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Workers Compensation Claim State Environmental Guide - Oklahoma OKLAHOMA – http://www.ok.gov/wcc/ Indemnity issues Temporary Total Benefits Temporary Partial Benefits For injuries prior to 02/01/2014: Min None Max $801.00 for injuries between 11/01/2013 and 02/01/2014. st Waiting period – 7-day waiting period, this is reimbursed after the 21 day of disability. % of Average Weekly Wage: 70% Limited Aggregate of 156 weeks, with a possible 52 week extension for consequential injuries. For injuries on or after 02/01/2014: Max $561.00 Waiting period is 3 days, which is never reimbursed or paid. % of Average Weekly Wage: 70% Limited Aggregate of 104 weeks, with a possible 52 week extension for consequential injuries. For injuries prior to 02/01/2014: Min None Max - Capped at 80% of AWW prior to injury Paid at 70% of the difference between AWW and earned wages. Waiting period–7-day waiting period which is reimbursed after 21 days of disability. Limited–Aggregate of 156 weeks, with a possible 52 week extension for consequential injuries. For injuries on or after 02/01/2014: 70% of the difference between the pre-injury AWW and earned wages. Only paid if weekly earned wages are less than the TTD rate. Total TPD in aggregate may not exceed 52 weeks. travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 This material is for informational purposes only. All statements herein are subject to the provisions, exclusions and conditions of the applicable policy. For an actual description of all coverages, terms and conditions, refer to the insurance policy. Coverages are subject to individual insureds meeting our underwriting qualifications and to state availability. © 2014 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE-10204-OK-EXT, Rev. 4-2014 Oklahoma Workers Compensation Claim State Environmental Guide Indemnity issues Permanent Partial Benefits Permanent Total Benefits WC Reference For injuries prior to 02/01/2014: Min $150.00 Max $323.00 as of 11/01/2011 % of Average Weekly Wage: 70% Limited to the scheduled body part Scheduled body parts: AMA–5th Edition 3 years to re-open from the date of the last order in which monetary benefits or active medical treatment was awarded or a CS-339-B was approved must be filed indicating a change of condition. For injuries on or after 02/01/2014: Min: None Max $323.00 % of Average Weekly Wage: 70% Body as a whole reduced from 500 weeks to 350 weeks. th AMA – 6 Edition For injuries prior to 02/01/2014: Min $30.00 Max $801.00 (same as TTD rate) Once determined to be Permanent Total by court order, paid until the claimant reaches the age of maximum Social Security retirement benefits or for a period of fifteen (15) years, whichever is longer, or a subsequent determination that the employee is no longer Permanent Total. Upon the death of an employee who has been adjudicated permanently totally disabled, the surviving spouse and or dependent child under the age of 23 is entitled to one lump sum payment equal to 26 weeks of weekly benefits. For injuries on or after 02/01/2014: No change in benefits under Administrative Workers’ Compensation Act. 2 Rev. 4/14 Oklahoma Workers Compensation Claim State Environmental Guide Indemnity issues Fatality Benefits For injuries prior to 02/01/2014: Min/Max–Varies depending upon the deceased’s AWW and Funeral Expense: Maximum Funeral Expense (with dependent): $10,000. Maximum Funeral Expense (no dependents): $8,000. Limited: 2 years of death benefits paid in a lump sum to spouse upon remarriage. Children up to the age 18 or no longer dependent. If surviving spouse and children immediate lump sum of $100,000 to spouse and $25,000 for one minor child, two minor children or more, $50,000. To be divided equally. If no surviving spouse, but 1 or more surviving minor children, immediate payment of $25,000 per child up to a maximum of $150,000 to be divided equally among children. Weekly benefits: for spouse 70% of deceased employee’s average weekly wage. Spouse plus children 15% per child, remainder to spouse. Children with no surviving spouse 50% of deceased’s average weekly wages for 1 child, and 20% of such wage for each additional child, divided equally among the children, and subject to the maximum limits. One dependent parent 25% of the deceased’s AWW, both dependent parents 50% of the deceased’s AWW. Dependent grandparents, grandchildren, or siblings 25% of the deceased’s AWW to each such dependent, divided equally, subject to the maximum limits. Limitations: termination of benefits upon reaching age 18 or no longer dependent. Maximum per week payout of death benefits not to exceed 100% of the deceased employee’s average weekly wage or the states average weekly wage (SAWW) rate at the time of death, currently $801. For injuries on or after 02/01/2014: No change in benefits under Administrative Workers’ Compensation Act, except that upon remarriage, benefits to the surviving spouse may terminate, and there is no additional lump sum payment. Vocational Rehabilitation For injuries prior to 02/01/2014: Is it required? An employee who has suffered an accidental injury or occupational disease covered by the Act shall be entitled to prompt and reasonable physical rehabilitation services. When, as a result of the injury, the employee is unable to perform the same occupational duties he was performing prior to the injury. What are the benefits? Evaluation, Retraining or Job Placement. For injuries on or after 02/01/2014: Is it required? Yes, if an injured employee cannot return to his pre-injury job or equivalent for the same employer. For injuries prior to 02/01/2014: Yes by way of a Compromise Settlement or Court Order For injuries on or after 02/01/2014: Yes, by way of a Joint Petition. Settlement Allowed Cap on benefits, exceptions Medical issues Initial Choice of Provider WC Reference For injuries prior to 02/01/2014: The Employer has choice of Physician; however, if treatment has not been provided within 7 days of actual knowledge of an injury, then the Injured Worker may choose a physician to treat with at the employer’s expense until the employer designates a treating physician. For injuries on or after 02/01/2014: 3 Rev. 4/14 Oklahoma Workers Compensation Claim State Environmental Guide Medical issues Change of Provider Medical Fee Schedule The Employer has choice of Physician; however, if treatment has not been provided within 5 days of actual knowledge of an injury, then the Injured Worker may choose a physician to treat with at the employer’s expense until the employer designates a treating physician. For injuries prior to 02/01/2014: The Injured Worker may request 2 changes of physician per claim, regardless of the number of body parts involved. Furthermore, the Injured Worker may not request a change of physician for a body part that authorized treatment has not been provided for a period of 180 days or more. For injuries on or after 02/01/2014: The Injured Worker may request 1 changes of physician per claim, regardless of the number of body parts involved. If the claimant requests a change of physician, the employer must submit 3 names of qualified physicians to treat the affected body part, and the claimant must pick one of the 3 names provided. Services are paid pursuant to the Oklahoma Fee Schedule which is typically at 150% of Medicare’s fee schedule. Managed Care Provider Choice. Utilization Review For injuries prior to 02/01/2014: No, pre-authorization not necessary For injuries on or after 02/01/2014: Closed formulary: Preauthorization required for all compound drugs and drugs that are not preferred or addressed by the ODG. Treatment Guidelines For injuries prior to 02/01/2014: Official Disability Guidelines (ODG) are mandatory for all injuries, and used in conjunction with the Oklahoma Treatment Guidelines for treatment of the spine and narcotic pain management. For injuries on or after 02/01/2014: ODG is not mandatory, but is the reference guide for reasonable and necessary medical treatment. Generic Drug Substitution Physicians shall prescribe and pharmacies shall dispense generic equivalent drugs when available. Medical Mileage Reimbursement Rate The injured worker is reimbursed for actual miles traveled in excess of 20 miles per roundtrip. The current rate as of 01/01/2014 is $0.56 Network Information First Health (primary) & CorVel (secondary). Ability to Terminate Medical Treatment For injuries prior to 02/01/2014: If not reasonable and necessary, or if the treatment is outside the recommendations of the ODG or OTG. Can be terminated by Adjuster or by Judge with utilization of objective medical findings (IME / Court Ordered IME). For injuries on or after 02/01/2014: If not reasonable and necessary, or if the treatment is outside the recommendations of the ODG or OTG, it can be terminated by Adjuster or by Judge with utilization of objective medical findings (IME / Court Ordered IME). If the claimant misses 2 or more scheduled appointments. Settlement Allowed For injuries prior to 02/01/2014: Yes, Medical can be settled by way of a Compromise Settlement 339-A. For injuries on or after 02/01/2014: Yes, medical can be settled by way of a Joint Petition. Cap on benefits, exceptions As of 11/01/05, disfigurement cap is $50,000. WC Reference 4 Rev. 4/14 Oklahoma Workers Compensation Claim State Environmental Guide Other Issues WC Hearing Docket Speed For injuries prior to 02/01/2014: Form A must set within 10 days. Prehearing Conferences may take 3 to 6 weeks, and Trials may take 4 to 8 weeks, depending on the Judge. Judges are liberal in their interpretation of the law and outcomes are pro-employee. For injuries on or after 02/01/2014: The Commission can hire as many Administrative Law Judges as necessary. There have been no hearings set before any ALJs as of the date of this report. It is anticipated that the hearings will be set quickly as new claims are filed under the Administrative system. The ALJs, by Statute, are to have a strict construction of the law. Staff Counsel David Klosterboer & Associates (405-264-2140) 211 North Robinson Avenue, Suite 430 Oklahoma City, OK 73102 Hearings require attorney or claim handler participation For injuries prior to 02/01/2014: Attorney representation at all hearings and Trials. Adjusters may be required to attend settlement conferences at the request of the Trial Judge. For injuries on or after 02/01/2014: Adjusters may be required to attend settlement conferences at the request of the Administrative Law Judge. Non-lawyer representatives are allowed to appear before the Commission. The non-lawyer representative must be pre-approved by the Commission and they must have full settlement authority. The Commission will maintain a list of authorized non-lawyer representatives. Non-lawyer representatives will be held to the same standards of conduct as attorneys, and are expected to follow the same rules of procedure. Occupational Diseases Only that disease or illness which is due to causes/and conditions characteristic of or peculiar to the particular trade, occupation, process or employment in which the employee is exposed to such disease. Employment must be the major cause of the resulting occupational disease and such is supported by objective medical evidence. Second Injury Fund availability Multiple Injury Trust Fund (Created 11/01/99) (Reinstated as of 11/01/05) Other Offset Opportunities Apportionment, Subrogation EDI No EDI required In-State Adjusting Required No License or Certification Required Removes mandate for workers’ compensation adjusters to complete 6 hours of OK specific continuing educations. Effective 11/1/2012. WC Reference 5 Rev. 4/14