INJURED WORKERS

Workers' compensation (or workers' comp) is a form of insurance providing wage replacement and medical benefits to employees injured in the course and scope of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence.

Immediately notify a supervisor of your injury so that it may be reported, and they may assist you with seeking medical attention if needed. You will need to receive authorization to treat once the accident report is entered. Once the accident report has been received by ERMS, a claim will be set up and a claim representative will be assigned.

Some employers have opted to insure themselves for workers’ compensation claims instead of obtaining insurance. In those instances, self-insured employers will enlist the services of an independent Third Party Administrator such as Employers Risk Management Services (ERMS) to handle any workers’ compensation claims that are filed by its employees.

First, report the injury to your employer. Your employer may direct you to a particular healthcare provider for initial treatment. Employees must have an “Authorization to Treat” form to bring to the provider. You may obtain this form from your employer. Should you need further medical treatment, you have the right to select one physician of your choice in each specialty field for treatment of the job-related injury.

Your employer is required to pay all approved necessary expenses for medical treatment and all reasonably and necessarily incurred travel to obtain treatment. Any non-emergency medical services over $750 must be pre-approved by ERMS.

Pre-certification (or pre-cert) is the process of providing authorization for any requested non-emergency medical treatment over $750.

The healthcare provider seeking authorization to exceed the $750 statutory limit for medical services must submit a request for such authorization to ERMS on the Form LWC-WC 1010 (Request of Authorization/Carrier or Self Insured Employer Response). A response will then be issued approving, denying, or approving with modification the request for medical treatment. ERMS may use the services of a utilization review company to assist in determining if the requested medical treatment is in accordance with the state’s medical treatment guidelines or is related to the work injury. If an employee disagrees with the pre-certification decision, a Form LWC-WC 1009 (Disputed Claim for Medical Treatment) may be filed with the Office of Workers’ Compensation Administration within 15 days of the decision.

Your employer has the right to choose the provider to furnish necessary prescription medications. ERMS has chosen Carlisle Medical as the only authorized prescription medication provider for employees. Carlisle Medical will assist you with your prescription needs. A Carlisle Medical pharmacy card was provided to you by ERMS in your initial claims packet. This card is to be presented at your local pharmacy when filling your prescriptions. If you have any questions about your pharmacy card or need another copy, please contact your assigned adjuster.

You must provide ERMS with a copy of the physician’s work status indicating you are unable to work. For the period of time that you are unable to work due to the work-related injury or illness, your employer is required to pay indemnity benefits as a replacement to the wages lost during the period of disability. There is a seven-day waiting period, however, before these benefits begin. Indemnity benefits are equal to 2/3 of your gross average weekly wage at the time of the injury. There is both a minimum and maximum weekly benefit established by the Office of Workers’ Compensation.

Once you’ve been released to return to work, you must provide ERMS with a copy of the physician’s work status indicating you are able to return to work and whether there are any restrictions imposed. If your physician has indicated any work restrictions, ERMS will need to verify with your supervisor that the restrictions can be accommodated. If there are no restrictions or the restrictions can be accommodated, your right to indemnity benefits stops, and should contact your supervisor for further instructions regarding when/where to report for work. If the restrictions cannot be accommodated, you will continue to receive indemnity benefits.

While employees have the right to choose their own treating physicians, the employer has the right to have the employee also examined by a physician of their choice, typically to address the employee’s medical condition or capacity to work. This is commonly referred to as a Second Medical Opinion (SMO). In the event of opposing medical opinions, either the employee or the employer may request an Independent Medical Examination (IME) by another physician appointed by the Office of Workers’ Compensation Administration. Failure to attend either an SMO or an IME may jeopardize the employee’s right to benefits.