Tide TRACKERHelping to Navigate the Troubled Waters of Workers CompensationWehereatRiskSolutionsare dedicated to upholdingthehigheststandardinclaimsadvocacyandensuringthatclaimsadministrators and defenseattorneys alike are held notonlytothestandardsofindustrybestpractice,buttoourownrigorousexpectationsforbeneficialoutcomesforourclients.Attimes,thismeansdefyinganadjustersrationaleforsettlingacaseratherthanriskingfurtherlitigation.Recently,ourphilosophyofvigorouslydefendingpost-terminationclaimspaidoffwith a Take Nothing finding from a judge attheLongBeachWorkersCompensationAppeals Board.In this case, a claimant allegedthathesustainedaninjurytohislowerback,bilaterallowerextremitiesandpsychologicalstress,arisingfromaspecificincidentatwork.His only problem was that he could not decidehowpreciselyhewasinjured.Theversionofeventstoldtotheemployer,histreatingphysician, and under oath all differed.Initially, the adjuster recommended settling thecaseforanunacceptablyhighvalueastheclaimant had rejected multiple prior offers.Ouranalysts picked up on this tactic right away andrequestedtheadjustertotakeallsettlementoffers off of the table.Additionally, our analystsfollowedupdiligentlywiththeemployeranddefense attorney to encourage them to stick totheirgunsonthedenialandtakethiscaseforward to trial.Summer 2015-There are few enough victories in the world ofWorkers Compensation.We when are ableachieve a significant reversal in the expectedoutcomeofaclaim,youcantblameusfortooting our own horn.In that spirit, we offerthefollowing:Asyoucansee,thisrarevictorydemonstratesnotonlyourcommitmenttodefendingagainstbogus post-termination claims, but ensuring thatallavailablestrategiesareemployed.Ouranalysts are trained to zero in on these retaliatoryclaimsandexploretheclaimantscredibilitybeforerecommendingsettlementversuslitigation.ThemostexcitingbenefitofaTakeNothing, of course, is the accompanying Unit StatrevisionwiththeWCIRBthatwipestheclaimfromtheemployersexperiencemodificationasif it never happened.Nothing makes us happierthan a Take Nothing.Itisimportanttounderstandthatastrongsafetyculturerequiresanongoingcommitment,andisnotoneofthosethingsthat get fixed.Recentlyacompanyweknowdecidedtoterminate their safety achievement program.Theirprogramwasbuiltonmonthlymeetingsinwhichtheworkforcewasengaged.The workers were appreciated fortheircontributionsandsuggestions,andrecognizedforbothteamanddepartmentaccomplishments.Everymeetingfeaturedtheworkersasactiveparticipants,applaudingandsupportingeachotherseffortstoestablishasafeandinjury-freeworkplace.In this case, the companys injury record hadgone down dramatically in the two years thattheprogramwasinplace,with75%fewerclaims than prior to the program.Based onthat, management decided that the programhad done its job, and was no longer needed.Theproblemwas"fixed"andastrongersafety culture had now been established.Really?Actually, there are several problemswiththat.Safetycultureaffectingmostinjuries-canneverbeestablishedasapermanentvalue;notwithoutconstantinvolvementandengagement.Itrequiresacommitment on everyones part especially2management-tothebeliefthatsafetyisthehighestpriorityinthecompany.Productivityisimportant,butitdoesntoutrankthepersonal safety of every individual who worksfor the company.Byminimizingengagement,thisemployersendsexactlythewrongmessage.Whenpeopleparticipateinsomething,itbecomesmore personal, and when people view safety inapersonallight,theyaremorelikelytotakepersonalresponsibilityfortheirbehavior.When that happens they are less likely to takeunnecessaryrisksandchances,andlesslikelytoknowinglyfileafraudulentclaim.Ultimately,itstheattitudethattheworkershavetowardssafetythatdeterminesthecompanys safety record.When this companychose to have less engagement, the signal theysenttotheirworkerswasthatsafetyisnowless important than it was.Thelessonhereisasimpleone:thecommitmenttobuildingastrongcultureofsafetyneedstobegenuine,andongoing.Tohaveminimalinjuries,safetyneedstobeembraced as a core value of the organization,with time, energy and resources devoted to itspromotion.Engagingandcelebratingthepeoplewhodotheirjobstherightwayprovides an important component of a strongsafety culture.Thecontractbetweenanemployerandemployeeisone of mutualresponsibility.Employersareresponsibleforprovidingasafeworkplacefortheiremployees.Inturn,theemployeesareresponsible for performing their job duties in asafe manner.Regularly inWorkers Comp, we3seeinjuredworkersaccusingtheiremployersofSeriousandWillfulMisconduct(S&W,forshort)whichledtoorcontributedtotheirinjury.Whileemployersmayfilethesameagainstaninjuredworker,werarelyseethis,evenwhenitiscompletelyjustified.Eitherpartycanbepenalizediftheirrespectiveactions, which resulted in the injury, qualify asSerious and Willful Misconduct.Labor Code 4551 provides a remedy for suchmisconduct.It states the following: Where theinjuryiscausedbytheseriousandwillfulmisconductoftheinjuredemployee,thecompensation,otherwiserecoverable,therefore shall be reduced one-half, except:(a) Where the injury results in death.(b)Wheretheinjuryresultsinapermanentdisability of 70 percent or over.(c) Where the injury is caused by the failure ofthe employer to comply with any provision oflaw,oranysafetyorderoftheDivisionofOccupationalSafetyandHealth,withreferencetothesafetyofplacesofemployment.(d)Wheretheinjuredemployeeisunder16years of age at the time of injury.TheemployermustfileapleadingoftheSeriousandWillfulMisconductwithin12months from the date of injury and it can onlybefiledifthereisapendingcaseattheWorkersCompensationAppealsBoard(WCAB) in the employers local district office.In order for the injured employees action to bemarkedasSeriousandWillful,itneedstogobeyondgrossnegligence.AccordingtotheLaborCode,itmustinclude"conductofaquasi-criminalnature,theintentionaldoingofsomething either with the knowledge that it islikelytoresultinseriousinjury,orwithawantonandrecklessdisregardofitspossibleconsequences".Inotherwords,theclaimanteitherpurposefullyinjuredhimself,orwasengagedinacriminalactionthatresultedininjury.The burden of proof lies with the employer toestablishthataSeriousandWillfulactwascausedbytheinjuredemployee.Althoughitmaybedifficulttoaccomplish,completingathorough accident investigation at the onset ofeachnewinjuryisthebestwaytoestablishintentionalmisconduct.Doingeverythingpossible to establish an employee's misconductnotonlybenefitstheemployerbutotherlegitimatelyinjuredworkers-thosetrulyintendedtobenefitfromtheWorkersCompensation system.4When an injured workers case finally settles, itcan feel like a time to bring out the balloons andcelebrate.Butdontpopthechampagneyet.Theremaystillbeonemorehurdletoclear:liens.A claim can stay open for months longer,due to liens.What is a lien? We all know that an employeris obligated to report an industrial injury to theirWorkersCompensationcarrierwithin24hoursofknowledgeoftheinjury.Asanemployer,onehasanobligationtofurnishmedicalcareandtreatmentthatisreasonablyrequiredasaresultofanindustrialinjury.Shouldtheemployerorcarrierdenymedicaltreatment,theinjuredworkerwillobtainmedicaltreatmentontheirown.Inthisinstance, not only has the employer lost medicalcontroloftheclaim,butnowhascreatedamedical lien-aservicehasbeenprovidedforwhichadoctorcanseekreimbursementfollowing settlement of the claim.Medicallienscansometimesbemorecostlythanthecaseinchief. Althoughtheinjuredworker's claim may have settled, as long as liensremainunresolved,theclaimwillcontinuetoshow as 'open' on the employer's loss run.Theoutstanding reserves will continue to affect theX-Mod and the financial bottom line. It benefitsallpartiestoresolvetheliensbasedongoodfaithnegotiatedsettlement-orusingtheOfficialMedicalFeeScheduleasaguideline-and achieves speedier file closure.When dealing with the liens we should :1.Determinewhethertheliensarevalid(watch out- liens may be filed for treatment thatnever took place).2.Determine if the bill needs Bill Review, perthe Official Medical Fee Schedule.3.Know your venue and judge.4.Pay what you owe.55. HoldthelienclaimantsaccountableforaBurden of Proof, based upon a preponderanceof evidence.6. Negotiate a settlement in good faith.7. If necessary, move the file to a lien confer-ence, before a judge.As a last resort, prepareto take the case to trial.Consideration for early settlement of the liensmustbelookedatassoonastheinjuredworkerscasehassettled.Thegoodnewsisthat most liens settle well below the provider'sdemand.Resolvingtheliensthroughinformalnegotiation will successfully avoid the hefty costof further litigation.Medicalliensdon'thavetobeahugeobstaclethatdragoutaclaim'slife.Aslongaspartiescommunicate, liens can be brought to a just andspeedyresolution,and,moreimportantly,theclaim can be well and truly closed.(951)943-6775 ext 151Fax: (951) 943-5221etaylor@risksolutions-Inc.comP .O. Box 18017602 17th St.T ustin, CA 92780reducing the costs ofdoing business6