Employer's Key Steps in Workers' Compensation
The Office of Workers' Compensation Administration (OWCA) was created in 1983 within the Louisiana Department of Labor to administer the provisions of the Workers' Compensation Act. The OWCA investigates allegations of fraud; monitors compliance with the requirement that employers insure their workers' compensation obligation; compiles information regarding workers' compensation claims; resolves disputes over the necessity, advisability, and cost of hospital care or services, as well as conflicts concerning medical, surgical and non-medical treatment; provides Occupational Safety & Health Administration (OSHA) consultation services; and assists Louisiana employers in the development and implementation of a safety management plan in their workplace.
The OWCA has exclusive jurisdiction to resolve disputes in workers’ compensation matters. There are ten disputed claims offices located throughout the state (see attached list) which provide the framework for the resolution of disputes regarding a claim for benefits, the entitlement to benefits, or other relief under the Workers’ Compensation Act.
Workers' compensation is a legal remedy whereby an employee who is injured on the job is automatically entitled to certain benefits. The benefits can include medical care for the injury, disability compensation, vocational rehabilitation services and death benefits. The benefits are the obligation of the employer to the employee.
Most employees in Louisiana are covered from the day they start employment. Employees may be full-time or part-time, seasonal or minors. Subcontractors and certain independent contractors may be considered employees if they are involved in the pursuit of the employer's trade, business or occupation or if they are performing substantial manual labor.
The law does contain some limited exemptions. Domestic employees, most real estate salespersons, uncompensated officers and directors of certain non-profit organizations, and public officials are specifically exempted. Most volunteer workers would not be entitled to benefits.
Employers are required to insure their workers' compensation obligation or to be approved to self-insure. If you have reason to believe your employer is not covered or if your employer requires you to pay for or purchase your own workers' compensation insurance policy, please contact the Fraud & Compliance section of the OWCA at toll free 1-800-201-3362.
The law covers both mental and physical harm from either accidents or occupational diseases; however, mental injury must be the result of a physical injury or of a sudden, unexpected and extraordinary stress related to the employment and in either case must be proved by clear and convincing evidence.
The event causing the injury must arise out of and be within the course of your employment. Generally, the fault of the employer or employee does not affect the compensability of an injury. However, no compensation may be allowed if the injury was caused by the employee's willful intention to injure himself or other; or by the injured employee's intoxication at the time of the injury, unless resulting from activities in pursuit of the employer's interests, or from activities in which the employer procured and encouraged the use of the beverage or substance. An employee may not be entitled to benefits if he is the aggressor in an unprovoked physical altercation. The employee may not be entitled to benefits if it is determined that he was a participant in "horseplay" at the time that the injury occurred.
You may select one doctor of your choice in each specialty field in which you seek treatment; however, you must receive prior approval from your employer or their insurance carrier for any medical cost above a total of $750 per provider. This limitation applies to doctors, hospital services, prescriptions, physical therapy, laboratory tests etc.
Your employer or their carrier may require you to submit to an examination by a physician of their choice. Failure to submit to any reasonable examination may cause your compensation payments to be suspended until the examination takes place.
Whenever you submit to any type of medical examination at the request of your employer, and a medical report is received by the employer, you are entitled to a copy of the written report within thirty days from the date of your written demand upon the employer, at no cost to you. Additionally, you are entitled to receive any medical information released to your employer by a health care provider.
Your employer or their insurance company are required to pay all approved necessary expenses for medical treatment and all reasonably and necessarily incurred travel to obtain treatment. Any non-emergency medical services over $750 and any non-emergency hospitalization must be pre-approved by your employer’s workers’ compensation carrier/self-insured employer. Your health care provider must submit a request for such authorization to the carrier/self-insured employer on a Request of Authorization/Carrier or Self Insured Employer Response (LWC-WC-1010) form. Within five (5) days of receipt of the LWC-WC-1010 along with certain minimum information from your health care provider, the carrier/self-insured employer will issue an approval, denial or approval with modification. The carrier/self-insured employer’s failure to act within five (5) days of receipt of the LWC-WC-1010 and certain minimum information is deemed to have denied the request, and may then be appealed to the OWCA Medical Director.
If you have paid any of your medical expenses, you should send itemized receipts to your employer or their insurer for reimbursement.
WHAT IF THE CARRIER/SELF-INSURED EMPLOYER FAILED TO RESPOND OR DENIED OR MODIFIED THE TREATMENT REQUESTED BY MY HEALTH CARE PROVIDER?
If the carrier/self-insured employer has failed to timely act on a properly submitted request by your health care provider, or the carrier/self-insured employer had denied or modified the requested treatment, your doctor, yourself or your attorney, may file a request for review of the medical necessity of the treatment with the Medical Director of the Office of Workers’ Compensation. This request is made on a Disputed Claim for Medical Treatment (LWC-WC-1009) form, and must be accompanied by supporting medical records, tests, etc. The 1009 and supporting documents must be presented to the Medical Services Section of the Office of Workers Compensation within fifteen (15) days of receipt of the denial or modification of treatment by the carrier/self-insured employer or within fifteen (15) days after the expiration of the fifth (5) business day with no response from the carrier/self-insured employer. Within thirty (30) days after receipt of the 1009, the Medical Director will determine whether the treatment your health care provider has prescribed is in accordance with the Medical Guidelines found at LA-R.S. 23:1201.1. Either side may appeal the decision of the Medical Director within fifteen (15) days to the local Workers’ Compensation Judge.
Independent Medical Examinations are still available when there are disputes over medical condition and on issues of whether or not you are able to return to work. If there is a disagreement on these issues, you may make such a request for an independent medical examination by filling out a Request for Independent Medical Examination (LWC-WC-1015) form or by contacting the Medical Services Section of the OWCA.
Requests for authorizations for treatment or Independent medical examinations may be made to the Medical Services Section of the OWCA at 1-800-201-2494 or 225-342-7559 or write: Office of Workers’ Compensation Administration, Medical Services Section, P.O. Box 94040, Baton Rouge, Louisiana 70804-9040.
You may be entitled to weekly compensation benefits if your injury prevents you from returning to work for more than seven calendar days. Benefits are payable beginning on the eighth day and you should receive your first benefit check within 14 days after you notified the employer of the injury. You will be paid for the first 7 days only if you are off work over 14 calendar days.
During the period of temporary disability, you are entitled to receive 2/3 of your average weekly wage at the time of the injury. The maximum benefit is 75% and the minimum benefit is 20% of the statewide average weekly wage. Maximum and minimum benefits are determined annually and apply to all claims occurring between September 1 and August 31 of the following year. The compensation benefit received and the maximum or minimum benefit that applies to that claim are determined according to the date of the accident causing the injury and are not adjusted annually for increases or decreases in the maximum or minimum benefit allowed. You may obtain the maximum and minimum rates at http://www.laworks.net/Downloads/OWC/AvgWage_MinMaxRates.pdf or by calling the OWCA. (See attached list).
An injured employee may be entitled to supplemental earnings benefits if that employee is able to return to work but is unable to earn at least 90% of the pre-injury wage. The supplement is calculated as 2/3 of the difference between the pre-injury monthly wage and the amount of the monthly wage that the employee is capable of earning. The supplement is subject to the same maximum and minimum benefits discussed above and is payable for a maximum of 520 weeks (including the time for which other workers’ compensation disability benefits were paid).
If you die within 2 years of the last treatment as the result of a job related accident, your surviving spouse and/or dependent children (or other dependents) would receive weekly benefits according to the schedule listed in the Act. If there are no dependents, surviving parents are entitled to a one-time benefit of $20,000 each.
If you apply for and receive Social Security Disability, benefits from an employer-provided disability plan, or Social Security Old Age Retirement, your workers’ compensation benefits may be reduced in accordance with the Act. This is not a simple dollar for dollar reduction and must be calculated individually according to the claimants’ circumstances. You cannot receive workers’ compensation disability benefits and unemployment benefits at the same time.
If you have a problem with your claim, you should first contact your employer or insurance carrier. If you cannot resolve the problem, you should contact the OWCA at the disputed claims office nearest you. (see attached list). You will be provided a Disputed Claim for Compensation (LWC-WC-1008) form available at http://www.laworks.net/downloads/owc/1008form.pdf, to complete and return to the appropriate office. A filing fee of $30 will be collected, but is not required at the time of filing. You may, however, be required to pay a $25 fee at the time of filing to cover the costs of service by the Secretary of State
You may consult an attorney if you wish, but it is not required. If you hire an attorney, you can be charged up to 20% of the amount recovered plus you will have to pay the attorney’s expenses. The fees and expenses may be deducted from your payments. Your local bar association may be able to recommend an attorney who is experienced in workers’ compensation.
You may enter into a lump sum or compromise settlement upon agreement of all of the parties and with the approval of the Workers’ Compensation Judge, provided that, (a) the settlement is clearly in the best interest of all of the parties, and (b) 6 months have passed since the end of Total Temporary Disability (TTD). However, the six months waiting period may be waived by consent of the parties.
Your employer may not be required to hold a job open for you when you are unable to perform the duties of your job or to create a new job for you when you are able to return to work. However, your employer cannot discharge you solely because you filed a workers’ compensation claim.
Under certain circumstances, you may qualify for vocational rehabilitation. Rehabilitation services are intended to return a disabled worker to work, with a minimum of retraining, as soon as possible after an injury occurs.
There are separate time limits for filing claims for medical and disability benefits. Filing a claim for one type of benefit usually does not stop the clock from running on any other type of benefit.
Claims for medical benefits generally must be filed within one year of the date of the accident causing the injury. If your employer or their insurance company has paid medical expenses, the period for asserting a claim is extended for 3 years from the last payment of a medical benefit.
Claims for disability benefits, often called weekly benefits, generally must be filed within one year of the date of the accident causing the injury. If your employer or their insurer has paid disability benefits, you may still assert a claim for temporary total, permanent total, or permanent partial disability if you do so within one year after the last payment of disability. Claims for supplemental earnings benefits may be made for up to 3 years after the last payment of any class of disability.
Claims for occupational diseases, including carpal tunnel, may be filed up to one (1) year from the date of knowledge of your disease, related disability, or your reasonable belief the disease is work related; whichever occurs last.