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Problems can occur when workers covered by Medicare Advantage Plans sustain workers compensation injuries and use the plan to pay for medical care.    

Congress created the original Medicare program (Parts A and B) in 1965. It was designed to offer older and disabled Americans access to affordable health insurance. With the Balanced Budget Act of 1997, Medicare Part C was born with the intention of giving beneficiaries a choice: opt for original Medicare or choose the newly created Part C plans, better known as Medicare Advantage Plans (MAP).

These plans, with coverage provided by private insurers, cover all Medicare services and offer additional benefits such as prescription coverage, dental, and vision. However, problems can occur when workers covered by these plans sustain workers’ compensation injuries and use the plan to pay for medical care.    

                                                  

Medicare and Workers' Compensation Insurance

If a worker is receiving Medicare benefits and is hurt on the job, workers’ compensation insurance (WC) is the primary payer. An insurer or workers’ compensation plan cannot, by contract or otherwise, supersede federal law--for instance by alleging its coverage is supplemental to Medicare.

WC is always the primary payer for Medicare beneficiaries’ work-related illnesses or injuries, and Medicare beneficiaries are required to apply for all applicable WC benefits. If a Medicare beneficiary has WC coverage, providers, physicians, and other suppliers must bill WC first.

In situations in which Medicare has paid for WC-claim-related care before the beneficiary has obtained a settlement, judgment, award, or other payment, those Medicare payments are referred to as “conditional payments.” They are considered conditional payments because Medicare pays under the condition that it is reimbursed when the beneficiary gets a WC settlement, judgment, award, or other payment.

Do Medicare Advantage Plans have the same right of recovery as original Medicare?

This an evolving issue in the courts, and it continues to be discussed and debated. Courts have ruled both ways on this issue. Here are some examples:

• In a Third U.S. Circuit Court of Appeals case in 2013, Humana Insurance Company, a MAP, demanded reimbursement from GlaxoSmithKline for payments Humana had made. The Court held that Medicare Secondary Payer regulations “unambiguously provide[s] Humana with a private cause of action.” Consequently, Humana’s payments were subject to reimbursement.
  
  
• The U.S. Supreme Court subsequently denied Glaxo’s petition for review, supporting the argument that MAP’s have the same right of recovery as does traditional Medicare—at least in the Third Circuit Court jurisdiction, which is New Jersey, Delaware, Pennsylvania, and the U.S. Virgin Islands.
  
  
• Later in 2013, a Ninth U.S. Circuit Court of Appeals case ruled the other way. Here, the Ninth Circuit Court of Appeals held that a Medicare Part C Plan--PacifiCare of Arizona--did not have the right, under federal law, to pursue a reimbursement claim.
  
  
• In a recent case in Florida, Humana Insurance Company sued Western Heritage for recovery of double damages. Humana argued that as a MAP they have the same right of recovery as does traditional Medicare, including recovery of double damages. The District Court ruled in Humana’s favor.

Recent rulings have created some uncertainty for employers

There is still uncertainty among insurers and employers when settling cases with Medicare beneficiaries who have ever received benefits from a MAP. Claim management departments need to consider the recovery rights of MAP’s when settling claims. The logical starting point would involve confirming the type of Medicare coverage at issue. Determine if the claimant is a beneficiary under traditional Medicare or under a MA plan.

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For help meeting your compliance obligations, or to obtain quality worker's comp insurance at the right price, call us at (800) 947-1270 or (610) 775-3848 or contact us onlilne.

Return-To-Work programs are instrumental in enticing employees out on a workers’ compensation claim to come back to work. Many employers struggle to manage and fill the void that is left behind when a worker is out; however, a solid Return-To-Work program will encourage employees to return to work quickly (once they are cleared to do so by a medical professional of-course), thereby contributing to lower workers compensation insurance costs.

It is extremely important that the return-to-work program is well-known and understood throughout the company. It needs to be an indispensable part of the corporate culture understood by owners, managers, and employees. If you want employees to return quickly and efficiently, it needs to be a system that everyone can follow and understand.

Five Essential Elements of a Successful Return-To-Work Program:

#1) Offer employees a transitional position

Present them with a temporary job that will ease them back into the workplace while still making them feel as though they are making a difference. If their job usually requires heavy lifting, consider offering a light-duty job instead. Make sure the job makes sense for both the employee and the company, otherwise you run the risk of further loss.

#2) Make the cost of workers’ compensation very clear to all employees

Each employee, regardless of their current position, should understand how expensive workers’ compensation claims are and how it affects the organization. Most employees have absolutely no idea that companies pay a large deductible each time an employee goes out on a claim and assume the insurance company is the only one paying. Employees may feel differently if they know it is coming directly from their employer’s pocket!

#3) Remain in constant contact with the employee

Never underestimate the power of a “get well” card! There will be many outside sources, such as friends, families, lawyers, etc., trying to tell your employee what to do. Make sure you call to check in with them frequently and keep them posted on any updates or changes within the company. In most states, the company is able to direct medical care for an employee as well, which allows them to check-in with healthcare professionals to ensure that the employee is following protocol and is not being dishonest about their care or their return to work date.

#4) Make necessary arrangements to “speed up” return time, if possible within four days

90% of all workers out on a workers’ compensation claim can return back to work within four days. Whether they are returning to a transitional job or their actual position, the quicker they return to the workplace, the less expensive it is for the employer. These four days are considered the waiting period and if you bring an employee back before the waiting period ends, the company’s workers’ compensation company may not have to pay indemnity or lost wage payments, which in turn saves the company from having to pay the claim deductible.

#5) Keep employees updated on company “happenings” while they are out

Even though an employee is unable to perform their regular duties, they may be able to continue attending trainings and meetings. If they are unable to attend these sessions in person, the company may be able to skype them in, or at the very least can provide them with a PowerPoint deck or notes from the meetings. Keeping them in the loop can encourage them to return quicker and will allow them to transition back into their position more easily when they do return.

One of the keys to keeping the cost of workers’ compensation in check, is to get employees back into their position as quickly as possible. This doesn’t happen by accident; it’s important for companies to take a proactive approach.

We'll Help You Save on Workers Compensation Insurance

For more information about saving on workers’ compensation costs, contact us online or give our experienced agents a call at (800) 947-1270 or (610) 775-3848. 

Hearing loss may be a compensable work injury leading to increased workers compensation insurance costs. Taking steps to reduce the risk of hearing loss is easier than you might think.

Loud noises in the workplace can damage your employees’ hearing. It’s estimated that 22 million workers are exposed to potentially hazardous noise levels at work. The National Institute for Occupational Safety and Health (NIOSH) recommends that workers should not be exposed to noise at a level that amounts to more than 85 decibels for 8 hours. In an effort to create a safer workplace by reducing noise levels, NIOSH suggests an approach that implements controls based on a hierarchy of effectiveness.

Control Workers Comp Premiums by Adopting the Hierarchy of Hazard Controls

Occupational health and safety professionals apply the following actions, listed from most effective to least effective, to reduce or remove a noise hazard:

1. Elimination: Physically remove the hazard
2. Substitution: Replace the hazard
3. Engineering Controls: Isolate workers from the hazard
4. Administrative Controls: Change the way employees work
5. Personal Protective Equipment: Protect workers with special clothing and equipment

Low-Noise Tools

Purchasing low-noise tools and machinery, reducing vibration where possible, providing barriers to isolate workers or loud equipment, and maintaining machinery with proper lubrication are effective methods for reducing noise in the workplace.

In addition, the Occupational Safety and Health Administration (OSHA) requires employers in general industry to maintain a hearing conservation program whenever noise exposure meets or exceeds the eight hour time-weighted average of 85 decibels. Baseline and annual audiograms, employee training, and hearing protection must all be included in the program.

But even with controls and programs in place to eliminate or reduce noise hazard on the job, some employees will experience work-related hearing loss resulting in a compensable work injury resulting in a workers compensation insurance claim.

Hearing loss may be a compensable work injury

The Workers’ Compensation Act provides for benefits for loss of hearing related to exposure to noise while at work, and it’s estimated that $242 million is spent annually on workers’ compensation for hearing loss disabilities.

While most states recognize hearing loss as compensable, the specifics of the law may vary (for instance, in some states the employee must have hearing loss of at least ten percent in both ears in order to be entitled to benefits). The employee must be evaluated by a physician who specializes in hearing problems to determine the percentage of hearing loss, and the worker must show that there was exposure to hazardous noise in the workplace.

The difficulty for any workers’ compensation adjuster will be determining what portion of hearing loss is work-related and what part of the loss is age-related or is due to non-work related activities (shooting a gun for sport or using a chainsaw on weekends). Another issue that the adjuster may face is finding a previous audiogram from which to compare the present test to get a true measure of hearing loss.

Protect your business against hearing loss claims

There are steps that employers can take to eliminate or reduce the size of a hearing loss workers comp claim, and in the process lower your long-term workers compensation insurance costs:

• New employees who will be exposed to excessive noise should have an audiogram completed as part their hiring requirements. This will provide the baseline for any future hearing loss claim.
• Do a risk assessment by having the decibel level of your plant checked. Any noise level above 85 decibels can then be addressed.
• If a worker is constantly exposed to tools and machinery that reach more than 85 decibels, an audiogram should be completed annually.
• The mandatory use of hearing protection (earplugs or earmuffs) should apply to all employees who work in areas of excessive noise.
• All employees should be provided with safety materials that address the importance of hearing protection at work and in non-work related activities that create high noise levels.

Occupational hearing loss is one of the most common work-related illnesses. Safeguard your workers and minimize the costs to your business by effecting and maintaining these essential controls and programs.

Workers Comp Questions? Contact Us!

To learn more about Workers Compensation Insurance, contact us online or call (800) 947-1270 or (610) 775-3848.

Over 4,000 employees are injured, and another 325 die each year in workplace electrical accidents. Do not let this be one of your employees! Protect your employees and minimize your workers compensation insurance costs through proper safety procedures.

Downed electrical wires are one of the leading causes of electrical accidents, and most can be prevented. Being aware and well educated on how to handle these situations can be the difference between life and death!

Extreme Danger: Downed Power Lines

Workers involved in clean-up and recovery efforts are three times more likely, when compared to other occupations with electrical hazards, to be injured or killed by downed and low hanging electrical wires. These disaster scenes are usually very chaotic and uncontrolled, which can easily lead to mistakes and injuries. When first arriving at a scene, it is important to stop and look around, evaluate the situation and assess for any loose or low hanging electrical wires, quickly make a plan, and then proceed.

Safety Tips for Handling Downed Power Lines

Checking on equipment and electrical lines is the first step to ensuring safe working conditions for everyone involved in the effort. It should ALWAYS be assumed that all electrical wires are live and active!

• Downed and low hanging wires must always be considered active, regardless of whether or not they are touching the ground, because voltage may still be running through them and one touch could be deadly! Also keep in mind that all wires are designed differently and just because the wire is well insulated, coated, and weatherproofed does not automatically make it a television or cable wire. It could still be a high-voltage electrical wire.
  
  
• Always assume that all equipment, such as generators and conductors, are live even if they are not sparking or humming. Some of this equipment does not automatically turnoff when damaged, and a simple touch to the equipment or the ground around it could kill you instantly!

Energy that is provided through electrical wires is amazingly powerful! Therefore, its strength should never be tested.

• Never drive over power lines. You run the risk of becoming trapped in your vehicle or at the very least your vehicle could become entangled within the wire. This goes for any equipment vehicles you may be driving.
  
  
• If you are in a regular or equipment vehicle, and you were to come into contact with an electrical wire, ALWAYS assume it is live. Your best choice to resolve this situation is to remain inside your vehicle and place a call for help. If this is not possible, such as if your vehicle is on fire, you need to jump as far away as possible from the vehicle making sure NOT to touch the vehicle and the ground at the same time. Proper landing technique is with both feet together, maintaining good balance, and then continuing to shuffle away in small steps to eliminate the path of electric current, and ultimately electrical shock.

Backfeeding occurs when electrical conductors are unexpectedly energized by outside sources such as lightning, downstream events, generators, and circuit ties/switch points, which can result in additional injuries or death. Therefore, it is important to understand how voltages are spread and how to disable all electrical equipment properly and efficiently from the start.

• Proper lockout/tagout procedures ensure that all necessary energy sources have been properly disabled and do not pose a threat of being reignited due to unexpected circumstances such as lightning or generator reboots.
  
  
• Since electricity spreads outward, in a circular motion throughout the ground, when you move outside of the main point of contact, you can be creating larger, more dangerous voltages. This creates a hazardous situation for yourself and anyone else standing close to you.

Keeping Business Insurance Costs in Check

Safety should be your number one priority for the safety of your employees and as a means to keeping insurance costs – health insurance, workers compensation insurance, liability, and disability insurance – in check. Sharing this information with employees who respond to a clean-up or recovery effort could save a life and help your company’s bottom line.

Contact Us

For more information about saving on all your commercial insurance costs, please contact us online or give one of our experienced agents a call at (800) 947-1270 or (610) 775-3848.

Employees who are injured on the job may be entitled to compensation for medical care and wage replacement through their employer’s Workers Compensation insurance. The insurance provides medical care, lost wages, and any rehabilitation needed to return to work. Sometimes an employee is permanently and totally disabled or disabled to the point that the employee cannot return to meaningful employment. These cases are usually complex and can be difficult to settle. If a lump-sum cash settlement does not resolve a case, a structured settlement may offer a solution.

What is a Workers Compensation Structured Settlement?

A structured settlement is a financial or insurance arrangement whereby a claimant agrees to resolve a personal injury claim by receiving periodic payments on an agreed schedule rather than as a lump sum. Structured settlements are often used to resolve workers’ compensation insurance cases in which the negotiations between the plaintiff’s attorney and the insurance company have reached an impasse. The responsibility of future payments to the plaintiff falls on an independent third party—usually a life insurance company from which an annuity has been purchased by the workers’ compensation insurer.

Congress has encouraged the use of these settlements through the federal tax code since 1983. Internal Revenue Code section 104 specifies the amount of each payment, and the earnings on payments are excluded from the settlement recipient’s income.

Not all payout schedules from a structured settlement are alike. There are three main forms of periodic payments from a structured settlement:

• Deferred Lump-sum Payments: Payments are structured under a schedule of pre-determined dates. These payments are usually larger than regular periodic payments.
• Flexible Settlement Plan: Payments in this plan consider the needs of the injured worker—important future events at different stages of life—while maintaining control of the costs for the employer and insurer.
• Period Certain Annuity: The injured employee gets a larger settlement by agreeing to shorten the time period that the annuity will pay.

An initial lump-sum payment can be included in the settlement to cover such items as housing and transportation, and the settlement can also be structured to increase periodic payments at fixed dates in the future to account for inflation.

Advantages of Structured Workers Comp Insurance Settlements

Structured settlements are helpful for the injured worker in compensation cases. They can be set up to provide tax-free money for long-term and immediate needs, while eliminating the worry of managing a large amount of money. In most cases, a structured settlement will provide more money over the long term than the employee would realize from a cash settlement. The plan can be structured around age and life expectancy, thereby providing funds for maintaining medical treatment, future surgeries, and replacement of durable medical equipment.

The closure of the claim, expedited through a structured settlement, is a major benefit to the employer. It also avoids the uncertainty of litigation and all of the expenses that go with it. In the case of a disability that lasts a lifetime, all of the mortality and investment risk is transferred to the third-party insurer.

Insurers benefit because they free up money that would have been used for a lump-sum settlement and can now concentrate on other cases.

The employee’s lawyer has a satisfied client for whom he has provided financial stability.

A word of caution

A structured workers comp settlement is a flexible tool for resolving troublesome claims. Keep in mind, however, that each state has different laws with regard to settling workers’ compensation claims. Be sure to partner with a professional who can confirm the laws of your state.

Learn More About Workers Compensation Insurance

For more information and advice on workers compensation insurance, contact us online or give us a call at (800) 947-1270 or (610) 775-3848.

Avoidinging Workers Compensation Insurance Claims via Risk Awareness

For construction workers and others whose jobs require them to be outside, winter means a few months of extreme cold and challenging days, during which they will be susceptible to cold-related injuries.

In addition to injuries resulting from slips and falls as temperatures dip below freezing, there is also the risk of cold stress. Cold Stress is the result of skin temperature being lowered, ultimately resulting in a reduced core body temperature.

The human body’s natural reaction when exposed to cold environments is to maintain its core temperature. To do so, blood shifts away from less critical body parts--hands, feet, arms, legs and skin--to concentrate in the vital chest and abdomen areas. As a result of the blood shift, the body parts containing less blood face an increased risk of cold-related injuries. Under severe conditions, tissue damage and death may occur.

Cold stress and the risk of cold-related injury can be reduced by increasing management and worker awareness of the hazards. In order to ensure a safe working environment, mitigate risk and prevent workers' compensation insurance claims, it is important to understand the elements of cold stress. 

Types of cold stress facts you need to know

• Hypothermia involves a severe loss of body heat, resulting in shivering, confusion, and loss of motor skills to an extent where workers cannot replenish their warmth.
  
  
• Frostbite is the freezing of an area of the body, typically the nose, ears, cheeks, fingers or toes. Severe cases of frostbite may lead to amputation. Symptoms include numbness, hard skin, tingling or blisters.
  
  
• Trench foot occurs when a worker's feet remain damp for a prolonged period of time. Although not directly tied to extreme cold (wet feet can contribute to the condition in warmer temperatures), it is a threat in winter with symptoms of red skin, numbness swelling, or bleeding.

Workers can help prevent cold stress

Workers will be able to monitor their own health and identify problems with colleagues if they understand the symptoms of cold stress. Following some simple guidelines will also help them to prevent cold stress injuries:

• Dress in several loose-fitting layers and don’t forget boots, gloves, and a warm cap
• Have at least one layer of waterproof clothing to protect at least some of their other clothing from getting wet
• Take breaks to get warm. If possible, go indoors for a few minutes or at least get out of the elements
• Stay hydrated. This is every bit as important in winter as it is in hot weather
• Keep spare clothing nearby in case the clothing they’re wearing gets wet

What can employers do about cold stress?

A cooperative approach with employees is important. A cold stress prevention program, outlining steps to limit cold stress and reduce risk of injuries and illnesses, is a good start.

Another step you can take is a review of your scheduling. If at all possible, plan outdoor work, equipment repairs and other tasks when the weather is more favorable. While it is not always possible to prevent workers from operating outside at all times, especially in the construction industry with its deadline pressures, you can limit the length they have to spend in the coldest temperatures. 

Next, you must train your team. Review the symptoms of cold stress in a group meeting. Emphasize the safety measures that workers must take, and discuss the best emergency response methods and who to notify should an employee begin to show signs of cold stress.

Finally, you need to provide resources for your workers. These can include insulated clothing, a heated shelter, warm beverages or educational materials. Above all else, call attention to cold-weather safety this winter. These measures will help to keep your workers on the job and your workers compensation insurance costs low.

Control Your Workers Compensation Insurance Cost

Click here to contact us for more information about reducing the cost of workers compensation insurance, or give give us a call at (800) 947-1270 or (610) 775-3848.

Workers Compensation Insurance as a Third Party for Medicaid

Medicaid is an entitlement program, jointly funded at the state and federal levels, which provides healthcare--both medical and long-term custodial care--to the poorest population of the United States.  Not to be confused with Medicare, the federally funded program available to most U.S. citizens and permanent legal residents who are age 65 or older, eligibility for Medicaid is means-based, and the program has strict income eligibility requirements that vary from state to state.

However, Medicare and Medicaid are not mutually exclusive--it is possible to be on both of those programs at the same time.

It is not unusual for Medicaid recipients to have additional sources of coverage for health care services. Since federal law dictates that Medicaid is the “payer of last resort,” this means that if another insurer or program (a third party) has the legal responsibility for costs involving a Medicaid-eligible individual, that “third party” is normally required to pay all or part of the cost of the claim before Medicaid makes any payments. Workers compensation insurance is one such third party insurer.

The Expansion of Medicaid

In the past, it had been uncommon for workers’ compensation claimants to also be entitled to Medicaid. If you were employed, chances were that you had too much income to qualify. That changed with the Affordable Care Act of 2010. Obamacare, as it is often called, expanded Medicaid coverage and allowed more workers to qualify for the program. Today, all U.S. citizens and legal residents, including adults without dependent children and with income up to 133% of the published poverty threshold, qualify for coverage. 

Workers’ Compensation Insurance and Medicaid Recovery

When Medicaid has paid the costs of an employee's medical treatment that was due to an employment-related injury, the workers' compensation carrier may find itself in the position of reimbursing Medicaid. Even if the carrier is unaware of the employee's entitlement to Medicaid benefits, it may still be liable for payment of past or future medical bills.

In December of 2013, Congress passed The Bipartisan Budget Act of 2013 (“Budget Act”). The Budget Act included a Medicaid Secondary Payer provision, which gave state agencies the ability to recover costs from a beneficiary’s entire settlement, rather than only those settlement proceeds designated as compensation for medical expenses. The Medicaid Secondary Payer provision was initially set to be effective on October 1, 2014. However, on March 31, 2014, Congress passed a bill that delayed the effective date until October 1, 2016, giving Congress and the states two extra years to evaluate the impact of the Secondary Payer provision.

Consequently, it becomes particularly important for a workers comp insurance carrier to evaluate a number of considerations during the settlement stage of a claim. It is also important that claim management teams become proactive when dealing with Medicaid recovery issues:

• Stay updated on any changes in Medicaid Secondary Payer recovery
• Identify claims from those who are receiving Medicaid benefits at the time of the insurance claim or who could become beneficiaries in the future
• Keep all parties that are involved in your settlements informed of Medicaid recovery efforts
• Put all appropriate state agencies on notice of their intervention and recovery rights

There is considerable effort being made to protect Medicaid's interests--especially in cases where Medicaid has absorbed the costs of medical treatment for which another party is deemed responsible. And some states are already beginning to flex their enforcement and recovery muscles in anticipation of Medicaid Secondary Payer becoming effective in October of 2016.

Help With All Your Workers Compensation Insurance Needs

If you have questions about this constantly evolving issue or workers’ compensation insurance in general, or if you would like to consider changes to your worker's comp insurance coverage, then contact us at (800) 947-1270 or (610) 775-3848.

When one of your employees is injured on the job, it sets off a sequence of procedures that must be adhered to in order to protect your business. If a claim is filed--whether compensable or contested—it is imperative that you have the necessary documents on file. Documentation for workers compensation insurance becomes particularly crucial with contested claims, as these documents become the lynchpin for a solid defense.

Start Documenting Workers Comp Claims Immediately

Documentation begins as soon as the compensation claim is received. An early intervention process allows for a claims expert to properly document pertinent information associated with the accident while the critical details are still fresh in the minds of the injured employee and anyone else involved.

Early workers comp insurance documentation has another advantage: often, the employee is still working, which allows unrestricted access to the worker before representation. This can lead to evidence that would be harder to uncover once a lawyer is involved. 

Other reasons for early documentation include:

• The injured worker and witnesses might change their stories if given the time
• Physical evidence can change or disappear
• Opportunities for research may be lost
• Proof of fraud or malingering may be missed
• Independent medical opinions may be jeopardized
• Symptoms are often exaggerated after a lawyer enters the picture

In addition, late documentation can damage an employer’s credibility and will sometimes lead to additional claims including harassment and discrimination.

Be Thorough in Collecting Evidence for Workers Comp Insurance Claims

It is worth noting that documentation of non-industrial injuries, tardiness, warnings, write-ups, and other personnel actions help to show the injured employee in a different light prior to litigation. Employers should be vigilant about maintaining proper WC documentation in the employee’s personnel file. This can be helpful in constructing an accurate portrayal of the worker before and after the injury.

Other workers comp documents that must be on file include…

• A comprehensive statement of the facts of the accident
• Witness statements, taken as early as possible
• Medical evidence obtained prior to litigation identifying the injury and body part
• Past medical records that are pertinent to the claim
• Independent medical examinations
• Personal and physical background information on the claimant
• Past claim records
• Photos and videos of the accident site
• Information procured from private investigators
• Copies of training programs and the employee’s participation in them
• Reports from professional experts and technical advisers
• A record of all telephone discussions with anyone connected with the claim
• A log of all employees’ functions from an up-to-date job description of all positions, especially modified duties

Medical Evidence is Key to a Workers Compensation Insuance Claim

While not every insurance claim will require this level of documentation, claim technicians will need many or all of these documents in some difficult cases. Many factors can affect the outcome of these cases. Experts seem to agree, however, that nothing is more important than medical evidence, procured prior to litigation, which identifies the injury or body part with a fair description of symptoms. Witness statements are also important, but witnesses have unreliable memories and are prone to leading questions. These factors lead back to the importance of early documentation.

Documenting a worker’s compensation claim is complex and time-consuming. But it is worth the hard work if it becomes necessary to defend a claim. Courts appreciate when complete and well organized paperwork is presented at a hearing.

Obtaining the Right Workers Compensation Insurance

Click here to contact us or give us a call at (800) 947-1270 or (610) 775-3848 to learn more about worker’s compensation and all of your insurance options. We'll help you choose the right policy and ensure you get a great deal because as indepenent agents we're free to shop among many competing workers comp insurance providers. Call or click today to get started.

Workers' compensation insurance allows employees who are injured on the job to receive payments for medical expenses, lost wages, and other expenses as they heal. It is usually paid by an insurance policy that has been taken out by the employer. Workers' compensation is required by law in most states, and receiving payment for workplace injuries may be an employee’s legal right.

But not everyone plays fair. Dishonest employees, employers, and health care providers are using fraudulent tactics to take money they do not deserve.

Fake Workers Comp Injury Claims by Employees

Most employees are honest, but the lure of free money, combined with the opportunity to bring in even more money at a second job, can be tempting. While only a small number of employees scam this coverage for personal profit, the damage can be substantial. Here are some of the ways dishonest employees can cheat the system:

• Embellished injuries: A worker insists that a minor injury received on the job is much more serious and requires a longer time away from work.
• Hurt off the job: Workers get injured elsewhere, but claim that they were hurt at work.
• Faking an injury: Some workers simply invent injuries. Injuries such as muscle problems with the back and neck are hard to disprove and easier to get away with.
• Previous injury: A worker with an old injury that never quite healed will claim he just got hurt on the job.
• Malingering: Workers pretend they're still disabled, even though they've healed enough to return to work.

Workers Comp Premium Scams by Employers

Fake injury claims far outnumber premium scams, but most workers comp insurance premium scams are much larger. A worker's bogus injury claim normally costs $2,000-$50,000 total. Employers can illegally reduce the workers comp insurance premiums they owe, costing hundreds of thousands of dollars in unpaid premiums in one year. Some scams can last for several years, resulting in millions lost. These cons can be complex and are hard to discover. Here’s how they work:

• Hiding employees: The company reports fewer employees or a lower payroll than it actually has. The owner might also falsely claim that some of the workers are independent contractors and don't count toward workers’ comp premiums.
• Misclassifying employees: The dishonest employer tells the workers’ comp insurer that many employees work at safer jobs than they really do.
• Avoiding coverage: The business doesn't buy state-required workers’ comp insurance, leaving workers dangerously exposed if they're injured.

Health Care and Lawyer Scams

Sometimes medical clinics and lawyers will team up to cheat workers’ compensation insurance. These are often well-organized and can steal millions of dollars a year. Here are some of the most common scams:

• Inflated injuries: Clinics may overstate the seriousness of injuries to workers, and bill insurers for costly and worthless treatments or tests.
• Phantom injuries: Clinics may bill insurance for treatment of injuries that never happened.
• Bogus lawsuits: Disreputable lawyers working with crooked clinics encourage uninjured workers to seek useless treatment. The lawyers then may threaten to sue unless the insurance company settles the phony claim quickly.
• Kickbacks: Dishonest clinics and lawyers hire recruiters to bring workers into the scams. The recruiters receive illegal kickbacks for referring patients to the lawyers or clinics.
• Bogus clinics: Some clinics are fakes. There are no licensed doctors or useful medical equipment. The clinic is merely a staging ground for bogus workers’ comp claims.

Workers’ Comp Insurance Fraud IS a Big Deal!

Workers’ comp fraud is a large crime in America. Tens of billions of dollars in false claims and unpaid premiums are stolen every year. That makes it a very big deal! Insurers pass on higher premiums to businesses, while consumers pay higher prices for goods and services from businesses. Workers may have their pay reduced or their jobs eliminated, while those who remain employed may be at risk in businesses that illegally avoid buying insurance.

Call Us to Get the Right Workers Comp Insurance Policy for Your Business

No businee is exempt from this problem.

Click here to contact us or give us a call at (800) 947-1270 or (610)775-3848 to get the right workers’ compensation insurance for your business.

Today’s businesses are paying greater attention to their employees’ wellness. Some are even taking a more holistic approach in which “wellness” is being supplanted by “well-being.” Whether your business is providing employees with fitness programs, diets, and screenings or adding meditation and massages into the mix, your employees reap tangible benefits…and so do you.

A healthy employee is more productive, has less absenteeism, does higher quality work, and gets injured less often. Production and quality help a company to be profitable and competitive. Fewer injuries lower workers compensation rates.

Sounds great, right? Why doesn’t every employer do this for their employees?

Connecting Wellness Programs to Workers Comp Insurance

While all of these wellness initiatives play an important role in improving employee satisfaction--along with the company’s bottom line--it is worth noting that if an employee is injured during an activity that was encouraged by the employer, it may be compensable. That's where having the right level of workers compensation insurance can make a real difference.

An Injury at a Fitness Center

Recently, an employee of a New York business suffered a spinal cord injury while participating in an exercise class at a fitness center. His employer had made the center available for all employees during working hours. The employer had also offered to pay some of the employees’ cost of the center. A Workers’ Compensation Law Judge determined that the claimant’s injury arose out of and in the course of his employment, and ruled that the employee was entitled to compensation for his injury.

The New York Appellate Division agreed. The court reasoned that the employer encouraged the claimant to have a gym membership, and offered reimbursement to its employees for half of their center’s membership fees. The court also noted that the claimant’s position required him to develop contacts with clients, and the claimant stated that he advanced that objective by taking classes at the fitness center. Since the employer sponsored the fitness center activity in this manner, the claimant’s injuries were ruled to be compensable.

A Lunch-time Basketball Game

In Pennsylvania, a Commonwealth Court found that an employee, injured while playing basketball on his lunch hour, was entitled to workers’ comp insurance benefits. The Court found that the employer had encouraged employees to engage in physical activities to improve their health, relieve stress, and to give them a better mental attitude at work. The employer encouraged such activities with postings on a bulletin board and by allowing its employees to use company facilities, including their gymnasium. Based on these facts, the Court found that the claimant was furthering the business interests of his employer when he was injured.

The Implied Requirement and the Need for Workers Comp Insurance

The South Carolina Supreme Court recently ruled that a man who organized a voluntary kickball game for fellow employees and shattered his leg during the game must be covered under workers’ compensation. In its decision, the court cited the testimony of the man’s supervisor, who said that while attendance at the game was not mandatory, he would have been “surprised and shocked” if the employee had not attended after organizing the event.

The case turned on the court’s view that the man was “impliedly required” to attend the event because of his role in organizing it. The decision doesn’t necessarily apply to other employees who are injured at an event where employees are encouraged--but not required--to attend. It does suggest, however, that employers should be aware that encouraging attendance may be regarded as an implied requirement.

Getting the Right Level of Workers Compensation Insurance Protection

For most employers, the benefits of promoting workforce wellness far outweigh the potential liability. But if your company is considering a wellness initiative, or continuing an existing one, it would be wise to seek the advice of an attorney in order to develop initiatives that promote the goals of the program while minimizing the risk of legal exposure.

Also, click here to contact us or give us a call at (800) 947-1270 or (610) 775-3848 to ensure that you have the right level of worker's compensation insurance to properly protect both your business and your employees.