Workers Compensation

Article Author:
Denise Knoblauch
Article Editor:
Sebastiano Cassaro
Updated:
6/18/2019 4:47:48 AM
PubMed Link:
Workers Compensation

Introduction

Workplace injuries are a major cause of disability and death. The workers' compensation system was developed to provide compensation workers for work-related injuries and illnesses. Workers' compensation laws delegate that employers assume most of the costs related to work-related illnesses and injuries, regardless of fault. In the United States, each state mandates its own system for compensation. Federal employees are covered by federal workers' compensation laws. The following are the basic benefits that are included in compensation systems of all states: 

  • Income replacement for temporary total disability
  • Dependent support for employee death
  • Payment for medical, hospital, and death benefits. 

Income replacement is usually at a reduced rate as determined by the state, often based on a percentage of the employee's average weekly wage when the worker is disabled or not accommodated at work with restrictions. The employee may have a waiting period before payments begin. Income benefits can be based upon a percentage of impairment that is the result of the injury or illness or a schedule related to a specific loss, such as the loss of a limb.[1][2][3]

Issues of Concern

Usually, workers' compensation is a no-fault system. When providing workers' compensation benefits, the employer is usually immune from further legal action. Each state usually defines compensability, but in general, the benefits are limited to accidents, injuries, and illnesses "which arise out of and in the course of employment." All states recognize responsibilities for work-related illnesses. Identifying work-related illnesses can be complex and multifactorial due to the onset from exposure to onset of illness/symptoms, insidious onset, and multiple causation issues. Workers' compensation is a legal system rather than a medical system. Courts within a territory interpret the workers' compensation language and issues, and usually, compensation is administered by the state commission or board level.[4][5][6]

The provider must be adept at gathering occupational health and exposure history. The history may include all jobs held, exposures, symptoms, symptoms among co-workers, nonwork exposures, tobacco smoke exposure, lead exposure, water supply, diet, pets, and home cleaning products. The treating physician may be asked to identify work-relatedness by the insurance adjuster, employer, or case manager so the non-occupationally health-trained physician, either specialist or general practitioner, may refer/request an occupational and environmental health boarded physician address work-related questions. Another common question asked by adjusters, employers, and case managers is the concept of maximum medical improvement or maximum medical recovery in which the treating physician opines the employee has recovered from the injury at a level at which the provider states no further treatment will significantly change the outcome of the medical condition. Often disagreements occur regarding the degree of disability, readiness to return to work, and if the condition is work-related.[7][8][9][10]

Many states utilize managed care concepts, fee schedules, and/or treatment guidelines to monitor usage of medical treatment for usual and customary charges. State statute determines the choice of medical care. Some states allow the employer to control care via a provider panel while others allow the employee free choice of providers. The employer has the right to have the employee examined by a physician of their choice, which may be referred to as an independent medical examination in which a non-treating physician evaluates the employee and provides an opinion regarding:

  1. General health condition
  2. Work status
  3. Recommendations for physical abilities
  4. Length of time to be unable to work
  5. Recommendation for current and future treatment
  6. Relationship of the condition to work and if the condition was aggravated or developed due to conditions at work, and estimation of maximum medical improvement.

The employee that is unable to work or is not accommodated due to restrictions is provided with disability payments which are categorized as:

  • Temporary total disability (TTD): the employee is unable to return to any continuous gainful employment due to an occupational illness or injury
  • Temporary partial disability (TPD): the employee is still under medical treatment for the work injury or illness but can return to work which has restrictions, or he/she is working at a lower paying position than the pre-injury position
  • Permanent total disability (PTD): this is paid when the employee has a condition in which is permanent and completely incapacitates the employee, so the employee is not able to ever perform gainful employment
  • Permanent partial disability (PPD): this condition results in the loss of body part or lasting impairment that is estimated to be unlikely to improve, and there is a potential decrease in wage-earning ability.         

Most states have statutes to provide income based upon specific losses (e.g., a limb, eye) or disfigurement. Employees receive income benefits based on a percentage of impairment resulting from injury or illness which may be temporary or permanent. Usually, pain and suffering issues are not part of the worker's compensation system awards. All states have a statute of limitations for the filing of worker's compensation claims which can be related to filing within a time frame after the accident or learning of the diagnosis or when the disease becomes symptomatic.

Injury cases which demonstrate barriers to recovery and rehabilitation include:

  • Prolonged treatment
  • Development of complex injury conditions after initial injury
  • Longer-than-expected recovery exceeding disability guidelines
  • Prolonged disability from a minor type injury
  • Multiple treating physicians, therapists, other practitioners
  • Co-morbidities
  • Lack of incentive (usually financial or psychosocial) to comply with medical treatment and return to work.

Clinical Significance

Occupational diseases can be difficult to identify as work-related, as a disease can have multiple causes, and it can be difficult to determine which specific factors "caused" the disease. In some instances, occupational diseases do not develop until years after the exposure. Some occupational injuries occur as a result of extended exposure to a hazard. Examples of cumulative disorders include hearing loss, carpal tunnel syndrome, and chronic low back pain. For cases in which multiple causes are present, occupational and personal health, the legal standard is to review the preponderance of the evidence to determine work-relatedness or not. The preponderance of the evidence means that it is more likely than not that the illness was caused by, aggravated by or hastened by the workplace exposure.


References

[1] Schwatka NV,Tenney L,Dally M,Brockbank CVS, Health Risk Calculator: An online, Interactive Tool to Estimate how Health Impacts Workers' Compensation Claim Incidence and Cost. Journal of occupational and environmental medicine. 2019 Apr 19;     [PubMed PMID: 31022100]
[2] Sears JM,Edmonds AT,Coe NB, Coverage Gaps and Cost-Shifting for Work-Related Injury and Illness: Who Bears the Financial Burden? Medical care research and review : MCRR. 2019 Apr 25;     [PubMed PMID: 31018756]
[3] Baker NA,Feller H,Freburger J, Does insurance coverage affect use of tests and treatments for working age individuals with carpal tunnel syndrome in the United States? Analysis of the National Ambulatory Medical Care Survey (2005-2014). Archives of physical medicine and rehabilitation. 2019 Apr 16;     [PubMed PMID: 31002811]
[4] Kane S,Gandidzanwa C,Mutasa R,Moyo I,Sismayi C,Mafaune P,Dieleman M, Coming Full Circle: How Health Worker Motivation and Performance in Results-Based Financing Arrangements Hinges on Strong and Adaptive Health Systems. International journal of health policy and management. 2018 Oct 29;     [PubMed PMID: 30980623]
[5] Di Donato M,Iles R,Lane T,Collie A, The impact of income support systems on healthcare quality and functional capacity in workers with low back pain: a realist review protocol. Systematic reviews. 2019 Apr 9;     [PubMed PMID: 30967157]
[6] Lee W,Kang YJ,Kim T,Choi J,Kang MY, The Impact of Working Hours on Cardiovascular Diseases and Moderating Effects of Sex and Type of work: Results from a Longitudinal Analysis of the Korean Working Population. Journal of occupational and environmental medicine. 2019 Apr 2;     [PubMed PMID: 30946183]
[7] Akbarzadeh Khorshidi H,Marembo M,Aickelin U, Predictors of Return to Work for Occupational Rehabilitation Users in Work-Related Injury Insurance Claims: Insights from Mental Health. Journal of occupational rehabilitation. 2019 Mar 14;     [PubMed PMID: 30874999]
[8] Weichelt B,Pena AA,Joyce J,Keifer M, Economic Evaluation and Systematic Review of Publicly Available Workers' Compensation Practice Details and Mod Rate Calculators Applied to Upper Midwest Agriculture. Journal of agromedicine. 2019 Apr 2;     [PubMed PMID: 30940000]
[9] Kim D,Do W,Tajmir S,Mahal B,DeAngelis J,Ramappa A, Mandated health insurance increases rates of elective knee surgery. World journal of orthopedics. 2019 Feb 18;     [PubMed PMID: 30788225]
[10] MacEachen E,Varatharajan S,Du B,Bartel E,Ekberg K, The Uneven Foci of Work Disability Research Across Cause-based and Comprehensive Social Security Systems. International journal of health services : planning, administration, evaluation. 2019 Jan;     [PubMed PMID: 30428268]