for injuries related to the _(date)_ accident. This Order for continuing medical benefits shall not be subject to the two year statute of limitations and such medical benefits shall continue for the life of the petitioner or until further order of this court."

By statute, workers' compensation awards are offset by pension awards. The medical issue remains open usually and medical benefits remain the responsibility of the employer. The medical issue becomes a complication when costs are attempted to be shifted to collateral medical carriers or Medicare. The subsequent reimbursement issue then generates medical lien claims that must be litigated. The incorporation of the language will greatly clarify responsibility and expedite medical care and payment.

For over 3 decades the Law Offices of Jon L. Gelman  1.973.696.7900  jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.


Thursday, August 18, 2011

State Acts to Restrict Medical Care

The State of NJ has proposed sweeping regulations to limit the payment of medical care under automobile insurance policies, and this action is seen as yet another signal that workers' compensation medical delivery may become even further restricted. In an effort to reduce insurance premiums, the NJ Department of Banking and Insurance, has proposed massive changes in the manner and method that doctors may bill for medical treatment and diagnostic procedures and has restructured the process for appealing a denied claim.

The State claims that medical delivery costs are soaring. It has been reported that for every premium dollar that insurance companies receive, they end up spending $1.23 on medical benefits. The regulations are designed to reduce medical services and produce a profitable insurance product.

Furthermore, the purpose of the regulations are to limit legal costs. The sate reported that in one instance a contested medical  resulted in the payment of $375 in medical benefits, but the legal costs awarded for that recovery were $3,380.

The regulations prohibit the use of innovative radiological diagnostic testing. "X-ray digitization or computer aided radiographic mensuration reported under CPT 76499 or any other code are not reimburseable under PIP."

The comment period for the new rules runs thorough early September 2011. The impact of the regulations is to reduce medical care and diagnostic procedures that will impact resulting workers' compensation benefits. Ironically providing the best medical benefits available would seemingly comply with the intent of the compensation act and ultimately economically benefit the employer by producing a healthy workforce, The process of cost cutting will only ultimately degrade the medical delivery component of workers' compensation even further.

Related articles

Saturday, July 30, 2011

National Analysis of Workers Compensation Medical Benefits


The just published, Issue 3 of the Workers’ Compensation Resources Research Report (WCRRR) provides 23 years of information on cash benefits, medical benefits, and total (cash plus medical) benefits per 100,000 workers for up to 47 jurisdictions each year. Workers’ compensation benefits per 100,000 workers varied significantly nationally over these years. 


In the most recent six years, total benefits per 100,000 workers increased by less than one percent in two years and declined in the other four years. There also typically are wide differences among jurisdictions in the generosity of benefits in a particular year. In 2007, for example, total benefits per 100,000 workers were more than fifty percent about the national average in five states and more than fifty percent below the national average in one jurisdiction. Over the 23 years, the differences among states have narrowed for cash benefits, medical benefits, and total benefits, although the differences among states in medical benefits have increased since 1998. 

The WCRRR is edited by John F. Burton, Jr. Additional information about Issue 3 and an order form are available at www.workerscompresources.com.
Related articles

Thursday, July 28, 2011

Deal or No Deal: Judge Relies on Court Appointed Physician

An Appellate Court has rule that a Judge of Compensation can select an independent physician to review the need for medical treatment. It doesn't matter whether or not the parties agreed formally or informally as to the binding effect of the physician's opinion as to causal relationship and the need for treatment.


The Court has discretion to merely rely upon the physician's opinion and reach a reach a decision based upon the report. The cost  of the evaluation is to be paid for by the employer /insurance carrier. Furthermore, the Court need not hold a hearing for oral argument on the issue and can reach a binding on the papers alone.


Thompson v. Quality Et al., 2011 WL 3107767, Docket No. A-1177-10T1 (NJ App. Div.) decided July 27, 2011.

Monday, July 11, 2011

The Debt Ceiling and Workers Compensation

President Barack Obama talks with members of his staff in the Oval Office following a meeting with the Congressional Leadership, July 7, 2011. Pictured with the President, from left, are: Chief of Staff Bill Daley; Rob Nabors, Assistant to the President for Legislative Affairs; Bruce Reed, Chief of Staff to the Vice President; National Economic Council Director Gene Sperling; Jason Furman, Principal Deputy Director of the National Economic Council; Office of Management and Budget Director Jack Lew; Senior Advisor David Plouffe; and Treasury Secretary Timothy Geithner. (Official White House Photo by Pete Souza)


As The Debt Ceiling Crisis continues to fester in a sluggish economy, the attack on public health programs like Medicare and Workers Compensation remain targets of cuts. Basically the medical delivery system just can't be supported and is imploding bringing down the entire house of cards.

Workers' Compensation, a patchwork of state programs, has a target on its back. The system is a massive Ponzi Scheme that now lacks a base of economic support and can no longer provide delivery of benefits in either the arena of medical or indemnity. It is the promise to Labor that just can't be kept.

Angry critics from cost to coast have targeted the system with a plethora of lame excuses why the system is ailing and why it is too costly to maintain as presently structured. While Industry continues somewhat to the downfall of workers' compensation, it cannot be blamed entirely. The compensation system was build on the foundation of the Industrial Revolution and a massive insurance scheme of the early 1900s that no longer realistically exists. Medical science has been transformed from the ancient French medical practice of the use of leaches, no anesthesia and zero sterilization, to an era of modern medicine with modern modalities, complex diagnostic and treatment and research protocols.  

As the debate unfolds in Washington DC on the debt ceiling, the focus with become more directed upon public entitlement programs and benefits that need to be modernized and revamped to meet the current changes to the economy and health of the nation. One of those targets will ultimately be workers' compensation and this time the politicians should look at it not in the light of negativity but rather for all the positive benefits workers compensation brings the nation.

Wednesday, February 2, 2011

California Report Makes Recommendations To Curtail Lien Claimants

A California workers' compensation report has made sweeping recommendations to reduce and manage the filling of liens in pending cases. One recommendation is to charge a $100 filing fee to be paid by a lien claimant.

The California workers compensation court has become a collection agency for unpaid bills. This issue is mirrored throughout the US as medical costs have soared and a single payer system has not yet been enacted as in European countries.

The study commission concluded that the volume of liens alone amounts to "coercion to settle." The report reveals that 35% of the present court calendar now involves liens. The cost to employers amounts to an estimated $200 Million annually. Over 450,000 liens are predicted to be filed this yea alone. Medical liens represent the vast majority of the liens filed in compensation cases.

Excluded from consideration in he report are Federal medical programs such a Medicare (Medicare Secondary Benefit claims), VA Medical claims and TRICARE (Military Health Plans.). Those claims can only be resolved only by a tribunal cloaked with  Federal jurisdiction.

Saturday, January 22, 2011

Out of State Medical Treatment Allowed By Workers Compensation Court

An employer is required to provide medical care, including surgery and followup care, to an employee even if the employee leaves the state within two days of an initial surgical intervention. Chubb Insurance was ordered to pay for medical care, including subsequent surgery, when an employee was required to leave the state for a family emergency.


The court held that the failure of the employer/insurance carrier to provide medical care for out-of-state treatment, even though requested by the employee, was deemed a refusal of the employer to provide adequate medical care to cure and relieve the worker of the work related injury. The employer/insurance company was ordered to pay for out-of-state medical care.


Ham v. Anchor Glass Container Corporation, Docket No. A-1797-09T3, Decided January 20, 2011 Not Reported in A.3d, 2011 WL 166206 (N.J.Super.A.D.)

Friday, November 26, 2010

Hospitals Are Not For Sick People

The New England Journal of Medicine reports that hospitals remain unsafe. A study comparing the last 10 years reflects that there have been no significant changes in safety rates for patients entering hospitals.  For decades the number has been stable, close to 25% of hospital patients get sicker because of unsafe or unhealthy hospital conditions or activities.

"Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100 admissions; 95% confidence interval [CI], 23.1 to 27.2). Multivariate analyses of harms identified by internal reviewers showed no significant changes in the overall rate of harms per 1000 patient-days (reduction factor, 0.99 per year; 95% CI, 0.94 to 1.04; P=0.61) or the rate of preventable harms. There was a reduction in preventable harms identified by external reviewers that did not reach statistical significance (reduction factor, 0.92; 95% CI, 0.85 to 1.00; P=0.06), with no significant change in the overall rate of harms (reduction factor, 0.98; 95% CI, 0.93 to 1.04; P=0.47)."

Adverse complications of medical care provided to injured workers are compensation under workers' compensation. Employers and insurance carriers should encourage safe and harmless medical care for injured workers.

Temporal Trends in Rates of Patient Harm Resulting from Medical Care, N Engl J Med 2010; 363:2124-2134November 25, 2010

Sunday, November 14, 2010

USPS May Declare Bankruptcy Citing High Workers Compensation Costs

A small United States Postal Service truck see...
The Washington Post reported Saturday that the US Postal Service (USPS) may declare bankruptcy and cited high combined benefit costs as a major cause for its financial instability.  The quasi-governmental agency is running into problems it claims because of its requirement to to pre-fund $5.4 billion to a retiree health benefit fund and pay $2.5 billion to the federal workers' compensation fund.

The USPS's troubles mirror that difficulties stangulating the nation's network of state workers' systems caused by the inability to fund soaring medical costs enhanced by complications caused by duplicate administrative costs engulfed by a multiplicity of collateral programs. In contested claims injured workers are shifted to other benefit programs to pay for medical costs. Those secondary programs ultimately seek reimbursement from the primary benefit program, workers' compensation coverage, and literally clog up administrative dockets and create greatly enhanced processing costs and monumental delays.

While the USPS will seek assistance from the Republican majority in
US Congress, it is uncertain what financial aid will be forthcoming, or whether Congress will take a deeper look at the nation's workers' compensation entirely. The last time the Republican's dominated Congress proposals were suggested by the former Speaker, Newt Gingrich, to over haul the national system entirely.

The medical component is now in critical condition. It remains uncertain if it will addressed in the next congressional term, or whether it will be the can that is kicked down the road to be dealt with in the future. The growing trend remains, that Federalization of the medical delivery component is the probable  solution to both the USPS's compensation difficulties as well as the the nation's.

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For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.

Thursday, November 11, 2010

New Jersey Issues Workers Compensation Guidance on Evaluating Disputed Medical Provider Claims

A NJ Workers' Compensation Task Force report has been published that provides guidance to the parties in evaluating disputed medical provider claims. While declaring that, "certainly there are no overnight solutions," the report provides a manual type of suggestions for negotiation, litigation and resolution.

1. The new WCRI report, Benchmarks for Designing Workers’ Compensation Medical Fee Schedules. Fee schedules vary dramatically from state to state and based upon the type of payer;

2. The fees customarily paid for like services within the same community;

3. The fees paid to the same physician or medical provider by other payers for like treatment;

4. The fees billed and the accepted payments for such bills by a given provider. The Court may wish to consider the disparity in payments accepted from different sources (i.e. Medicare vs. PIP and commercial carriers);

5. A review of the Health Insurance Claim Forms (“HCFA”) submitted by the provider to the claim payer and the Explanations of Benefits (“EOB”) that that claim payer sends to the provider. The EOB provides the amount billed for a given procedure or service performed on a particular date of services. The EOB also provides the amount paid and, where applicable, identifies the reason why a disparity may exist in the amount billed and the amount paid. The use of certified professional coders may be employed to review the bill along with the medical records to be sure that it is consistent with CPT coding standards;

6. The HCFAs or EOBs from other medical providers in the same geographic area or community for the same medical treatment provided;

7. Using commercial and/or private databases such as Ingenix’s Prevailing Healthcare Charges System (“PHCS”); the Medical Data Resource (“MDR”) database, and; Wasserman’s Physician Fee Reference (“PFR”) database to name a few;

8. The type of facility where the procedure was performed. For example, was the services provided at a Level 1 trauma center versus a community hospital;

9. Consideration of whether there was a contract between a claim payer and the medical provider, such as a PPO network, in which case the contract would be controlling;

10. Consideration ofMedicare/Medicaid reimbursement rates;

11. Testimony from medical office personnel as to what services were billed for, the payments received and how the bill was formulated;

12. Consideration of state sanctioned PIP fee schedules;

13. Consideration of commercial carrier authorized payments.

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For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.

Thursday, September 2, 2010

Spinal Kinetics-A New Computer Assisted Radiographic Mensuration Analysis

A new approached to the objective measurement of spinal damage is now being offered by Spinal Kinetics. The technique provides standards for the measurement for spinal ligamentous assessments using Computer Assisted Radiographic Analysis (CRMA). Board Certified Radiologists utilize a new computer assisted program to  determine: a treatment plan, ability to play and work, as well a pain management.


Click here to read more about this Spinal Kinetics
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For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered occupational exposures.

Sunday, August 8, 2010

Insurance Company Liable in Tort for Delay of Medical Treatment

A US District Court Judge held that a valid cause of action existed directly against an insurance company for the delay treatment to an injured worker. The court, in denying a motion for summary judgment, held that when an insurer negligently ignored the advice of its own medical expert concerning medical treatment, a claim against the insurer itself was not barred by the Exclusivity Doctrine.


Davis v One Beacon, et al., 2010 WL 2629053 (D.N.J.) Civil Action No. 09-cv-4179 (NLH)(KMW) Decided June 28, 2010.


Click here for more information on how Jon L Gelman can assist you in a claim for workers' Compensation claim benefits. You may e-mail Jon  Gelman or call 1-973-696-7900.