NJ Commissioner of Labor Adopts Rules for Emergent Medical Motions in Workers Compensation Matters

David J. Socolow, Commissioner of Labor and Workforce Development, on September 3, 2009, formally adopted the pending Rules for Emergent Medical Motions. The new Rules became effective on Monday, October 5, 2009 and a notice published in the NJ Register on that date, 41 NJ Register 3807(a).

A public hearing concerning the pending Rules was held on June 2, 2009 and there were no attendees. A written comment was submitted by Kenneth A. Stoller, Senior Counsel, American Insurance Association, Washington, DC. One comment concerned the assessment of fines against an insurance carrier for activities of the employer. The Department declined to modify the pending Rules, but stated, “…the insurance carrier would not be fined or penalized where it is in no way culpable for the violation.”

A typographical correction was recognized. “Upon review, the Department has noticed a typographical error, which it would like to correct through a change on adoption. Specifically, the reference within proposed N.J.A.C. 12:235-3.3(r) to, "the decision and order rendered under (o) above," should read, "the decision and order rendered under (q) above..." Consequently, the Department is substituting "(q)" for "(o)" within N.J.A.C. 12:235-3.3(r).”

The Honorable Peter J. Calderone, Director and Chief Judge of the Division, will discuss the new Rules in an upcoming academic seminar sponsored by the NJ Institute for Continuing Legal Education on Wednesday, October 7, 2009.

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The Rules:

12:235-3.2 General motions for temporary disability and/or medical benefits

(a)-(i) (No change.)

12:235-3.3 Motions for emergent medical care pursuant to N.J.S.A. 34:15-15.3

(a) With or after the filing of a claim petition, a petitioner may file a motion for emergent medical care directly with the district office to which the petition is or will be assigned (See N.J.A.C. 12:235-3.1 for claim petition filing and assignment).

(b) The notice of motion for emergent medical care shall be on a form prescribed by the Division and shall contain or be accompanied by the following:

1. A statement by the petitioner or the petitioner's attorney of the specific request(s) for medical treatment made by the petitioner or the petitioner's attorney to the employer and/or the employer's insurance carrier, including the name of the person(s) to whom the request(s) was/were made;

2. Medical documentation, including a statement by a physician indicating that the petitioner is in need of emergent medical care, that the delay in treatment will result in irreparable harm or damage to the petitioner and the specific nature of the irreparable harm or damage;

3. All medical records relating to the requested medical care, which are in the possession of the petitioner or the petitioner's attorney;

4. Copies of the claim petition and answer.

i. If no answer to the claim petition has been filed, the notice of motion shall include the following information if known by the petitioner: the telephone number and the fax number of the employer, the name of the employer's workers' compensation insurance carrier and the insurance carrier or self-insured employer contact person's telephone number and fax number, as required to be maintained under N.J.A.C. 12:235-3.4; and

5. Proof of service under (c), (d) and (e) below.

(c) Where an answer to the claim petition has been filed by the respondent, the notice of motion and supporting papers shall be served on respondent's attorney by fax and by a one-day delivery service.

(d) Where no answer to the claim petition has been filed by the respondent, the notice of motion and supporting papers shall be served on the employer and, if known by the petitioner, upon the employer's insurance carrier.

1. Service on the employer under this subsection shall be either by personal service or by fax and a one-day delivery service.

2. Service on the insurance carrier under this subsection shall be by fax and a one-day delivery service to the contact person listed pursuant to N.J.A.C. 12:235-3.4.

(e) Where the employer is uninsured or where the employer's insurer is not known by the petitioner, the notice of motion and supporting papers shall, in addition to the requirements under (c) or (d) above, be served on the Uninsured Employer's Fund by fax and by a one-day delivery service.

(f) The date of the personal service, the date of the fax service or the date of receipt of the one-day delivery service, whichever is latest, shall be considered the date of service under (c), (d) and (e) above.

(g) No later than five calendar days after receiving service of the petitioner's notice of motion for emergent medical care, the respondent shall file with the district office an answer to the motion.

(h) Within 15 calendar days after the petitioner has served the notice of motion for emergent medical care upon the appropriate party or parties under (c), (d) and (e) above, the employer or the employer's insurance carrier may have a medical examination of petitioner conducted.

(i) The petitioner is required to attend and cooperate with the medical examination process under (h) above.

(j) Motions for emergent medical care shall take precedence over all other court listings.

(k) The judge should use telephone conferences and afternoon hearings, as appropriate, to expedite the disposition of motions for emergent medical care and to avoid as much as possible the disruption of other court proceedings.

(l) Within five calendar days of the filing of an answer by respondent or, if no answer has been filed, within five calendar days from the date an answer should have been filed, an initial conference on the motion for emergent medical care shall take place.

(m) The district office shall provide notice of the initial conference to the following parties under the following circumstances:

1. Where an answer to the notice of motion for emergent medical care has been filed, the district office shall provide notice of the initial conference by telephone and fax to the petitioner's attorney or petitioner pro se and to the answering party using the telephone numbers and fax numbers indicated in the notice of motion for emergent medical care and the answer, respectively;

2. Where an answer to the notice of motion for emergent medical care has not been filed and where the employer is insured, the district office shall provide notice of the initial conference by telephone and fax to the employer and to the insurance carrier contact person listed in the notice of motion for emergent medical care; or

3. Where an answer to the notice of motion for emergent medical care has not been filed and where the employer is not insured or the insurer is not known, the district office shall provide notice of the initial conference by telephone and fax to the employer and to the Uninsured Employer's Fund.

(n) If the motion for emergent medical care has not been resolved at the initial conference and the employer or the employer's insurance carrier has not requested a medical examination of the petitioner under (h) above, the judge shall hold a hearing on the merits of the motion for emergent medical care as soon as is practicable, but no later than five calendar days from the date of the initial conference.

(o) If the motion for emergent medical care has not been resolved at the initial conference and the employer or employer's insurance carrier has requested a medical examination of the petitioner under (h) above, the judge shall hold a hearing on the merits of the motion for emergent medical care as soon as is practicable after the medical examination of the petitioner, but no later than five calendar days from the date of the medical examination of the petitioner.

(p) With regard to the hearing on the merits of the motion for emergent medical care, the judge may require a continuous trial or may use other procedures to ensure that the motion is expeditiously heard.

(q) The judge hearing the motion for emergent medical care shall render a decision and issue an order on the motion within one business day of the conclusion of the trial testimony.

(r) The judge may supplement the decision and order rendered under(q)above at a later date.

(s) If a motion for emergent medical care does not meet the requirements under this section, but does meet the requirements for a general motion for temporary and/or medical benefits under N.J.A.C. 12:235-3.3, the motion shall be listed and proceed as a general motion for temporary and/or medical benefits.

12:235-3.4 Insurance carrier or self-insured employer contact person procedures pursuant to N.J.S.A. 34:15-15.4

(a) Every insurance carrier providing workers' compensation insurance and every workers' compensation self-insured employer shall designate a contact person who is responsible for responding to issues concerning medical and temporary disability benefits where no claim petition has been filed or where a claim petition has not been answered.

(b) The contact person referred to in (a) above shall also receive notice of motions for emergent medical care under N.J.A.C. 12:235-3.3.

(c) The full name, telephone number, mailing address, e-mail address and fax number of the contact person referred to in (a) above shall be submitted to the Division utilizing the Division's contact person form in the manner instructed on the form.

(d) The Division's contact person form shall be made available on the Division's website and at the Division's district offices.

(e) Any changes of contact person or in information about the contact person shall be immediately submitted to the Division using the Division's contact person form.

(f) After an answer to a claim petition has been filed, the attorney of record for the respondent shall be the point of contact for issues concerning temporary disability and/or medical benefits.

(g) A contact person roster using the information provided under (c) above will be available on the Division's website.

(h) Failure to comply with the requirements of N.J.S.A. 34:15-15.4 or this section shall result in a fine of $2,500 for each day of noncompliance, which fine shall be payable to the Second Injury Fund.

1. The Division shall send notice of noncompliance and of the fine amount by certified mail, return receipt requested, to the business address of the insurance carrier or self-insured employer.

2. The insurance carrier or self-insured employer shall have 30 calendar days to pay the fine or to contest the fine.

3. Where the insurance carrier or self-insured employer contests the fine, the Division shall hold a conference in an attempt to resolve the dispute.

Recodify existing N.J.A.C. 12:235-3.3 through 3.13 as 3.5 through 3.15 (No change in text.)

12:235-3.16 Enforcement

(a) A party may, by written motion pursuant to N.J.A.C. 12:235-3.5(a) and (b), move against an employer, insurance carrier, petitioner, case attorney or any other party to a claim petition for enforcement of any court order or for the enforcement of the requirements of the workers' compensation statute or rules.

(b) The motion under (a) above shall identify the order, statute or regulation sought to be enforced.

(c) The party against whom the motion has been brought shall file a written response to the motion within 14 calendar days of the notice of motion.

(d) The response under (c) above shall include the reasons for any noncompliance and the manner and time period to ensure compliance.

(e) Any time after the 14-day period to respond under (c) above has elapsed and on notice to the parties, the judge shall hold a hearing on the motion.

(f) A judge on his or her own motion may at any time, upon notice to the affected parties, move to enforce a court order or to enforce the requirements of the workers' compensation statute or rules.

(g) Prior to ruling on a motion under (f) above, the judge shall provide the parties an opportunity to respond to the motion and to be heard on the record.

(h) Upon a finding by a judge of noncompliance with a court order or the workers' compensation statute or rules, the judge, in addition to any other remedy provided by law, may take any or all of the following actions:

1. Impose costs and simple interest on any monies due.

i. The judge may impose an additional assessment not to exceed 25 percent on any moneys due if the judge finds the payment delay to be unreasonable;

2. Levy fines or other penalties on parties or case attorneys in an amount not to exceed $5,000 for unreasonable delay or continued noncompliance.

i. A fine shall be imposed by the judge as a form of pecuniary punishment.

ii. A penalty shall be imposed by the judge to reimburse the Division's administrative costs.

iii. The proceeds under this paragraph shall be paid into the Second Injury Fund;

3. Close proofs, dismiss a claim or suppress a defense as to any party;

4. Exclude evidence or witnesses;

5. Take other appropriate case-related action to ensure compliance; and/or

6. Allow a reasonable counsel fee to a prevailing party, where supported by an affidavit of services.

(i) Upon a finding by a judge of noncompliance by a party with a court order or the workers' compensation law or rules, the judge, in addition to any other remedy provided by law, may hold a separate hearing on the issue of contempt.

(j) Following a hearing under (i) above and upon a finding by the judge of contempt, the successful party in the contempt hearing or the judge may file a motion with the Superior Court for contempt action.

(k) Any fine, penalty, assessment or cost imposed by a judge under this section shall be paid by the entity or party found to be in noncompliance and shall not be included in the expense base of an insurance carrier for the purpose of determining rates or as a reimbursement or case expense.

Recodify existing N.J.A.C. 12:235-3.15 and 3.16 as 3.17 and 3.18 (No change in text.)

SUBCHAPTER 7. UNINSURED EMPLOYER'S FUND

12:235-7.1 Purpose; scope

(a)-(d) (No change.)

(e) A petitioner may move to relax or dispense with requirements under this subchapter.

1. After a hearing on the motion to relax or dispense with requirements under this subchapter, the judge may grant the motion upon a finding that the subject requirements under the particular facts of the case are unduly burdensome and that grant of the motion would not adversely affect the UEF.

(f) Where petitioner seeks current medical treatment and/or temporary disability benefits and the only issue is the cancellation or non-renewal of an insurance policy, the judge may order the insurance carrier to provide treatment and/or benefits without prejudice and subject to reimbursement by the employer or, if not paid by the employer, by the UEF, if it is subsequently determined that the policy was not in effect.

(g) (No change in text.)

12:235-7.4 Medical bills; physician's examination

(a) Any medical bills or charges for which petitioner seeks payment from the UEF must be timely submitted by the petitioner to the UEF and be supported by the following:

1. Related treating records, itemized bills and a physician's report, which reflects that the bills and charges were reasonable, necessary and causally related to the work accident or occupational exposure alleged in the claim petition; and

2. Other necessary medical documentation or information required by the UEF.

(b) Any dispute under this section concerning the treating records, bills, physician's report or UEF request for other medical documentation or information shall be determined by the judge after a hearing upon oral or written motion by the UEF or another party.

Recodify existing (b)-(e) as (c)-(f) (No change in text.)

For more information concerning medical care and workers’ compensation click here.

The Great Health Care Debate

As the US Senate signals the beginning of the floor debate of the proposed health care legislation, a new chapter is about to be written in the Workers' Compensation medical benefit delivery system. If any of the five proposed bills, or prodigies of any, are enacted into law the nation's workers' compensation will be impacted.

The health care delivery system of the nation's compensation system is a patchwork of acts enacted in 1911 that have changed little since then. While modern medical science has move at the speed of light to develop new methods for diagnosis and new modalities for treatment, workers' compensation has stood still like a classic picture in the museum of time. While the US compensation system was crafted in 1911 to provide immediate and remedial medical care for industrial accidents in a swift and summary manner, the recognition of occupational diseases, and their enormous complex etiology, has been met by what some critics observe as a "deny and delay" strategy by Industry resulting in a failure of the system to provide benefits in an efficient and effective manner. Compounding the issue is the massive maize of collateral benefits of global insurance systems that have now resisted inappropriate benefit shifting to them and are mandating reimbursement for improper initial payments in the past and protection from looting in the future, ie. The Centers for Medicare and Medicaid Services.

The workers' compensation stakeholders have been silent participants in the drafting of the new health care legislation and have sat quietly on the sidelines. Only on the eve of the US Senate Finance's Committee's debate on the Rockefeller Amendment, for mandated broad and potentially universal coverage, was the chorus of compensation defense attorneys' heard to rally support in opposition without offering a creative solution.

The proposed legislation will embrace massive change for the nation's medical delivery and involve every individual, business, hospital and doctor. Yet to be determined is whether every employer will be mandated to provide health insurance. While the number of the nation's uninsured has continued to rise in epidemic proportions, the "safety net" for those who have been denied medical benefits under the workers' compensation systems have also grown logarithmically.

Issues remain open as the floor debate opens on health care. To be debated are many issues including: mandatory coverage; the extent of business involvement; financing the program; a public plan; government subsidies; and the cost of care. Any or all of these immense issues will ultimately impact the national workers' compensation system as it now exists.

As the unpredictable health care legislation is debated in Congress, the legislators will hopefully take notice of how other industrial countries have met the challenge to treat workers. The European countries, where workers' compensation had its geniuses almost a century ago, have already solved the problem through the enactment of universal health care.

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For more on workers' compensation and national health care reform click here.

Defense Department to Investigate Hexavalent Chromium Exposure Claims

The US Department of Defense has announced that it will investigate emerging environmental and health risks arising from chemical exposures. One of the particular areas of concern is the exposure to hexavalent chromium that occurred Iraq.

On October 8, the Senate Committee on Veteran’s Affairs will hold a hearing on chemical exposures including the hexavalent chromium incident.

Chromium exposure has been associated with lung cancer. Breathing high levels of hexavalent chromium can irritate or damage the nose, throat, and lungs. Irritation or damage to the eyes and skin can occur if hexavalent chromium contacts these organs in high concentrations or for a prolonged period of time. Exposure to chromium can occur from inhalation of dusts, mists, or fumes containing hexavalent chromium, or from eye or skin contact with hexavalent chromium.

For more information about chromium exposure click here.

Sears Roebuck Pays $6.2 Million for Inflexible Workers Compensation Exhaustion Policy

The Federal Court in Chicago approved the largest monetary amount ever in a single EOCC ADA law suit in a case involving Sears Roebuck.

The following was announced by the EEOC:

"The U.S. Equal Employment Opportunity Commission (EEOC) today announced the entry of a record-setting consent decree resolving a class lawsuit against Sears, Roebuck and Co. (Sears) under the Americans With Disabilities Act (ADA) for $6.2 million and significant remedial relief.

The consent decree, approved this morning by Federal District Judge Wayne Andersen, represents the largest ADA settlement in a single lawsuit in EEOC history. The EEOC's suit alleged that Sears maintained an inflexible workers' compensation leave exhaustion policy and terminated employees instead of providing them with reasonable accommodations for their disabilities, in violation of the ADA.

"The facts of this case showed that, nearly twenty years after the enactment of the ADA, the rights of individuals with disabilities are still in jeopardy," said Commission Acting Chairman Stuart J. Ishimaru. "At the same time, this record settlement sends the strongest possible message that the EEOC will use its enforcement authority boldly to protect those rights and advance equal employment opportunities for individuals with disabilities."

EEOC Chicago District Director John Rowe, who supervised the agency's administrative investigation preceding the lawsuit, said that the case arose from a charge of discrimination filed with the EEOC by a former Sears service technician, John Bava. According to Rowe, Bava was injured on the job, took workers' compensation leave, and, although remaining disabled by the injuries, repeatedly attempted to return to work. Sears, Rowe said, "Could never see its way clear to provide Bava with a reasonable accommodation which would have put him back to work and, instead, fired him when his leave expired."

Regional Attorney John Hendrickson of the EEOC Chicago District Office said pre-trial discovery in the lawsuit revealed that hundreds of other employees who had taken workers' compensation leave were also terminated by Sears without seriously considering reasonable accommodations to return them to work while they were on leave, or seriously considering whether a brief extension of their leave would make their return possible.

"The era of employers being able to inflexibly and universally apply a leave limits policy without seriously considering the reasonable accommodation requirements of the ADA are over," Hendrickson said. "Just as it is a truism that never having to come to work is manifestly not a reasonable accommodation, it is also true that inflexible leave policies which ignore reasonable accommodations making it possible to get employees back on the job cannot survive under federal law. Today's consent decree is a bright line marker of that reality."

In addition to providing monetary relief, the three-year consent decree includes an injunction against violation of the ADA and retaliation. It requires, in addition, that Sears will amend its workers' compensation leave policy, provide written reports to the EEOC detailing its workers’ compensation practices' compliance with the ADA, train its employees regarding the ADA, and post a notice of the decree at all Sears locations.

According to Greg Gochanour, EEOC supervisory trial attorney in Chicago, "This is not merely a garden variety so-called 'cost of litigation' settlement. We discovered well over a hundred former employees who wanted to return to work with an accommodation, but were terminated by Sears - and some of them found it out when their discount cards were rejected while shopping at Sears. We believe Sears' decision to accept this decree makes good sense."

The lawsuit, filed in November 2004, was assigned to Federal District Court Judge Wayne Andersen of the Northern District of Illinois and Magistrate Judge Susan Cox, and is captioned EEOC v. Sears Roebuck & Co., N.D. Ill. No. 04 C 7282. Today's decree is dated September 29, 2009. The court will hold a final hearing, currently slated for approximately February 2010, at which time the court will make a final determination as to the fairness of the individual distributions from the $6.2 million settlement fund.

The EEOC litigation team has included, in addition to Hendrickson and Gochanour, Chicago trial attorneys Aaron DeCamp, Ethan Cohen, Deborah Hamilton and Laurie Elkin.

The EEOC enforces federal laws prohibiting discrimination in an employment. Further information about the Commission is available on its web site at www.eeoc.gov.

AAAS Enthusiastically Endorses the Nomination of Dr. David Michael as Assistant Secretary of OSHA

The prestigious, American Association for the Advancement of Science (AAAS) has endorsed the nomination of Dr. David Michaels to become Assistant Secretary of Labor for The Occupational Safety and Health Administration (OSHA). In a letter to Senator Tom Harkin, Chairman of the Health, Education, Labor and Pensions Committee, Albert H. Teich, Director of Science & Policy Programs for AAAS enthusiastically endorsed the Michael’s nomination.

Teich wrote, “My colleagues and I agree wholeheartedly. Michaels is an expert on the health effects of exposure to toxic chemicals and understands the ways that science can be used- and misused- in legal and regulatory decision making. Much of his research and policy work has focused on the health of the disadvantaged.”

Michael’s was the recipient of AAAS Scientific Freedom and Responsibility Award, an annual prize created by the AAAS in 1980 to “honor scientists and engineers whose exemplary actions have served foster scientific freedom and responsibility.”

The AAAS’s endorsement letter in support of the nomination further stated, …. “The citation on Dr. Michaels's award recognizes him both for his " commitment to obtaining justice for workers whose health has suffered from working in nuclear weapons programs and for his advocacy for scientific integrity in public policy making."

The American Association for the Advancement of Science, 
"Triple A-S" (AAAS), is an international non-profit organization dedicated to advancing science around the world by serving as an educator, leader, spokesperson and professional association. In addition to organizing membership activities, AAAS publishes the journal Science, as well as many scientific newsletters, books and reports, and spearheads programs that raise the bar of understanding for science worldwide.

For more information about OSHA click here.

US EPA Targets Hazardous Chemicals for New Regulations

The Obama Administration has announced a proposed initiative to regulated hazardous substances. The workplace and the Workers' Compensation system has been literally plagued for decades with an epidemic of disease caused by the use of dangerous and unregulated chemicals in the workplace.

Lisa Jackson, US EPA Administrator, in a speech before the Commonwealth Club in San Francisco announced the Administrations proposed initiative to finally ban the use of asbestos. Asbestos, still permitted to be used in the US, is well known carcinogen that has been causally connected to asbestosis, lung cancer and mesothelioma (a fatal illness).

Citing the failure of the 1976 Toxic Substances Control Act (TSCA), Jackson has proposed new legislation that will require that manufactures to develop new data on safety of existing chemicals and new chemicals used. She stated:

"As with existing chemicals, the burden of proof falls on EPA. Manufacturers aren’t required to show that sufficient data exist to fully assess a chemical’s risks. If EPA has adequate data, and wants to protect the public against known risks, the law creates obstacles to quick and effective action.Since 1976, EPA has issued regulations to control only five existing chemicals determined to present an unreasonable risk. Five from a total universe of almost 80,000 existing chemicals. In 1989, after years of study, EPA issued rules phasing out most uses of asbestos, an exhaustively studied substance that has taken an enormous toll on the health of Americans. Yet, a court overturned EPA’s rules because it had failed to clear the many hurdles for action under TSCA.

"Today, advances in toxicology and analytical chemistry are revealing new pathways of exposure. There are subtle and troubling effects of chemicals on hormone systems, human reproduction, intellectual development and cognition. Every few weeks, we read about new potential threats: Bisphenol A, or BPA – a chemical that can affect brain development and has been linked to obesity and cancer – is in baby bottles; phthalate esters – which have been said to affect reproductive development – are in our medical devices; we see lead in toys; dioxins in fish; and the list goes on. Many states – including California – have stepped in to address these threats because they see inaction at the national level.

"Senator Lautenberg, Chairman Waxman, Senator Boxer, Congressman Rush and others in Congress have already recognized that TSCA must be updated and strengthened. EPA needs the tools to do the job the public expects. And we are working together with President Obama on this issue.

The Administration's 6 part initiative will include the following according to Jackson:

"First, we need to review all chemicals against safety standards that are based solely on considerations of risk – not economics or other factors – and we must set these standards at levels that are protective of human health and the environment.

"Second, safety standards cannot be applied without adequate information, and responsibility for providing that information should rest on industry. Manufacturers must develop and submit the hazard, use, and exposure data demonstrating that new and existing chemicals are safe. If industry doesn’t provide the information, EPA should have the tools to quickly and efficiently require testing, without the delays and procedural obstacles currently in place.

"Third, both EPA and industry must include special consideration for exposures and effects on groups with higher vulnerabilities – particularly children. Children ingest chemicals at a higher ratio to their body weight than adults, and are more susceptible to long-term damage and developmental problems. Our new principles offer them much stronger protections.

"Fourth, when chemicals fall short of the safety standard, EPA must have clear authority to take action. We need flexibility to consider a range of factors – but must also have the ability to move quickly. In all cases, EPA and chemical producers must act on priority chemicals in a timely manner, with firm deadlines to maintain accountability. This will not only assure prompt protection of health and the environment, but provide business with the certainly that it needs for planning and investment.

"Fifth, we must encourage innovation in green chemistry, and support research, education, recognition, and other strategies that will lead us down the road to safer and more sustainable chemicals and processes. All of this must happen with the utmost transparency and concern for the public’s right to know.

"Finally, we need to make sure that EPA’s safety assessments are properly resourced, with industry contributing its fair share of the costs of implementing new requirements.

For more information concerning "occupational illnesses" and workers' compensation click here.

AIG Claims Conspiracy by Liberty and Hartford

AIG, an insurer bailed out by the US, now claims that other workers' compensation carriers entered into a conspiracy against them by underreporting their premiums. In an amended complaint filed last week in the Federal Court in Chicago (USDCT N.D. Ill.), AIG alleged that Liberty Mutual and Hartford/ACE entered into a conspiracy to underreport their premiums.

Premium calculations determine contributions to State compensation funds that cover State operated programs for employers unable to secure coverage in the open market. These include high risk employers.

National Workers Compensation Reinsurance Pool v. American International Group Inc., 1:07C-2898, U.S. District Court, Northern District of Illinois

For more about AIG click here.

CMS Terminates Voluntary WC Data Match Program

CMS has formally terminated the voluntary WC Data Match program that it instituted several years ago. With the enactment of Section 111 Mandatory Insurance Company reporting the voluntary program afforded to States and Insurance Company has been terminated.

In a letter to those participating CMS stated:

"This voluntary reporting arrangement has now ended. On July 1, 2009, Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (the MMSEA) became effective for Workers’ Compensation insurance coverage. As of that date, the reporting of Workers’ Compensation information in support of Medicare Secondary Payer (MSP) determinations by CMS became mandatory. All existing voluntary reporting arrangements involving Workers’ Compensation programs are now null and void.

"July 1, 2009, is the date Section 111 reporting became effective, but it is not the date that states will begin to report Workers’ Compensation information under the Section 111 requirements. In summary, states that will be reporting Workers’ Compensation data through the Section 111 process are required to register for Section 111 reporting by September 30, 2009. The testing of the electronic data exchange process will start January 1, 2010. The first “production” file exchanges will start April 1, 2010.

"The process for arranging Section 111 reporting, and all the reporting timeline benchmarks that have been established are described in full on the Section 111 Website, www.cms.hhs.gov/mandatoryinsrep . The current version of the “NGHP User Guide” and additional instructions needed to report Workers’ Compensation information are located on the Website’s “Liability Insurance, Self-Insurance, No-Fault Insurance and Workers Compensation (NGHP)” page."

CMS Updates Submission Process for WCMSAs

CMS has announced two changes for the WCMSA submission process:

1. Updated checklist; and

2. Intent to provide a secure portal for submission of WCMSAs.

"Good news, over 85 responses were received to the "Survey for Workers' Compensation Medicare Set-Aside (WCMSA) Process." The results confirm entities who report workers' compensation settlements that contemplate future medical (including prescription drug) treatments support, overwhelming the availability of a secure Internet web-based portal or interface. Further, the vast majority of responders stated that they are capable of uploading and transmitting documentation in a PDF format into a secure Internet web based portal application.

Based on the results, CMS will be moving forward with its plan to make available a secure Internet web-based portal or interface for the WCMSA submission process."

For more information about CMS and WCMSAs click here.

NY Opens 1 Year Window for 9/11 Claims

NY Governor David A. Patterson has signed into law a bill that permits otherwise time-barred claims against NY municipalities arising out of terrorist activities that occurred on September 11, 2001.

The City of NY just released the 2009 Annual Report concerning the health consequences of the 9/11 attack. The report concludes:

"Results from large epidemiologic studies suggest that probable posttraumatic stress disorder (PTSD) is the most common WTC-related health condition among exposed adults. Probable PTSD means that individuals scored above a certain threshold when responding to a mental health screening questionnaire but have not undergone the psychiatric interview necessary to confirm the diagnosis.

I The risk for developing probable PTSD was higher among those who were:

• Caught in the dust cloud released by the buildings as they collapsed

• Injured as a result of the attacks

• Directly exposed to the events of 9/11, including proximity to the WTC site, witnessing horrific events and knowing someone who was killed or injured in the attacks

• Among rescue and recovery workers, working at the WTC site for a long time or doing tasks outside of their trained area of expertise.

I Several studies indicated that respiratory symptoms, sinus problems, asthma, and loss of lung function were found in people or reported by some who were exposed to WTC dust, including rescue and recovery workers, residents and evacuees. Other studies have suggested that risk of developing sarcoidosis (an inflammation that usually affects the lungs) was elevated in the first few years after the event. Many exposed adults were also diagnosed with or reported having heartburn, acid reflux or gastroesophageal reflux disease (GERD), often in conjunction with other respiratory or mental health symptoms. GERD is a common condition among the general population, however; further research is needed to understand the association between GERD, WTC exposure and other WTC-related health conditions.

I The risk for developing respiratory problems has been examined most thoroughly among rescue, recovery and clean-up workers, and was increased among those who:

• Arrived early at the WTC site • Worked at the WTC site for long periods of time.

I Few studies addressed the impact of WTC exposure on child and adolescent health, especially physical health.

I Whether there is a relationship between WTC exposure and other longer-term illnesses, including cancer, is unknown but clinicians, epidemiologists and other researchers are actively studying this. They also are studying the relationship between WTC exposure and mortality.

I At the time of the report’s publication last year, treatment for WTC-related conditions was available for exposed groups, including children and adolescents, in the NewYork City area."

For additional information on 9/11 Compensation click here.

Medical Costs Soar in the US $55.4 Billion Workers’ Compensation Business

Medical costs continue to soar as a cost in Workers’ Compensation insurance costs nationally. Despite the nations economic downturn a recent report issued by the National Academy of Social Insurance (NASI) reveals that medical spending increased 3.3%.

The costs of the workers’ compensation medical care nationally now represents 49% ($27.2 Billion) of the benefit package. Cash benefits grew a modest .8% over last year.

For about medical benefits and Workers’ Compensation click here.

Risk Assessments for Asbestos Present Difficulties

For decades asbestos has been known human carcinogen and major health hazard causally related to asbestosis, lung cancer and mesothelioma. It is still not banned in the United States. Recent efforts to provide statistics assessments of the hazard haven’t proven to be unsuccessful.

A study published in the September 2009 issue of The American Journal of Industrial Medicine concludes, “None of the efforts to use statistical models to characterize relative cancer potencies for asbestos fiber types and sizes have been able to overcome limitations of the exposure data. Resulting uncertainties have been so great that these estimates should not be used to drive occupational and environmental health policy. The EPA has now rejected and discontinued work on its proposed methods for estimating potency factors. Future efforts will require new methods and more precise and reliable exposure assessments. However, while there may be genuine need for such work, a more pressing priority with regard to the six regulated forms of asbestos and other asbestiform fibers is to ban their production and use.”

The Urgent Need for Workers Compensation Flu Pandemic Planning

The 2009 influenza pandemic (flu) has created a new framework of acts and regulations to respond the World Health Organization’s (WHO) phase 6 pandemic alert. Governmentally imposed employment disruptions resulting from regulatory work disruptions to prevent the spread of disease maybe massive. While workers’ compensation was envisioned as a summary and remedial social insurance program, the challenges facing the workers’ compensation system to deliver benefits as promised may be seriously burdened.

There has been a global reaction to the 2008 influenza pandemic. On April 25, 2009, the WHO director-General Dr. Margaret Chen declared the H1N1 virus outbreak as a “Public Health Emergency of International Concern.” The international declaration indicated that a coordinated international response was potentially necessary to prevent curtail the spread of the disease that was perceived as a public health risk. Recommendations to restrict both trade and travel may follow.

The United States has structured its response on both a State and Federal level to the 2009 influenza alert. The Public Health Service Act (PHS) permits the Secretary of Health and Human Service (HHS) to access a special emergency fund, allows or the use of unapproved medical treatments and tests, and allows waiver of certain reimbursement of Medicare and Medicaid expenses, and waives penalties and sanctions for violation of the HIPAA Privacy Rule requirements. Additionally, the President may issue an emergency declaration under The Stafford Act to co-ordinate emergency relief under State and Federal programs, ie. use and distribution of anti-viral medications.

The Federal government has sweeping powers under the PHS that could disrupt employment throughout the country. Recommendations for school closings will impact children and staff well beyond the approximate 700 facilities that were closed in the Spring of 2009 during the H1N1 initial outbreak. The Federal government under the PHS has authority to quarantine (interstate and border) and to isolate. An Executive Order (E.O. 13375, April 2005) enumerates the “quarantainable diseases.” Travel restrictions may be imposed to limit the spread of a communicable disease. Employees may not be permitted to board flights under either voluntary airline restrictions or through the Federally imposed “Do Not Board” lists.

These closings and restrictions have raised issues as to what programs, if any, will be able to provide benefits to the employees because of the involuntary nature of the closings and disruptions. A recent Harvard School of Public Health study reveals that 80% of businesses foresee severe problems in maintaining operations if there is an outbreak. The workers’ compensation system could be requested to provide temporary disability benefits for occupational disease absences on a massive scale never before experienced. Pre-emption by superseding emergency regulatory actions may curtail employment that will trigger the implementation of State workers’ compensation benefits. The employer and the workers’ compensation insurance carriers will be required to pay temporary disability and medical benefits as a direct consequence of efforts to prevent the spread of a communicable disease. The carefully crafted employee-employer notification structure integrated into the workers’ compensation system may be partially or entirely disrupted by the consequences and chaos of the global health emergency.

Workers’ Compensation claims arising out of the influenza pandemic of 2009 will need to fit into the convoluted framework statutory acts and regulation. Reimbursement from the usual collateral third-party reimbursement sources may be restricted. In addition to the Doctrine of Sovereign Immunity, enjoyed by the Federal and State governments, other legislation including The “Public Readiness and Emergency Preparedness Act" (PREP Act) limits liability of others under certain specific emergency circumstances.

The enormity of the Pandemic presents a new and novel challenge to the system and one that must be considered by both Federal and State planners. Workers’ Compensation programs have adapted to emergencies before including natural disasters and terrorist attacks. The urgency of the situation requires that the system be vaccinated now.

For more articles on Workers' Compensation and the Flu Pandemic click here.

Breast Cancer Linked to Night Shift Work by Danish Compensation System

The Danish government has begun to pay compensation benefits to women who develop breast cancer after working night shifts and irregular work hours. So far approximately 40 women have received benefits according to BBC reports.

The Danish agency relied upon a finding of the International Agency for Research on Cancer (IARC) a unit of the the United Nation's World Health Organization (WHO) in concluding that night shift work was a probable cause of cancer.

The National Board of Industrial Injuries announced that, "Danish women with breast cancer who have worked night shift for usually 20-30 years and at least one night per week are encouraged to apply for compensation for their cancer disease."

Dr. Vincent Cogliano (photo) of the IARC said, "The level of evidence is really no different than it might be for an industrial chemical."

CMS Schedules Town Hall Meeting to Discuss a Secure Internet Portal for Submissions of Proposed WCMSAs

On September 9, 2009 CMS has scheduled a "Town Hall" telephone conference call to discuss:

1. Overview of CMS plans to make available a secure Internet web-based portal or interface for the WCMSA submission process for the various affected stakeholders.
2. Question & Answer Session. Only questions regarding the ongoing implementation of a secure Internet web-based portal or interface for the WCMSA will be addressed. No policy or case specific questions will be accepted.

Call in number and Pass Code click here.

CMS Lists How to Avoid 10 Top WCMSA Errors

The Centers for Medicare and Medicaid Services has now posted the 10 top errors on Workers' Compensation Set Aside Agreement submissions and how to avoid them:

1. No medical records for the last two years of treatment

2. Claims payment history missing or undated

3. Response to development requests incomplete

4. Calculation method stated as fee schedule when state does not have a fee schedule

5. Calculation method not stated for the medical set-aside

6. Total settlement amount missing or unclear

7. No rated age statement from submitter confirming that all rated ages obtained on the claimant have been included

8. Payout amount not used in annuity situations

9. Proposed medical set-aside amount is missing, unclear, or inconsistent with other information

10. Proposed prescription drug set-aside amount is missing, unclear, or inconsistent with other information

Click here for the solutions.

Congressional Action on Workers’ Compensation

From coast to coast, the patchwork of state workers’ compensation systems remains under constant scrutiny for change. The problems seem global in character as the frustrations continue to rise. The fate of the entire system may hinge on efforts to enact or defeat legislation establishing a new national commission on workers’ compensation.

NIH Defense Asbestos Expert Pleads Guilty to Lying

A physician who was working full time in a senior position with the National Institutes of Health (NIH) pleaded guilty to lying about moonlighting as an expert in litigation at $425.00 per hour. Dr. Jack Snyder pleaded guilty recently and was convicted of a felony.

Study Reveals The Decline in Occupational Injuries Caused by Loss of Manufacturing Sector

A recent report in the American Journal of Industrial Medicine links the decline of occupational injury rates to the loss of manufacturing jobs. The study reviewed statistical data from 1976 to 2000 and concludes that the 18% in occupational injuries is a direct result of the decline in manufacturing sector jobs.

American Journal of Industrial Medicine 10.1002/ajim.20742