By Chris Boggs, CPCU, ARM, ALCM, LPCS, AAI, APA, CWCA, CRIS, AINS

Published with the author’s permission.

A pandemic is defined as, an outbreak of a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the population.” Although the media lives by the motto, If it bleeds, it leads,” declaring a pandemic anytime more than a few people contract a virus, this time even the World Health Organization (WHO) is warning of possible Coronavirus (COVID-19) pandemic. Coronavirus expert, Professor Gabriel Leung, Chair of Public Health at Hong Kong University, says that unchecked, the virus could infect 60 percent of the global population meeting the definition of a pandemic.

My intent is not to accuse the media of sensationalism, nor to intimate that WHO is overreacting (I don’t think they are); my purpose is to answer the question, what makes an illness an occupational illness” and thus compensable under workers’ compensation? More specifically, how does or might workers’ compensation respond to the Coronavirus?

By Donna Motley, Vice President of Claims

An Occupational Clinic plays a very important role in the world of Workers’ Compensation insurance. An Occupational Clinic differs from an Urgent Care Clinic. The treating personnel at Occupational Clinics, primarily, if not exclusively, treat work related injuries.

Work injuries greatly differ from an injury that may occur at home or result from a motor vehicle accident. Think about machine shops, foundries, stamping plants, etc. and all the equipment utilized to manufacture product within those facilities. Even a restaurant kitchen exposes an employee to more hazards than would be encountered at home. Work injuries can affect virtually every part of the human body (and we have seen it all!).

Occupational Clinic personnel “specialize” in work injuries. We encourage you to develop a close working relationship with your chosen Occupational Clinic. Invite a physician or therapist from your Occupational Clinic to tour your facility so they can see the type of work being performed; so they are familiar with the type of injuries that may occur; and thereby also aid them in determining whether or not the injured worker can return to work with restrictions. Most Occupational Clinics are very familiar with the rules governing Workers’ Compensation and attempt to treat accordingly. The personnel know a disability slip is required for an employee to provide to his employer. Occupational Clinics generally know authorization for testing is required prior to scheduling.

By Donna Motley, Vice President of Claims 

The path an injured worker’s claim can take, can go in many directions.

The perfect claim would be: an employee sustains an injury in the course of employment; it is reported immediately to the employer (supervisor or Human Resources) per company protocol; the injured worker is immediately sent to the Occupational Clinic for an evaluation, diagnosis and treatment plan; the claim is filed with the MTMIC Claims Department within 24 hours of the injury; the injured worker may be off the “rest of shift” and return to work the next day, with or without restrictions; the injured worker returns to the clinic, the injury has resolved, a full release and discharge from care has been given; medical bills are forwarded to MTMIC for payment; and the claim closes in 90 days or shortly thereafter!

It may sound somewhat “drawn out” but, basically, this is an example of a “simple” claim.

By Donna Motley, Vice President of Claims

I received notice of litigation the other day regarding an injury that allegedly occurred many years ago. The injury did not occur while MTMIC was the Workers’ Compensation carrier, but we currently insure the employer where the employee works. The original injury occurred in 2002. That’s correct – the employee sustained an injury to his foot when he jumped off a truck 17 years ago, and he is now alleging “total disability”. The employee has been working these past 17 years, not necessarily without incident or treatment, but certainly there have been other circumstances in his life that may have had an impact on his feet!

By Donna Motley, Vice President of Claims

A while ago I wrote about the medical profession’s new diagnosis of “Text Neck” – concerns about physical conditions being created by a person’s head being constantly bent forward while using a cell phone. Reading material I have received recently from a physical therapy facility now lists additional “new” diagnoses: Texting Thumb, Selfie Elbow, Text Neck and Tablet Tingling. These are new titles for “overuse conditions” officially titled Trigger Thumb, DeQuervains Tenosynovitis, Epicondylitis and Carpal Tunnel Syndrome. All of these conditions relate to straining and overuse of said body part resulting in inflammation.

By Donna Motley, Vice President of Claims

Truly, it wasn’t that long ago everyone was complaining about snow, ice, cold and asking the question “Where is Spring?” As most assumed, we really didn’t have a “Spring”, instead, we went right into summer. That “sudden change” is a stressor to our bodies. Being immediately thrust into heat and humidity can take a toll on anyone. Typically, Spring gives us time to gradually acclimate to warmer weather conditions. Now that the heat has arrived we have to learn to deal with it!

We are excited to announce that we have enhanced our customer portal so that you will now have the ability to upload medical documents as a means to get them to the claims adjuster that is handling your claim. This can be done by following these simple steps:

By Donna Motley, Vice President of Claims

One of the important reasons we stress an injured worker should seek medical treatment soon after an injury is to obtain an accurate diagnosis. what may appear to be a “simple cut or laceration” may actually be diagnosed as a “nicked” or lacerated tendon. An MRI may be required for an accurate diagnosis. 

Tendons attach or connect muscle to bone, which in turn allows for movement at the joint. Tendons control your hand and fingers, wrist, elbows, feet and toes, ankles and shoulders. Tendon laceration will result in trouble in bending or straightening the (attached) body part. These injuries typically require surgery. Hands and fingers should be repaired within 48 hours to prevent scarring. Tendon adhesions can become stuck to nearby tissue, usually requiring a surgical release. Delayed treatment will result in scar tissue and the tendon retracting. Depending on the mechanism of injury, there could also be damage to the bone, nerve and/or ligament.

By Donna Motley, Vice President of Claims

At this time of year, particularly this year, we seem to talk and complain about the weather. The winter season 2018 – 2019 has been confusing, if nothing else. We’ve had snow, ice, sleet/freezing rain, temperatures that range from sub-zero to almost spring. As a result of our yo-yo weather, a lot of people have gotten sick and a lot of people have sustained an injury. Our department is receiving a lot of claims for “slip and fall on ice and snow” resulting in broken bones, sore muscles and head injuries that are being defined as a “concussion”. A concussion is considered to be a “traumatic brain injury” – a mild traumatic brain injury – the least serious type of brain injury. A concussion is defined as a short loss of normal brain function.

We are excited to announce that we have enhanced our customer portal so that you will now have the ability to upload medical documents as a means to get them to the claims adjuster that is handling your claim. This can be done by following these simple steps:

• Log into the portal
• Go to the claims tab
• Click on the open claims tab
• Look up the name of your injured employee
• Click the Upload Documents button and attach the documents in either a .pdf or .jpg format

As soon as the documents are uploaded, the claims adjuster assigned to the claim will receive an alert that there is medical documentation waiting for them. You will be able to view the documentation after it is uploaded. Please contact Patty at (248) 715-0013 or patricia.allen@mtmic.com/blog with questions.

We are excited to announce that we have enhanced our customer portal so that you will now have the ability to upload medical documents as a means to get them to the claims adjuster that is handling your claim. This can be done by following these simple steps:

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By Donna Motley, Vice President of Claims

Employees are often eligible for multiple benefits with their employer. Workers’ Compensation coverage is mandatory in the State of Michigan. Optional benefits may be Short Term Disability (STD), Long Term Disability (LTD), Sick Time, Personal Time Off (PTO), Family Medical Leave (FMLA).

Of these programs, FMLA is “unpaid” with time limited to 12 weeks away from work, but the employee’s job is “protected” – meaning a position is to be available to the employee at the end of 12 weeks at the same rate of pay and same benefits.

STD and LTD generally pay a percentage of the employee’s wages. Of the STD cases I have seen (and handled), the employee has been paid approximately 65% of their wages. STD is generally limited to a set number of weeks, and LTD may or may not have a time limit (but again, recipients are paid at a lesser rate of pay).

Sick Time and PTO may or may not pay for days missed and generally have a time limit of eligible days that can be taken.

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By Donna Motley, Vice President of Claims

The Michigan Workers’ Compensation Act & Administrative Rules originated in 1912. The Act was revised with Amendments in 1969. Then in 2011, at 100 years old, the Act was updated with Statute changes to accommodate the past amendments and hopefully, better address, with clarity, issues facing our ever changing world. One of the updated issues was to define “disability”. No longer is the injured worker considered disabled because they cannot return to the job that caused their injury. Disability as defined by the Workers’ Compensation Act is: “A limitation of an employee’s wage earning capacity in work suitable to his or her qualifications and training. . . . . . The establishment of disability does not create a presumption of wage loss.”

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By Cindy Boyce, Senior Claims Adjuster

I have worked for MTMIC for 26 years in growing capacities, and currently am the Senior Claims Adjuster. In this role I handle the majority of the litigation in the office, especially the complex ligation issues. I have had the pleasure of working with a great deal of you throughout the years, however since we have seen growth in the number of our insured’s some of you may not know me. If you don’t know me, that’s a good thing as most likely your company has not involved in a complex claim or related issue. I am licensed in the State of Michigan as an Insurance Claims Adjuster and have a degree in business and as a medical assistant, along with extensive training and experience in all aspects of workers’ compensation claims including, causal relationships of injuries, medical issues, medical treatments, and remedies related to typical and complex cases. In addition to being knowledgeable, you will also find me easy to work with and comfortable that you will always be in good hands!

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By Donna Motley, Vice President of Claims

As I was reading the newspaper recently and a heading caught my eye – “OFFICE FASHION – TATTOOS ARE IN – TIES ARE OUT”! WHAT? I was shocked. I know I’m going to “date” myself (first of all, I was “reading” an actual newspaper), but when I first started in the world of Claims for a large self-insured company, the claims were handled within the Law Department. As is somewhat customary, there was a senior attorney and a junior attorney. I worked for the junior attorney – and he had a “moustache”. You would have thought he committed a crime – attorneys at that time were frowned upon if they had any facial hair! (Again, I know I am dating myself.) Now, when at the Workers’ Compensation Agency, in addition to facial hair, I’ve even seen a pony tail or two!

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By Donna Motley, Vice President of Claims

We’ve had good days and we’ve had bad days – winter weather that is. About a week ago it snowed 6 days out of 7 days – I know, because I had to shovel the snow! The most recent week, we’ve had a couple days of solid rain and it reached 60 degrees. All in February! What does that kind of weather do to a Claims Department that handles accidents and injuries?

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By Donna MotleyVice President of Claims

The American Diabetes Association reports that as of 2015, 30.3 million Americans (9.4%) had diabetes. Of the 30.3 million Americans, only 23.1 were diagnosed, with 7.2 million Americans undiagnosed. On top of that, 84.1 million Americans (18 years or older) were considered “pre-diabetic”. As of 2015, diabetes was the 7th leading cause of death in the United States; a statistic most likely under-reported.

So what relationship does diabetes have with a work injury? Obviously, work does not “cause” diabetes. But can diabetes “cause” a work injury?

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By Donna Motley, Vice President of Claims

I think, as an insurance company, we are automatically given a bad reputation. Most people, at one time or another over the course of years, have had an experience with their insurance carrier, either vehicle or home owners. I am no exception. I would agree with most people that when dealing with a home or auto insurance carrier, there is a huge emphasis placed on damages that equates with “money”. While it is the carrier’s responsibility to make the insured whole, the dollar and cents are watched closely. And I do realize there is a lot of fraud in auto and home owners insurance make this scrutiny necessary.

In Workers’ Compensation, our responsibility is to make the “injured worker” whole. With all the possible variables surrounding a work related injury, how do you place a dollar value on that? There is a book sometimes utilized in the Workers’ Compensation industry entitled “Official Disability Guidelines” – or the ODG. Easily accessible on the Internet, the ODG categorizes by injury and provides the average number of days away from work for that injury, the estimated Indemnity and Medical costs associated with that injury, billing procedure codes, best practices for a return to work (with or without surgery) and suggested restrictions for returning to work based on job duties of the injured worker. In a perfect world, right?

While interesting reading, we at MTMIC do not utilize the ODG. Similarly, medical (treatment) decisions are not based on the “cost” of a procedure. Yes, when a claim is established in our system we have to establish a dollar figure that should cover full treatment until the injured worker is recovered and returned to work. This “reserve” is medical based description of the injury, extent of the injury, taking in to consideration the age of the injured worker, possible co-morbidities and physical skills required to return to work. It is not the decision of the Claims Department for an employee to have a CT Scan vs. MRI – that is the decision of the treating physician. We can make suggestions and ask questions, ask for an explanation and decide to dispute the requested test, but the dispute is based on medical evidence and not dollars spent or to be spent. We do make sure testing or physical therapy is not being performed because “they can”. Before authorization is extended, there has to be a medical basis and is warranted.

I can’t tell you how many times injured workers have accused us of making a decision “just to save money”. Or that we only allow injured workers to treat with a “Workers’ Compensation” doctor. It is true that we will not allow treatment with certain doctors, our decisions are not based on money, they are based on medical outcomes. We handle a lot of claims in our office and are able to witness physicians’ results. We want the best doctor for the injury. No one benefits, physically or monetarily, if the treating physician is not skilled in their practice – not the employee, employer or insurance carrier.

Adjusters are human too! Among our Claims Department staff and family members, we have experienced broken bones, trigger finger, tendinitis and carpal tunnel syndrome. And who did we seek to treat – the same physicians that we utilize for our claimants. If we are personally satisfied with the physician’s results, why wouldn’t an injured worker be satisfied? We tend to utilize physicians that are no nonsense so maybe the injured worker just doesn’t like what the doctor has to say. We are not cold or heartless, our goal is to have the injured worker recover, while at the same time keeping an eye out for fraud!

By Donna Motley, Vice President of Claims

As your Workers’ Compensation carrier, we provide a service. Hopefully, part of that service is to make your job a little easier. In today’s world, everyone is busy. We can help take some tasks off your shoulders. After a work related injury, we can contact the doctor’s office or medical facility and provide the insurance and/or claim information. Any authorization to treat, refer for testing or to another physician, should be provided by our department pursuant to the Workers’ Compensation Act and Michigan Health Care Services Rules. We can contact the injured worker and relay necessary information; and answer the employee’s questions as to “how does this (the compensation process) work”?

In order for us to help “you”, we need you to help “us”. The first and best way to aid in the Workers’ Compensation process is to promptly report the injury to us. The second best way, is to make sure we have complete and detailed information. While I realize sometimes the Employer’s Basic Report of Injury (Form 100) has to be completed in haste, the more information provided, the least likely we are to call or e-mail you with questions or requests for additional information. Please realize, when detailing “how” an injury occurred, what may make perfect sense to you may raise additional questions in our minds. We are not necessarily familiar with your facility, the employee’s work duties, work process, the machines on site or how they operate.

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