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The Workers' Compensation Act is a compromise between labor and management resulting in an employer giving up most of its defenses in personal injury actions that arise out of the employment relationship. Employees give up large potential damage awards in exchange for temporary total disability benefits, reasonable and necessary medical expenses and permanent partial disability benefits. The original intent was to limit the cost to employers for work related injuries. But over time workers' compensation has become a major cost of doing business. Last year workers' compensation cost employers $70 billion dollars. Sixty percent of that cost or $42 billion was related to indemnity payments which includes wage replacement, vocational rehabilitation, loss of productivity and final disability impairment. The other 40% or $28 billion was related to medical care.
There are eight basic issues presented in each Workers' Compensation case. They are:
| 1) | Employer/Employee relationship; | ||||
| 2) | Accident; | ||||
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| 3) | The Statute of Limitations and Notice Requirements; | ||||
| 4) | Causal Connection; | ||||
| 5) | Average weekly wage; | ||||
| 6) | Temporary total disability benefits; | ||||
| 7) | Medical expenses; | ||||
| 8) | Permanent partial disability benefits. |
In order for an injured or disabled worker to obtain the full compliment of workers' compensation benefits, that worker must prove each of the foregoing eight elements.
The Americans With Disabilities Act of 1990 (hereinafter ADA) requires employers to make reasonable accommodations for the known, physical or mental limitations of otherwise qualified applicants or employees with disabilities. Thus, the ADA requires more than treating disabled individuals equally. The Act compels employers to spend money, alter personnel and work practices and take other steps to affirmatively accommodate the needs of disabled employees and applicants unless to do so would cause the employer undue hardship.
Congress' mandate under the ADA initially applied to all private employers with 25 or more employees effective July 26, 1992. On July 26, 1994, the ADA reached its ultimate effect and now applies to all private employers with 15 or more employees.
The ADA protects all qualified individuals with a disability. That means individuals with;
| 1) | A physical or mental impairment that substantially limits one or more major life activities; |
| 2) | A record of such impairment; |
| 3) | Is regarded as having such impairment. |
Major Life Activities are activities such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.
Substantially Limited is an inability to perform a major life activity like an average person in the general public. The performance of a major life activity is restricted as to the condition, manner or duration under which that individual can perform said activity.
The ADA does not apply to temporary disabilities. Broken limbs, sprained joints and temporary illnesses are not usually considered disabilities under the ADA.
A Record of Impairment relates to those individuals with a history of a disability such as a history of back injuries or cancer in remission. "Regarded as impaired" relates to those who have no impairment but are regarded as such, for example, disfigurement.
The ADA prohibits employers from discriminating against a qualified individual with a disability. A qualified individual with a disability is any person who with or without reasonable accommodation can perform the essential functions of the employment position that such individual holds or desires to hold.
A qualified individual is one who has all the requisite training, experience and aptitude necessary to perform the job. The ADA requires reasonable accommodation for such qualified individuals with a known disability.
Reasonable accommodation can include one of the following categories.
| 1) | An accommodation to insure equal opportunity in the application process; |
| 2) | An accommodation that enables an employee with a disability to perform the essential functions of the position held or desired; |
| 3) | An accommodation that enables employees with disabilities to enjoy equal benefits and privileges of employment as they are enjoyed by employees without disabilities. |
The Family and Medical Leave Act (FMLA) was the first major piece of legislation signed by President Clinton. It requires all public and private employers with 50 or more employees at a single work site to grant up to 12 weeks of leave for a 12 month period for:
| 1. | The birth of a child and in order to care for such child; |
| 2. | The placement of a child with the employee for adoption or foster care; |
| 3. | To care for an immediate family medical member of the employee with a serious health condition; and |
| 4. | The serious health condition of the employee that makes the employee unable to perform the functions of the employee's position. |
A spouse does not include unmarried domestic partners. If both spouses are working for the same employer their total leave in any 12 month period may be limited to an aggregate of 12 weeks if the leave is taken for either a birth or adoption of a child or to care for a sick parent.
A Serious Health Condition means an illness, injury, impairment or a physical or mental condition that involves;
| 1) | Inpatient care; |
| 2) | Any period of incapacity requiring an absence from work, school or other regular daily activity of more than three calendar days and that involves continuing treatment by a health care provider; |
| 3) | Continuing treatment by a health care provider for a chronic or long term health condition that is incurable or which, if left untreated, would likely result in a period of incapacity of more than three days or for prenatal care by a health care provider. |
Continuing Treatment is broadly defined and includes;
| 1) | Two or more visits to a health care provider; |
| 2) | Two or more treatments by a health care practitioner on referral from or under the direction of a health care provider; |
| 3) | A single visit to a health care provider that results in a regimen of continuing treatment or; |
| 4) | In the case of a serious, long-term or chronic condition or disability that cannot be cured being under the continuing supervision of, but not necessarily being actively treated by a health care provider. |
The FMLA also provides for intermittent or reduced leaves of absences. An employee may take leave intermittently (for a few days or even a few hours) or on a reduced leave schedule to care for an immediate family member with a serious health condition or because of a serious health condition of the employee when medically necessary.
Medically necessary means there must be a medical need for the leave and that the leave can best be accomplished through an intermittent or reduced leave schedule. The employee may be required to transfer temporarily to a position with equivalent pay and benefits that better accommodates her leave when the need for the leave is foreseeable based upon some planned medical treatment.
The employer must continue to provide group insurance coverage under its group health plan during the leave under the same terms offered to employees not on leave.
Where a leave of absence is foreseeable an employee must give notice to her employer at least 30 days before the start of the leave. Where a leave of absence is unforeseeable notice should be given as soon as practical.
Where the leave of absence is for a serious health condition the employee must provide a medical certification stating the date the condition began, its probable duration, diagnosis, a brief statement of the regimen of treatment, whether inpatient hospitalization is required, and the employee's inability to perform his or her essential job functions or work of any kind. Where the leave of absence is for the employee to take care of a family member the certification must also include a statement as to why the employee's presence would be beneficial to the patient.
In certain situations, a dispute may arise as to whether or not the employee has a serious health condition. The FMLA prohibits the employer from contacting or seeking additional information from the health care provider selected by the employee. The employer's only option is to obtain a second opinion at its own expense. The second opinion obtained by the employer cannot by a physician who the employer regularly uses. If the employee's and employer's designated health care providers have different opinions, the employer may require the employee to obtain certification from a third health care provider is final and binding.
The ADA and the Workers' Compensation Act relate to injured or disabled employees. The FMLA relates to employees with a serious health condition or a family member with a serious health condition.
The Workers' Compensation Act focuses on compensating the injured employee. The ADA focuses on accommodating the disabled individual.
| A. | Exclusivity | ||||||
| The Workers' Compensation Act has always been the
exclusive remedy of an injured employee against the
employer. The injured employee's remedy was limited by
scheduled benefits provided by the Workers' Compensation
Act. Medical expenses, temporary total disability
benefits, permanent partial disability benefits were all
fairly predictable within certain known ranges That exclusivity protection has now been seriously eroded by the FMLA and the ADA. Now an employee has a direct action against his or her employer. Unlike the remedies available under the Workers' Compensation Act, the ADA remedies are unscheduled and unpredictable. |
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| B. | Employer-Employee Relationship | ||||||
| The pre-ADA workers' compensation advice was to do
thorough and complete pre- employment physical
examinations. The conventional thinking was that a
pre-employment physical examination would allow an
employer to avoid hiring those individuals with pre-
existing conditions that could be aggravated or
accelerated by the day-to-day activities in the work
place. Since pre-employment physical examinations are now illegal under the ADA, employers are no longer able to take a pro-active approach in avoiding potential workers' compensation cases. In most cases, an employer will not know until it is too late that it has hired an individual with a pre-existing condition. In some cases, an employer may hire an individual who will need an occasional leave of absence because of the pre-existing condition and that fact will not become known until after the employee is hired. For example, an individual suffering from depression or occasional bouts of depression may need to take time off usually with very little notice. Since a pre-employment physical examination has been outlawed under the ADA, an employer may end up hiring someone who will need fairly regular leave of absences. The effect of this is most clearly seen with pre-existing back problems. Before the ADA and FMLA an employer could legally choose not to hire an individual with a pre- existing back condition. Under the ADA, an employer will not know about that pre-existing condition until it is too late and under the FMLA the employer may be required to give an occasional leave of absence because of that pre-existing back condition. |
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| C. | Accident | ||||||
Workers' compensation contains a technical definition
of accident. An employee must show that the
"accident"
Since it is a technical term an employee need not show that an accident occurred as a result of an unsafe activity or as a traumatic accident but only that the nature of the work caused a final breakdown of a body part. Before the ADA, an employer's obligation to an employee for a work place injury was defined by the Workers' Compensation Act. If an employee ended up with a permanent physical restriction an employer could have legally terminated that employee if he was unable to perform the work. If the injury resulted in a long-term absence, an employer could have legitimately terminated that employee for excessive absenteeism even if those absences arose out of a work place injury. Prior to the enactment of the ADA, if an employer successfully defended the workers' compensation case using an accident defense it's liability to that disabled employee would end. For example, if an employee claimed to have injured his or her back at work resulting in a 50 pound lifting restriction and the employer successfully proved that the employee had injured his or her back at home, it had no legal obligation to that injured worker. Thus, no liability In the post-ADA era, if that same employer wins the workers' compensation case it may still face continuing liability under the ADA. Since the ADA is not concerned with the cause of the disability only its existence, the employer will still have an obligation to that injured worker to provide reasonable accommodation. |
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| D. | Causal Connection | ||||||
| Most Workers' Compensation statutes hold employers
responsible for an aggravation or acceleration of an
employee's pre-existing condition. Thus, in the prior
example if an employer successfully showed that an
employee's back injury was unrelated to the employment,
the employer may have an obligation under the ADA to
return that employee to work through reasonable
accommodation. After that return, if he or she aggravates
or accelerates that prior pre-existing condition, then
the entire workers' compensation process starts over. The
employer may ultimately be responsible for compensating
that employee through workers' compensation because of
the aggravation of his or her pre-existing condition. In
other words, an employer may have to compensate that
employee for the condition that was previously found
non-compensable. Since the ADA requires an employer to make an effort to offer reasonable accommodation to an injured or disabled employee, he imposes an additional obligation on the employer to return that employee to work. Thus, before the ADA if an employee ended up with a permanent 50 pound lifting restriction as a result of a workers' compensation case the employer could have legitimately terminated that employee if they were unable to do the job. After the ADA the employer may have to offer that employee reasonable accommodations and retain that individual as an employee. As that employee continues to work, however, the company faces a continuing obligation/exposure if that employee should sustain another work place injury aggravating or accelerating that pre-existing condition. |
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| E. | Medical Evidence | ||||||
| Under most, if not all, Workers' Compensation
statutes an employer has the absolute right to have the
Petitioner undergo an evaluative examination for use at
arbitration. An employee seeking disability payments is
required, if requested by the employer, to submit
himself, at the expense of the employer, for an
examination to a duly qualified medical practitioner or
surgeon selected by the employer at any time or place
reasonably convenient for the employee either within or
without the state. In addition, most, if not all, Workers' Compensation statute's give the employer the right to obtain the Petitioner's treating records. The FMLA imposes restrictions on the employer's ability to contact the employee's treating physician. When an employee applies for a leave of absence under the FMLA he can be required to provide a medical certificate stating the date the condition began, its probable duration, diagnosis and a brief statement of the regimen of treatment and the employee's inability to perform his or her essential job functions or work of any kind. The FMLA prohibits the employer from contacting that medical provider directly and obtaining any additional information or questioning the basis for the medical certification. The only remedy the employer has in determining whether or not a leave of absence is warranted is by having the employee examined by an independent medical practitioner. The FMLA specifically prohibits the employer from having the employee examined by a doctor that the employer regularly uses or has a relationship with. In other words the FMLA requires that the physician chosen by the employer be a true "independent" physician. There is no such requirement that the employee obtain an "independent" medical opinion, in fact, the employee is free to be examined by his family physician who he may have had a relationship with for years. This is an open and obvious conflict between Workers' Compensation and the FMLA. Under the Workers' Compensation Act, the employer can have the employee examined by a physician that the employer knows and, in fact, has a relationship with and feels comfortable with. Under the FMLA, the employer has to choose an "independent" physician. In addition, under the Workers' Compensation Act the employer can usually correspond with the treating physician. Under the FMLA they cannot. Where the independent physician chosen by the employer under the FMLA disagrees with the employee's physician the parties can then choose an independent third physician for an exam. |
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| F. | Temporary Total Disability Benefits | ||||||
| The FMLA has altered an employee's rights to return
to work on a restricted basis following a work-related
injury. Since the FMLA provides for an intermittent leave
of absence, an employee who is able to return to work for
only six hours a day as opposed to eight hours a day
would be able to treat the remaining two hours as a leave
of absence. Thus an employee would be able to work an
entire year at only six hours a day and take the rest of
the time against his elected medical leave of absence
under the FMLA. Since the FMLA prohibits the employer from taking any adverse action against an employee for exercising their rights under the FMLA, the employer would not be able to take into account the employee's restricted work schedule in evaluating that employee at the end of the year. If the employer refuses to accommodate that restricted work level, it may face liability both under the FMLA and under the ADA for failure to provide reasonable accommodation to the disabled individual. |
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Last updated on Monday Nov 01, 1999 at 10:55 PM ![]()