The Colorado Division of Workers’ Compensation recently released the new 2022 Guide to Adjusting Workers’ Compensation Claims, formerly the Adjuster’s Guide. What you’ll find in the new guide is the addition of engaging graphics, improved organization, more concise coverage of adjusting considerations, called out calculations with associated examples and increased references to valuable complementary resources.
Spring is in the air – it must be time for Colorado legislative and Division of Workers’ Compensation updates. As always, we are here to ensure you are aware of and understand them all. Below is our review of the April 30th changes, the upcoming changes effective July 1st, as well as proposed legislation.
Round 1. Rules first:
Rule 2: Workers’ Compensation Insurance Premium and Payroll Surcharge (EFFECTIVE 7/1/21)
Last year, Of Counsel Frank Cavanaugh pointed this rule out, as an approved rate reduction in “loss costs” had occurred. This year it again went down. Loss costs are the average cost of lost wages and medical payments paid to or on behalf of the injured worker. This is a component of an employer’s premium calculation. Rule 2 changes do not have anything to do with claim handling and, therefore, do not require coverage.
Rule 4: Carrier Compliance (EFFECTIVE 4/30/21)
4-1(A): The changes in this section are primarily removing language and have little practical effect; however, it is important to understand the content. Believe it or not, some of the terminology throughout the rules did not match. So efforts were made to apply clarity.
4-1(C): In this section again, language was removed, and it was clarified that fines can be imposed if the carrier does not meet 90% or higher compliance in each of the 10 categories audited.
4-1(D): The change under this section requires that after the carrier receives the preliminary audit they may request an extension of time beyond the 30-day time frame to disagree with the findings. The request, however, must be submitted in writing within the 30 calendar days from receipt of the report to respond. If the response is not submitted in writing, it will be considered a “waiver of the right” to file a disagreement with the audit.
There were some additional changes under this section; however, these changes were not substantive.
4-2: Fines for Claims Audits
4-2(E): The change to this section removed the fines per audit deficiency per compliance category. The rule provides for a fine for deficiencies in each category; however, they removed the increased fine for “subsequent finable occurrences”.
Rule 5: Claims Adjusting Requirements (EFFECTIVE 7/1/2021)
5-1: Completion of Division Forms
5-1(D): This was an added section requiring electronic filing. It specifies that there can only be one file per electronic submission and all attachments must be included. You must include the claimant’s first and last name and the type of document being filed with a certificate of the date it was submitted. It is specific that admissions, petitions to modify, terminate, suspend, request for lump sum payments, and motions to close for lack of prosecution must be sent to CDLE_DOWC_FILINGS@STATE.CO.US. It also formalized a requirement recently added that all motions to close must have email addresses for all parties or they are to be submitted via regular mail.
All motions, other than those to close a file, and submissions for prehearings and settlements must be submitted to CDLE_DOWC_PREHEARINGS@STATE.CO.US. All other communications are to be submitted to CDLE_WORKERS_COMPENSATION@STATE.CO.US.
5-2: Filing of Employers First Report of Injury
5-2(B)(1): This change requires the filing of a First Report of Injury within 3 days of notice to the insurance carrier or the self-insured when a fatality occurs, or when 3 or more employees are injured in the same accident.
5-2(B)(2): Language was added to emphasize that a First Report of Injury must be filed no more than 10 days after notice to an employer or self-insured of an occupational disease resulting in lost time from work in excess of 3 shifts or calendar days, occurrence of permanent physical impairment, or contraction of a specified occupational disease.
5-5(A): Admissions of Liability
The language changed to specifically require that the narrative report and the worksheets should include a statement from the authorized treating physician regarding the date of maximum medical improvement, permanent impairment, and the need for maintenance medical benefits. Under paragraph (1), if maintenance medical benefits are being denied, a reference must be made to the date of the medical report which supports your denial, along with the physician’s name. The DOWC has already changed the FAL forms. Under paragraph (3) (dealing with medical-only claims that have been reported to the Division), if no impairment, either a narrative report or the physicians report of workers’ compensation injury form can be used as long as they are attached.
5-8: Admission for Permanent Total Disability Benefits
In this section (B)(2) was removed, which required receipt or proof of payment of compensation to the claimant through the date of death.
5-9: Revising Final Admissions
The change to this rule removed paragraph (C), which dealt with admissions of liability on or after July 1, 1991- and before August 5, 1998. This change appears to be more housekeeping in nature.
Rule 6: Modification, Termination or Suspension of Temporary Disability Benefits (EFFECTIVE 7/1/2021)
The changes in this rule are to clarify terminology. Under paragraph 6-1(A)(2), there was a change from the term “regular employment” to “full or regular duty.” Paragraph 6-1 (A)(3) changed “report” to “Statement” and added language regarding claimant returning to work “at full wages and hours.” The other changes clarified language but did not substantively change the rule.
6-4: Suspension, Modification or Termination of Temporary Disability Benefits by Petition
The significant change in this rule is under paragraph (B). When retroactively decreasing temporary benefits but with a previously filed admission of liability, the petition must be filed within 30 days of the original admission and this process cannot be used for a safety rule violation. The right to set a hearing remains and is usually needed for the denial of the petition.
7-1: Closure of Claims and Petitions to Reopen (EFFECTIVE 7/1/2021)
7-1(C)(1): This was added confirming the Division’s position that they will not allow case closure for failure to prosecute if a claimant is receiving temporary disability benefits. Under paragraph (2), they have also emphasized the motions or petitions to close can be submitted via email if there are email addresses for all parties. If not, they are to be filed by mail.
7-2: Petitions to Reopen
The change in this rule outlines that the process to reopen a claim is by filing an application for hearing endorsing the issue of reopening. It effectively took away the process of a petition to reopen on a standard Division form.
Round 2. Legislation:
Legislation is a yearly struggle, given the makeup of the legislature in Colorado. We see a continual battle to shift the control of claims to the claimants which, of course means, to their attorneys. Each year there are behind-the-scenes negotiations to try to compromise what could be drastic changes, and this year is no exception.
SB21-096: Sunset Workers’ Compensation Classification Appeals Board
Most of you would not be involved with this process. This board was set up to hear grievances brought by employers against insurers concerning the calculation of experience modification factors and classification assignment decisions. This board was due to expire and it has now been continued with clarification. This was signed by the Governor on April 15, 2021 and is the law.
HB21-1213: Conversion of Pinnacol Assurance
This bill was introduced to change Pinnacol from a political subdivision of the state to a stock insurance company. It is now postponed indefinitely.
HB21-1207: Overpayment of Workers’ Compensation Benefits
There has been a push through legislative actions and through the case law to dramatically alter the ability of respondents to collect overpayment of benefits. This bill defines overpayment in a very restrictive manner, to include only benefits paid as a result of fraud, or duplicate benefits that are resultant of offsets regarding disability or death benefits. It does still allow for offsetting and taking credit for any indemnity benefits paid beyond the date of MMI. If the error was a miscalculation issue, it can be remedied within the 30 days allowed for an objection to the admission. This bill is still under consideration.
HB21-1050 Workers’ Compensation
This bill has been referred to as the compromise bill. There are some major inclusions, which in the past have given flexibility, but now the outcome is defined.
- In the present form, if passed, the bill will require appointment of Guardian ad litem and conservators to the list of medical aid that an employer must furnish.
- This bill also limits credit for Social Security benefits to those benefits which the claimant was not receiving at the time of injury. In the past, we have been able to take credit for SSDI benefits even though they were being received at the time of injury.
- The ability to take apportionment against TTD, TPD and medical benefits is gone. The ability to reduce PPD and PTD is still at issue.
- There are also specific limitations when selecting IME physicians.
- One of the more drastic changes that will affect benefits is changing the percent of impairment needed to exceed the first PPD cap from 25% to 19%.
- Respondents will now be unable to withdraw an Admission of Liability when two years have passed from the admission, with the exception of fraud.
- For the purpose of appeals, this bill would require the Director or the ALJ to award benefits when compensability or liability are at issue. This does help respondents, as claimants can’t get an order that a case is compensable and prevent an appeal of that decision as the ALJ didn’t order benefits paid. There are also discussions regarding appeals, orders, and the review process.
- The amount that a claimant must earn for respondents to reopen a prior determination of PTD is increased from $4,000 to $7,500.
- The claimant will now have to submit mileage reimbursement within 120 days and the carrier has 30 days to pay or dispute.
This bill is currently still being considered so the final version is unknown.
SB21-197: Workers’ Compensation Physician
This bill is probably the most dangerous of them all. Over the past several years, claimants’ bar has pushed to reduce and change respondents’ ability to control medical care. This bill, if enacted, will give all control of choice of physician to the claimant.
The current designation of physician process would be gone. The employer would have 7 business days after notice of the injury to give the employee or claimant an authorized physician designation form developed by the Director. At that point, the claimant would be able to designate any level I or level II accredited physician as the authorized treating physician. They are able to make this designation up until the time they reach MMI. The claimant can also make a request to have his/her personal physician or chiropractor be the treating physician. If the treating physician will no longer treat the claimant, the insurer or self-insured must advise the claimant that they need to choose a new physician.
This bill is currently in the Senate Business, Labor, and Technology Committee so the final version is unknown.
If you have any questions about the updated Rules, or any employment or workers’ compensation related question, please contact us.
The Division of Workers’ Compensation seems to be on a constant mission to tweak various workers’ compensation rules of procedure. Some of these changes are directed at situations that clearly need attention, while others are less clear. This year is no different. There have been several rule changes from the Division of Workers’ Compensation that take effect at the first of the year or have already taken effect. I will try to break down the rule changes as briefly and clearly as I can.
Rule 2: Workers’ Compensation Insurance Premium and Payroll Surcharge EFFECTIVE 7/1/20
As you may or may not be aware, an approved rate reduction in “loss costs” occurred this year. Loss costs are the average cost of lost wages and medical payments paid to or on behalf of the injured worker. This is a component of an employer’s premium calculation. Rule 2 changes do not have anything to do with claim handling and, therefore, do not require coverage.
Rule 16: Utilization Standards EFFECTIVE 1/1/21
16-2 Standard Terminology for Rules 16, 17 and 18
Believe it or not some of the terminology throughout the rules did not match. Here are some housecleaning efforts.
16-2(E): You may not have known this, but a “certified medical interpreter” had a specific definition. They were individuals with certification from the Certification Commission for Healthcare Interpreters or the National Board of Certification for Medical interpreters. 16-2E struck the definition of a Certified Medical Interpreters. If you recall, several years ago there were concerns raised that medical conditions referenced by the injured worker were not making it into reports based on language barriers. This requirement had the unintended consequence of making it hard to find a certified medical interpreter, hence the change.
16-2G: There has been inconsistency throughout the rules in that some rules used “business days” for time measurement while others simply used “days.” This particular change clarifies that “day” is a calendar day unless otherwise noted. So now day means day unless the rules says business day, or some other type of day. This really does clarify things.
16-2H: If I used the term designated provider list in the workers’ compensation setting what you think it would mean? If you struggled for an answer other than the doctor list the employer provides to an injured worker join the club. Well never fear, this change clarifies that “designated provider list” means the physician list as required under Section 8-43-404(5)(A)(1), C.R.S.
16-2N & Q: This rule change better defines a non-physician provider to include a surgical assistant. It also defines a “Physician Provider” as someone who is board licensed in their area of practice. For instance, a physician provider would need to be licensed by the Colorado Medical Board, a dental provider would have to be licensed by the Colorado Dental Board, etc. It is recommended to simply review this rule if the question is encountered.
16-3A: This requires that any provider not listed in 16-2 as a “Physician Provider” requires prior authorization to provide services for a work injury.
16-3B, C & D: This now requires that all providers have a referral from a physician provider managing the claim (or NP/PA working under that physician provider). It used to be that only non-physician providers had to have a referral from a physician provider, but now it is everybody.
16-6: This rule deals with a provider’s notification to treat an injured worker. It basically sets forth the way in which a provider advises a payer of the treatment to get paid for that treatment. This year’s change requires the payer’s response time to a notification to treat. It goes from 5 business days to 7 calendar days. Although this makes the rule more uniform, in certain circumstances, such as determining a holiday that would otherwise not be included as a business day, this could make it difficult to respond to such a request.
16-7: Prior Authorization issues are always difficult. This section of Rule 16 changes the payer’s response time from 7 business days to 10 calendar days. Once again, while making the rule more uniform in certain circumstances, such as determining a holiday that would otherwise not be included as a business day, this could make it difficult to respond to such a request.
16-7-1: Deals with prior authorization denials – when a denial is made based upon a medical report that predates the request. Under this change, an IME or report from an ATP used to deny a prior authorization request based solely on relatedness to the injury cannot be older than one year from the date of the prior authorization request. Further, such a report can only be used if there is not an admission of liability filed admitting the relatedness of the requested treatment, or a final order has not been entered finding that the specific medical condition is related to the admitted injury. Otherwise, the IME report or ATP opinion must be after the prior authorization request. The thinking behind this rule change is that a stale report cannot be used to deny prior authorization request. One wonders what happens when the request is for the same treatment over and over. Can the requests get stale too?
16-7-2: This section deals with appeals of a prior authorization denial. Now the requesting party has 10 days from the date of the denial to appeal the denial. By the same token the payer has 10 days from the date of the appeal to issue a final decision.
16-9A & B: This section deals with required medical record documentation to get paid. This rule was modified so that a claimant’s functional response to treatment no longer needs to be documented. There is also no longer a requirement that the documentation reference specifics for a treatment plan.
16-10A: This section deals with payment requirements for medical bills. There was a suggested change that would have no longer required bills be submitted by a provider but could be submitted by anybody. Fortunately, over these suggested changes that would have allowed submission by the attorney or party, the rule remains that the submission must be made by the provider.
16-10-2A: This section deals with denying payment of billed treatment for non-medical reasons. This change to this section now allows for denial for non-medical reasons for improper use of a CPT code.
16-10-2C: When denial for non-medical reasons the payer’s denial does not have to be made within 30 days of receipt of the bill.
16-10-4: this section deals with appealing billed treatment that has been denied. The billing party has 60 days from the date of the written notice to request reconsideration to appeal. The appeal now has to have the specific code being appealed.
Rule 18 Medical Fee Schedule EFFECTIVE 1/1/21
18-4(I): Telemedicine: This provides guidelines and requirements for telemedicine. Telemedicine must comply with requirements found under the Colorado Medical Practices Act and the Colorado Mental Medical Board and the Colorado Board of Psychologist Examiners. A physician-patient relationship must be established for telemedicine to occur. The same documentation required of an in-person evaluation is required of telemedicine.
18-9D: App-Based Interventions: This new subsection allows the provider to write an order for an app-based intervention for the injured worker. For instance, as part of biofeedback perhaps the apps Hello Mind or Mindspring could be prescribed. For more physiologic app, perhaps some sort of activity tracker would be prescribed. Such an order is to have a designated time frame for use and must be payable by invoice and billed directly to the payer the maximum allowable charges $25 a month and the maximum duration is three months per order. Anything over this amount requires prior authorization.
If you have any questions about the updated Rules, or any employment or workers’ compensation related question, please contact us.
Colorado recently took steps to increase the salary threshold for employees falling under the “white collar” exemptions. On January 22, 2020, the Colorado Department of Labor adopted the Colorado Overtime and Minimum Pay Standards Order #36 (“COMPS Order”), with most of its provisions becoming effective on March 16, 2020. The new minimum salary thresholds for exemption from overtime began on July 1, 2020. The COMPS Order makes significant changes for both exempt and non-exempt employees, and further outlines critical Colorado wage rights and responsibilities. The COMPS Order replaces the Minimum Wage Orders previously issued by the Division and supplements the thresholds provided by federal law, under the Fair Labor Standards Act. Under the Order, whenever employers are subject to it, as well as to federal and/or local labor laws, the law providing the greatest protection to employees shall apply. Contrary to previous wage orders, under the COMPS Order virtually all private employers, in all industries, will be subject to Colorado’s minimum wage, overtime and working condition rules, unless they fall into one of the specifically enumerated exceptions. The Order requires employers to track, record, and compensate all non-exempt employees for all “time worked”. The Order redefines “time worked” as all the time for which the employer requires or permits an employee:
To be on the employer’s premises, on duty, or at a prescribed workplace (but not merely permitting an employee completely relieved from duty to arrive or remain on-premises) — including but not limited to, if such tasks take over one minute, putting on or removing required work clothes or gear (but not a uniform worn outside work as well), receiving or sharing work-related information, security or safety screening, remaining at the place of employment awaiting a decision on job assignment or when to begin work, performing clean-up or other duties “off the clock,” clocking or checking in or out, or waiting for any of the preceding. . . .
COMPS Order Rule 1.9.1.
Under the Order, beginning July 1, 2020, the annualized salary required for an employee to be considered “exempt” is $35,568.00, with some exceptions for nonprofits and small businesses. After 2020, the salary threshold for exempt employees will rise every year on January 1st. The COMPS Order also imposes a wide array of additional requirements relating to a variety of issues, including meal and rest periods, employer-provided uniforms, permissible wage deductions, calculation of non-hourly pay for overtime, and posting and distribution requirements for ease of employee access. Employers have only one month to comply with all documentation and notices required by the Order, such as new posters, employee handbook inserts, acknowledgment forms, etc. Interpretive Notice & Formal Opinion (INFO)#1: Colorado Overtime & Minimum Pay Standards Order (COMPS Order) #36, which can be found on the Colorado Division of Labor’s website, summarizes key parts, interpretations of, and exemptions to, COMPS Order #36.
If you have any questions about the requirements of COMPS Order #36, or any employment or workers’ compensation-related question please contact us.
As of December 15, 2019, the Colorado Department of Labor and Employment (CDLE) has a new rule in place clarifying that companies may cap but not take away employees’ earned, unused vacation pay. The viability of “use-it-or-lose-it” vacation policies under the Colorado Wage Claim Act (the “Act”) has been in flux for years, with the latest conflict stemming from a 2019 Colorado Court of Appeals decision upholding a policy under which employees forfeited vacation pay in some circumstances (e.g., if they resigned without providing two weeks’ notice). The CDLE’s new rule (7 CCR 1103-7, Rule 2.15) rejects the Court of Appeals’ holding and clarifies that an employer may have a policy limiting how vacation pay accrues but may not diminish earned vacation days other than through an employee’s actual use of vacation time.
Colorado employers with conditional vacation payout policies should immediately address the application under the new rule. If needed, consultation should be made with an employment law attorney to address a companies’ needs. Companies should address the difference between having vacation policies and general “paid-time off” policies. The new rule is not applicable to the latter type of policies. Therefore, companies with vacation only policies should address the potential implications of wage exposure to employees under the new rule. For example, upon termination, under the new rule, an employee with unused vacation time is now entitled to wages for that unused time. Conversion over to general “paid-time off” policies may be better suited to avoid this type of liability.
As always, if you have any questions regarding employment or workers’ compensation insurance laws, please contact us.
One of the main strategies in workers’ compensation claims involves the selection of a particular venue for the DIME process. For numerous years, Rule 11 was silent on the selection of a location for the Division IME. The party requesting the DIME had the option of selecting any venue in Colorado for the appointment to take place. From there, the DIME unit would select 3 physicians in the geographic location that the selecting party indicated on its Application and the DIME process would move forward. Essentially, any part of Colorado was “fair game” as the location in which to have a DIME. From a strategy perspective, selecting a specific geographical location for the DIME to take place could prove advantageous for the requesting party depending on the pool of physicians within that location. For example, it was not uncommon for residents from Fort Collins to request a DIME in Colorado Springs. One of the most common requests involved residents of Grand Junction traveling to Denver for their DIME appointment.
Respondents in certain geographical regions also had the strategy of requesting a pre-emptive DIME on a claim in which the treating physician placed the claimant at MMI with no impairment. For example, if a claimant in Colorado Springs was placed at MMI without impairment and was almost certain to request a DIME in Colorado Springs, Respondents would have the option of going for the DIME themselves as a pre-emptive measure and to take away claimant’s right to select a particular, more liberal venue to have the DIME.
Rule 11 is still silent on the venue for a DIME to take place. However, the recent changes to the Application for a DIME have added a specific portion to the Application form regarding venue selection. On the Application for a DIME, it states as follows, “preferred geographical location of examination. (The location in which the claimant resides may take precedence over the preferred location).” Of note is the use of the word “preferred” and specifically noting that claimant’s residence may take precedence instead of the preferred location selected. This is a new change that the DIME unit is focusing on and it appears in the past several months that the DIME unit is using a reasonableness standard when selecting physicians in a particular geographic location. For example, Respondents may want to challenge a treating physicians’ rating from the western slope and request a DIME in Denver. Gone are the days in which a three-doctor Denver panel was guaranteed. Instead, the DIME unit may put a combination of Denver and western slope physicians on the panel for selection. The process involves many variables as to which physicians are on the panel, including but not limited to, available physicians, specialties, current physicians performing DIMEs, timing, etc.
This new approach by the DIME unit is a topic of discussion and poses many issues. One issue is whether the venue preference will be applied equally to both parties and if bias is removed from the panel selection process. If Respondents are getting physicians from a select geographical location but claimants are not, (and vice-versa), it doesn’t present fairness to the DIME process for both parties. Another issue is the amount of physicians present in one geographic location and whether the pool of DIME physicians throughout the state are performing examinations routinely. For example, if Colorado Springs is frequently selected as a venue, and physicians within that pool are performing DIMEs more frequently than other physicians, does it eliminate the concerns that the new changes to the Rule hoped to address in having a wider variety of physicians participate in the process? Yet another issue is either party wanting a specific venue due to a fact specific reason in the claim, and not particularly receiving it despite the request of one or both parties. The new Rule allows the parties to agree to a number of issues, including the physician to perform the DIME and the cost. However, can the parties agree to a venue when there is a disagreement to the physician and cost?
Major changes to any Rule are usually met with many questions about its implementation. Venue selection for the DIME process has always been a strategic focus for both parties and now poses even more questions based on the changes to the Application for DIME. Now that the DIME unit is exercising some control over the venue selection, it may change the focus of the strategy for the DIME in a different direction. Respondents may want to rely upon the fact that a DIME panel may not entirely be composed of physicians within one region, but instead, focus on the potential for obtaining a panel with more variety that could ultimately impact the case in different ways. Employers and carriers may want to focus the fight on a different aspect of the DIME such as cost. In light of the changes to Rule 11, it is important to discuss the DIME strategy with counsel and the client to ensure that all of the facts and potential options are being discussed to best forward the claim to resolution. Always remember that the Prehearing Unit retains jurisdiction to resolves issues pertaining to the DIME. Once a Motion is filed, the DIME is held in abeyance pursuant to Rule 11. If the parties are able to agree on the venue, it may be worthwhile to reduce the agreement to a stipulated Order and provide a copy of it to the DIME unit so that there is no question as to which physicians can be selected from a certain geographical region.
If you have any questions regarding the changes to the Rules or the updated statutes, feel free to contact us.
In 2019, Colorado earned the top spot for the highest percentage of employees who work from home, according to Flex.Jobs https://www.flexjobs.com/blog/post/infographic-which-states–have-most-full-time-telecommuters. While telecommuting is not realistic for every company, many jobs have at least some component that employees can do flexibly even if a job requires an employee to be onsite for specific hours. Perhaps the employee reconciles call logs or works on quarterly reports on a Sunday afternoon. The question then arises, “What is an employer’s liability for injuries occurring at an employee’s home or when traveling between the home and work?” A compensable injury is one which “arises out of” and “in the course of” the employment. An injury “arises out of” of a work-related activity if it is “sufficiently interrelated to the conditions and the circumstances under which the employee usually performs his job functions that the activity may reasonably be characterized as an incident of employment, even though the activity itself is not a strict obligation of employment and does not confer a strict benefit on the employer.” City of Boulder v. Streeb, 706 P.2d 786 (Colo. 1985). For example, in Schwindt v. Red Roof Delivery Inc., W.C. No. 4-009-534 (September 14, 1992), the Claimant, a restaurant manager, was injured when she fell down a stairway in her home at approximately 4:30 a.m., sustaining significant injuries. The Claimant had been working on schedules for the employer, and was authorized, but not required, to do so at home. The Claimant was performing this work in her living room, but began to fall asleep, so she gathered her materials to go to an office adjoining her bedroom. Just prior to approaching the stairway, the Claimant closed a door. The resultant reduced lighting impeded the Claimant’s visibility. Claimant lost her step in the hallway and fell down the stairs. The Claimant testified she “probably” would have taken a shower and returned to scheduling had the fall not occurred. The ALJ concluded the injury was compensable. He found the Claimant’s work demands permitted her to complete administrative work at home, and that, at the time of the fall, the Claimant “would have been asleep in bed” had she not been working on the schedules. The Respondents made several arguments on appeal, including that the connection between the fall and the Claimant’s employment was too remote, and that the Claimant’s act of closing the door severed the causal connection. The Panel rejected the Respondents’ arguments, holding there was a sufficient nexus between the conditions of employment and the injury. The Panel reasoned, the claimant “need only have been acting in a manner consistent with, or incidental to, the employment” to establish compensability.
Similarly, in Bates v. Coors Brewing Co., W. C. No. 4-348-224, 1998 WL 872454, (Nov. 13, 1998), the Claimant worked as a plant manager for the employer. On May 14, 1997, the Claimant left the employer’s plant in her personal vehicle to travel home, where she was going review work-related material she was taking on a business trip the following day. On her way home, the Claimant was injured in a motor vehicle accident. The ALJ found the claim compensable, holding the Claimant’s travel home on this occasion was in pursuit of the employer’s business and conferred a benefit to the employer beyond her own presence at work. On appeal, Respondents contended that the facts of this case did not fall within the travel status exception because the Claimant was not required to work at home and was not required to bring her personal vehicle to work. The Panel rejected Respondents’ arguments, holding an injury does not have to be the result of a mandatory employment activity to be compensable. University of Denver v. Nemeth, 127 Colo. 385, 257 P.2d 423 (1953); Rather, it is sufficient if the injury arises out of a risk which is reasonably incidental to the conditions and circumstances of the particular employment. This includes discretionary or “optional” activities on the part of the employee which are devoid of any duty component.
The case Roe v. Alpine Plumbing & Heating, Inc., W.C. No. 3-766-435, 1987 WL59197, (July 20, 19987), had similar facts, but a contrary result. In Roe, the Claimant who was employed by Respondent as a plumber, was injured in an automobile accident. The Claimant testified that the accident occurred while he was “driving up to the job” near Boulder. As a result of a previous injury, the Claimant was performing light-duty work for the Respondent. The Claimant’s duties included working on plans at his home. However, the ALJ found that the Claimant was “allowed to work at home for his own convenience” and that “the Claimant’s home was not an alternative job site.” Consequently, the ALJ concluded that the Claimant was not within the course and scope of his employment at the time of the accident.
Finally, in Sedgwick CMS v. Valcourt-Williams, in a 12-2 decision, the District Court of Appeals of Florida, reversed an ALJ’s decision awarding worker’s compensation benefits to an at home worker. During working hours on April 27, 2016, Valcourt-Williams, a workers’ compensation claims adjuster, reached for a cup of coffee in her kitchen and tripped over one of her dogs, fell and sustained injuries to her knee, hip and shoulder. She filed a worker’s compensation claim, which the employer denied, contending her injuries did not arise out of employment. The ALJ held the Claimant’s injuries were compensable because the work from home arrangement meant the employer “imported the work environment into the claimant’s home”. On appeal, the District Court held the Claimant’s non-employment life—her dog, her kitchen, reaching for her coffee cup—caused the accident, not her employment. The court, however, said their decision would not “immunize” employers from workers’ compensation claims in work-at-home arrangements. Two judges issued dissenting opinions. One dissenter said it was “expected that employees who work from home will take periodic breaks and may suffer compensable injuries from falls from a variety of causes”. The second dissenter argued that workplace injury from a neutral risk has been “undoubtedly compensable” and that the majority erred in their decision. The judge found that tripping over the dog was “no different than if the claimant had slipped on a liquid substance on the floor” and was consistent with a decade of case law holding that a trip and fall in the workplace is compensable.
The trend to allow employees to work from home raises many wrinkles in the event of injury, including applicability of the “dual purpose doctrine”, travel status, and obvious problems with proof. In certain factual situations, the dual purpose doctrine has been applied to cover injuries sustained while the claimant is traveling between home and the job site. One such instance exists when the nature of the claimant’s employment is such that “it can genuinely and not fictitiously be said that the home has become part of the employment premises.” In those circumstances “travel between two parts of the employer’s premises is in the course of employment.” 1 Larson’s Workers’ Compensation Law, § 16.10. Larson adds the following at § 16.10: When reliance is placed upon the status of the home as a place of employment generally, instead of or in addition to the existence of a specific work assignment at the end of the particular homeward trip, three principal indicia may be looked for: the quantity and regularity of work performed at home; the continuing presence of work equipment at home; and special circumstances of the particular employment that make it necessary, and not merely personally convenient, to work at home.
The reported cases suggest compensability of injuries suffered by an employee permitted to work from home are highly fact specific. If you have questions about the compensability of such an injury, or any injury, contact us.
Having litigated several “assault” cases, nothing ceases to amaze this author more than the vast number of unfortunate ways people find themselves in the most bizarre and unforeseeable situations. Courts across the United States adjudicating assault-based cases in the workers’ compensation context are faced with determining whether the events leading to the assault arose out of an injured workers’ employment or whether the event was purely personal in nature. Here are some of the more inexplicable events that could give rise to a claim — you decide whether these claims would be compensable.
In 2007, an individual was feeding a bear at the Great Bear Adventure in northern Montana. It was undisputed that the individual had smoked pot prior to entering the bear cage with food. The manager of the park had told the individual not to feed the bear as the food was being tapered due to hibernation. When the individual entered the enclosure, he was mauled by the bear. Although the employer argued that the individual was outside the scope of the employment, the Montana appellate court found that the bear was “an equal opportunity mauler” who attacked regardless of the marijuana use. As noted by the decision, the use of drugs (which the court admonished at best) had no bearing on the actual animal attack.
More traumatically, in August 2018, police were called to a construction scene in Wisconsin. The police discovered that a co-worker allegedly attacked and killed another co-worker with a circular saw. The co-worker was arrested at the scene. A subsequent investigation documented that the co-worker assailant had told other crew members during the day of the attack that other crew members were teasing him about a one-night stand he had had the evening before. The legal question, other than the criminal liability of the assailant, is whether the decedent’s estate/dependents would be entitled to workers’ compensation death benefits? Was the attack work related, or did it arise out of a direct personal dispute between the assailant and decedent? Based upon the facts of this case, you be the judge.
Although the case above could be on the border of compensability depending on the facts, a more clear-cut assault occurred in January 2018 in South Carolina. During that event, the manager of a fast food restaurant got into a heated verbal altercation with an employee over shift scheduling. When the manager told the employee to “stop being a crybaby,” the employee wrapped up the argument by throwing a hot, “loaded burrito” at the manager. According to the manager, melted cheese stuck onto the manager’s left side and leg. Apparently, the manager recovered from the hot cheese injuries, but could a mental impairment injury also be included in this type of event?
Finally, imagine yourself working as a fast food drive through employee. It’s a typical day of serving food and drinks, handing the items to customers through an open window. Now imagine serving a soft-drink, and, while the window is open, the customer throws a three-and-a-half-foot alligator through the window at you. In 2016, that is exactly what happened to a fast food employee in Florida. The customer was later apprehended and claimed that he threw the alligator into the restaurant as a funny prank. While it is unclear whether the employee sustained any physical injuries, the assault by semi-aquatic reptile exemplifies what a neutral force assault is in terms of workers’ compensation liability for injuries arising out of employment.
The above cases raise unique issues concerning assaults, whether by an animal, a co-employee, or a random person who just happened to pick up an alligator from the side of the road prior to getting lunch, that can be tricky and fact dependent. When you need help untangling the facts and details surrounding a claim, please contact us.
As we recently celebrated the 4th of July with family and friends, we must not lose sight of the Founding Fathers and formation of the Constitution. Interestingly, John Hancock was the only one to sign on July 4, 1776, while the others signed at a later date. We are fortunate that the Founding Fathers drafted the Constitution to incorporate a judicial system that allows people the opportunity to be heard as that luxury does not exist in many other places in the world. Often, the higher courts will have to decide issues from the lower courts to interpret a statute, applicability of the law, admissibility of evidence, etc. The workers’ compensation laws are subject to the same scrutiny as any other law or statute.
The Workers’ Compensation Act and system was created to provide a quick and efficient resolution to injured workers and the ability through the administrative courts to avoid the long delays that could ensue in the trial courts. Ironically, workers’ compensation claims can be tied up in litigation much longer than the trial courts which was not the intent of the legislature. While the hope and intent are clear, due to the many nuances and different interpretation of the workers’ compensation laws, there will continue to be disputes that arise.
While different in each state, workers’ compensation medical benefits are subject to a fee schedule set by the legislature. By statute, a medical provider could not collect payment for medical expenses beyond those paid by the plaintiff’s workers’ compensation insurer. The intent (hopefully) is to have a level playing field and no disputes over what fee is to be charged to avoid any delay to the injured worker for medical care.
Plain and simple, the cost for a medical benefit under a workers’ compensation claim is subject to a set fee by the legislature regardless of what the provider may charge outside of the system for the same service. This also, for policy reasons, provides some relief to the carriers given the volume of workers’ compensation claims. They will not be burdened with extreme medical costs providing medical benefits to claimants as medical providers are limited to the amounts under the fee schedule.
With that said, in May of this year the Colorado Court of Appeals rendered an opinion that focused on the admissibility of past medical expenses when the claimant/plaintiff is injured on the job and sues the third-party tortfeasor. The Court considered whether “billed” medical expenses versus what was actually “paid” were to be considered by the court and jury in awarding damages to a claimant/plaintiff. Before trial, the defendant had extinguished the insurer’s subrogation interest in the amounts paid by paying off the insurer’s claim for those damages.
The case was brought before the Court based on claimant/plaintiff’s appeal that the trial court erred in excluding evidence of the amounts “billed” by his medical providers and only admitted the amounts “paid” by the carrier for his medical care and treatment. The Court was to determine whether billed versus paid medical benefits were permitted in a third-party lawsuit.
The Court held:
- The collateral source rule barred admissibility of the medical expenses paid by the workers’ compensation carrier.
- The plaintiff could present evidence at trial of the higher i.e. “billed” medical expenses by the providers.
Briefly, claimant worked for United Airlines (“United”) and was struck by an employee of Delta Airlines (“Delta”) at Denver International Airport – both were driving similar luggage tug vehicles. Claimant’s injuries were in the course and scope of employment, therefore, admitted and his indemnity and medical benefits were paid by his employer pursuant to statute.
Claimant’s employer sought reimbursement and sued Delta and its at-fault driver. Claimant sued the same defendants to recover for his personal injuries related to his work injury. United’s claim against Delta was settled for $328,799.16 and the case was dismissed with prejudice leaving only claimant and Delta as parties. Delta admitted liability but disputed claimant’s claimed damages so the case went to trial. At the first trial, claimant was awarded $1.5 million but a new trial was granted due to misconduct by claimant’s attorney.
At the second trial (which interestingly was a bench trial), plaintiff was not allowed to provide evidence of the higher “billed” amounts from the providers for medical expenses but only the amounts actually “paid” by the employer. The plaintiff was awarded $259,176 in damages of which $194,426 was for economic damages. The court subsequently entered an order to set-off claimant’s economic damages by the amount defendant had paid to settle the workers’ compensation claim. Plaintiff argued this was not fair since his award for economic damages was reduced to zero.
The injured worker appealed. In its decision, the Court ruled that the collateral source rule applied to workers’ compensation benefits. The collateral source rule, or collateral source doctrine, is an American case law evidentiary rule that prohibits the admission of evidence that the plaintiff or victim has received compensation from some source other than the damages sought against the defendant. In Colorado, the first component requires a trial court to set off tort verdicts by the amount of certain collateral source payments received by the plaintiff unless the payments were made because of a contract entered into and paid for on the plaintiff’s behalf. § 13-21-111.6, C.R.S. 2018. The second component bars evidence of a plaintiff’s receipt or entitlement to benefits received from a collateral source, most often an insurance company, “because such evidence could lead the fact-finder to improperly reduce the plaintiff’s damages award on the grounds that the plaintiff already recovered his loss from the collateral source. Wal-Mart Stores, Inc. v. Crossgrove, 276 P.3d 562 (Colo. 2012).
The Court noted that “even though claimant did not personally pay premiums toward his workers’ compensation insurance, he gave consideration for the same in the form of his employment services.” Van Waters & Rogers, Inc. v. Keelan, 840 P.2d 1070, 1074 (Colo. 1992). The same holds true to the defendant, who did not contribute in any way to the premiums paid to him and, therefore, the benefits paid were wholly collateral to the defendant. Therefore, the collateral source rule applies, and the defendant may be responsible for plaintiff’s damages regardless of what was paid by the workers’ compensation carrier. “The Court rationalized this will prevent a wrongdoer from reaping the benefits of a contract to which he is not a party.” The National Law Review, Colorado Court of Appeals Permits Evidence of Billed Workers’ Compensation Benefits at Trial.
In further reasoning of its decision, the Court acknowledged the workers’ compensation statute provides that amounts billed in excess of the statutory fee schedule are “unlawful, void, and unforceable.” This statutory language effectively prevents the plaintiff, as a matter of law, from having any legal obligation to pay such billed amounts. The Court cited a decision from the Colorado Supreme Court that stated, “the fact a bill is uncollectable does not render it entirely irrelevant to the reasonable value of the medical services provided.” Volunteers of America v. Gardenswartz, 242 P.3d 1080 (Colo. 2010).
There was a dissenting opinion issued by the Court which identifies the effect this ruling will have for claims in the future. “To allow injured workers to pursue expenses against the defendant in excess of what workers’ compensation already paid for his/her injuries contravenes the intent and purpose of the Workers’ Compensation Act. In part, this now affords the injured worker a windfall which the Act was not designed to do.” The dissenting opinion also makes note that the court is in the position of enforcing unenforceable contracts since the billed amounts are void and unenforceable based on the fee schedule specific to workers’ compensation claims.
The opinion of the Court has certainly created a stir as it now essentially creates a windfall in favor of the injured worker and settlement with workers’ compensation carriers before trial essentially meaningless.
We will wait to see if the Court’s decision is brought before the Colorado Supreme Court for further review and determination of this now complicated, and to be highly debated, topic.
Colorado is addressing the ongoing opioid epidemic with an array of public and private initiatives. Per the American Medical Association, the state Medicaid agency (the Colorado Department of Health Care Policy and Financing [HCPF]) and the Division of Insurance (DOI) are spearheading the initiatives. On March 16, 2018, the revised Guidelines for Prescribing and Dispensing Opioids were adopted by all six of Colorado’s prescribing and dispensing Boards: the Colorado Dental Board, the Colorado Medical Board, the State Board of Nursing, the State Board of Optometry, the Colorado Podiatry Board and the State Board of Pharmacy. On May 21, 2018, then Governor, John Hickenlooper, signed Senate Bill 18-22, Clinical Practice for Opioid Prescribing. The bill, which limits the number of opioid pills a healthcare provider can prescribe, went into effect immediately upon the Governor’s signature. Under the new law, a prescriber must limit a patient’s initial prescription of an opioid to a seven-day supply, if the prescriber has not written an opioid prescription for the patient in the preceding twelve months. All six dispensing Boards recommend a prescription of less than 50 MME per day and utilization of long-acting or extended relief formulations. These limits do not apply in certain discrete situations, including, if, in the judgment of the prescriber, the patient:
- Has chronic pain that typically lasts longer than 90 days past the point of healing, as determined by the prescriber;
- Has been diagnosed with cancer and is experiencing cancer-related pain;
- Is experiencing post-surgical pain, expected to last longer than fourteen days due to the nature of the procedure; or
- Is undergoing palliative care or hospice care designed to improve quality of life.
After the first prescription, the prescriber may exercise discretion in issuing a second-fill for a seven-day supply. In cases of a second-fill, the prescriber is required to check the Prescription Drug Monitoring Program (PDMP) database before prescribing additional opioids for the same patient. Failure to check the PDMP constitutes unprofessional conduct if the prescriber repeatedly fails to comply with this PDMP requirement. The requirement to check the PDMP on a second-fill does not apply in situations exempting compliance with the seven-day first-fill, with two additional exemptions:
- The patient is receiving the opioid in a hospital, skilled nursing, residential, or correctional facility; or
- Is receiving treatment during a natural disaster or where mass casualties have taken place.
After the second opioid prescription, the law has no additional restrictions on the healthcare provider’s prescribing practices.
In keeping with SB 18-22, the Colorado Division of Workers’ Compensation recently released its amendments to Rule 18, W.C.R.P., the Medical Fee Schedule. The updated fee schedule took effect January 1, 2019. While several important changes were made in the amended fee schedule rule for 2019, including inclusion of the most current CPT code terminology, HCPCS codes, Colorado Z-codes (state-specific billing codes) and Medicare’s most current National Physician Fee Schedule Relative Value file, with updated conversion factors, the amended rule also incorporates the revised physician prescription/dispensing restrictions on opioids. The amended rule language provides:
Opioids classified as Schedule II or Schedule III controlled substances that are prescribed for treatment lasting longer than seven days shall be provided by a pharmacy.
The changes to Rule 18, W.C.R.P. suggest the Division of Workers’ Compensation intends to move forward and integrate any necessary modifications to drive full compliance with the new restrictions on physician dispensing of Schedule II and III opioids. Physicians prescribing chronic opioids through the Workers’ Compensation system are also expected to comply with Colorado’s Medical Treatment Guidelines, Rule 17, Exhibit 9, addressing chronic pain disorder. While the Guidelines do not have the force of law, they are intended to assist practitioners in the safe prescribing and dispensing of opioids.
If you have any questions about the Medical Treatment Guidelines, changes to the Medical Fee Schedule, or any other topics, please contact us.