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Temporary Total and Temporary Partial Incapacity Benefits - The Basics

Compensation for Incapacity. Temporary Total and Temporary Partial Incapacity Benefits - The Basics. Payment with Prejudice. Order or award of compensation. OR Employer/Insurer accepts the claim. MOP Box 20(A) Creates a compensation payment scheme.

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Temporary Total and Temporary Partial Incapacity Benefits - The Basics

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  1. Compensation for Incapacity Temporary Total and Temporary Partial Incapacity Benefits - The Basics

  2. Payment with Prejudice • Order or award of compensation. OR • Employer/Insurer accepts the claim. • MOP Box 20(A) • Creates a compensation payment scheme.

  3. Section 204: Waiting period; when compensation payable Compensation for incapacity to work is not payable for the first 7 days Exception – firefighters not subject to waiting period In a broken period of incapacity, the waiting period may be determined by wages lost, or by benefits lost.

  4. Waiting period; when compensation payable Forms and Petitions Manual Appendix D • AWW Method • Employee loses wages because of the injury which cumulatively equal or exceed the employee’s pre-injury AWW. • Ordinarily expedites the obligation to pay. • Comp Rate Method • Employee loses wages because of the injury that would otherwise require the insurer to pay one week of benefits (equal to or greater than the employee’s WCR). • Used by the Board’s Audit Division. • Other methods may be acceptable

  5. Waiting period; when compensation payable • Example 1: A broken period of incapacity (Temporary Total Disability) • Injured 1/29/13, paid ½ day • OOW 1/29/13 – 1/31/13 • RTW 2/1/13 • Back out of work 2/15/13 – ongoing When is the 7 day waiting period met?

  6. Waiting period; when compensation payable • Example 1 Calculations • 1/29/13: When an employee is paid 1/2 day or more wages on the date of injury, the date of injury will not be considered a day of incapacity (Section 212 and Rule 8.3). • 1/30/13 – 1/31/13: 2 calendar days • 2/15/13 – ongoing: 5 calendar days = 2/19/13 • Waiting period met 2/19/13; first day of compensability after waiting period is met (MOP Box 22) is 2/20/13.

  7. Waiting period; when compensation payable • Example 2: Temporary Partial Disability • DOI 3/11/13 (filing status not relevant) • Pay period Sunday – Saturday • Pre-injury AWW $650 / WCR $433.33 • Post-injury actual earnings $450 / WCR $300.00 • Partial rate = $433.33 - $300.00 = $133.33

  8. Waiting period; when compensation payable • Example 2 Calculations • First day of compensability after waiting period is met (MOP Box 22): 4/6/13

  9. Waiting period; when compensation payable In case incapacity continues for more than 14 days, compensation is allowed from the date of incapacity. Must pay for the waiting period.

  10. Waiting period; when compensation payable • Example 2 Calculations (cont.) (WCR $433.33) (2 x WCR $866.66)

  11. Benefit payment Section 205 and Rule 1.1 • The first payment of compensation is due and payable within 14 days of notice or knowledge of a claim for incapacity or death benefits, on which date all compensation then accrued must be paid. • In the previous example, the first day of compensability after the waiting period is met is 4/6/13 (8th day); first payment due 4/12/13.

  12. Benefit paymentSection 205 and Rule 8.4 Subsequent incapacity payments must be made weekly (every 7 days) and directly to the employee entitled to that compensation at that employee’s last known mailing address, or at any place that employee designates.

  13. Discontinuance or reduction of payments Section 205.9 and Rule 8.11 Section A – employee must return to work with the employer of injury. Reductions and discontinuances must be based on the employee’s actual earnings unless the employee returns without restrictions or limitations.

  14. Discontinuance or reduction of payments Section 205.9 • Section B – all circumstances other than the employee’s return to work with the employer of injury. • Payment without prejudice (voluntary payment) – must file WCB-8. • Payment with prejudice (order or award of compensation or compensation payment scheme) – must petition the Board.

  15. Discontinuance or reduction of payments Section 205.9 and Rule 8.15 • RTW with a different employer and employer/insurer is filing a 21-day certificate of discontinuance/reduction (WCB-8): • Actual documented earnings must be provided by the employee or their representative to the employer/insurer within 7 days of their RTW (to substantiate the discontinuance/reduction) • The employer/insurer must include, with the 21-day certificate, form WCB-231A (with a statement) • Within 14 calendar days after the expiration of the 21-day period, the employer/insurer shall file with the Board the documentation it has received along with an amended 21-day certificate which shall also include any necessary adjustments based on the documentation received by the employer/insurer.

  16. Discontinuance or reduction of paymentsExamples • RTW with the employer of injury • Jane $600 AWW / RTW earning $620 • WCB-4 Discontinuance (with or without restrictions or limitations) • Julie $600 AWW / RTW no restrictions or limitations earning $560 • WCB-4 Discontinuance (maintain proof of full duty release on file) • Janice $600 AWW / RTW with restrictions or limitations earning $560 • WCB-4 Modification (to partial) • If reduced earnings are strictly due to economic conditions (i.e. overtime no longer available), may discontinue with a WCB-8 • Joslyn $600 AWW / RTW without restrictions or limitations according to her treating health care provider, but there are conflicting medical records from another health care provider with respect to the lack of restrictions or limitations, earning $560 • WCB-8 (21 Day) Discontinuance

  17. Discontinuance or reduction of paymentsExamples (continued) • RTW with the employer of injury • Judy $600 AWW / RTW earning $560 because she chooses not to work optional overtime which she worked prior to the injury • If RTW was with restrictions or limitations, WCB-8 (21 Day) Discontinuance • If RTW was with no restrictions or limitations, WCB-4 Discontinuance (maintain proof of full duty release on file) • RTW with a different employer • Joyce $600 AWW / RTW with different employer and with restrictions or limitations earning $560 • WCB-8 Modification (to partial)

  18. Maximum benefit levelsSection 211 Adjusted annually on July 1 – adjust on that day. File a modification. Date of Injury prior to 1/1/2013 - 90% of the state average weekly wage as determined by the Department of Labor. Date of injury on/after 1/1/2013 100% of SAWW

  19. Compensation for total incapacitySection 212 • Date of injury prior to 1/1/2013 - weekly compensation equal to 80% of the employee’s after-tax average weekly wage, but not more than the maximum benefit under section 211. • Date of injury on or after January 1, 2013, 80% after tax computation is replaced with two-thirds of the AWW (AWW divided by three, times two).

  20. Compensation for partial incapacitySection 213 and Rule 8.8 Date of injury prior to 1/1/2013 - difference between 80% of the injured employee’s after-tax average weekly wage before the injury and 80% of the after-tax average weekly wage after the injury, but not more than the maximum benefit under section 211. Date of injury on/after 1/1/2013 - the 80% after tax computation is replaced with two-thirds of the AWW.

  21. Compensation for partial incapacitySection 213 and Rule 8.8 Things to remember: • Employers must be notified of their obligation to promptly furnish all post-injury information necessary to facilitate timely indemnity payments (need weekly information even if the pay cycle is different). • Match partial benefit calculations to the employer’s pay cycle. • There is no such thing as a partial week of partial benefits.

  22. Modifications from TTD to TPD or from TPD to TTD When an employee is both partially and totally incapacitated in the same week: • Calculate and pay TTD benefits due for the days of total incapacity. • Calculate TPD benefits due for the week. • Deduct TTD benefits paid during the week for which partial benefits were calculated and pay the difference. • If the result is a negative amount, no additional indemnity benefits are due for the week.

  23. Modifications from TTD to TPD or TPD to TTD Example 1: John is injured 3/2/13, he is paid for half a day on that day • Pay period Sunday – Saturday • Pre-injury AWW $800 • OOW 3/2 - 3/13/13, RTW 3/14/13 with restrictions • Post-injury actual earnings $300

  24. Modifications from TTD to TPD or TPD to TTD

  25. Modifications from TTD to TPD or TPD to TTD Example (cont.) • Pre-injury AWW $800 • WCR $533.33/Daily Rate $76.19 • TTD 3/2 - 3/13/13 • 3/2/13 paid ½ day; not considered a day of incapacity • Calculate TTD 3/3/13 - 3/9/13 ($76.19 x 7 days = $533.33) • Waiting period, do not pay yet • Pay TTD 3/10 - 3/13/13 ($76.19 x 4 days = $304.76) • Calculate Partial benefits for week ending 3/16/13

  26. Modifications from TTD to TPD or TPD to TTD Example (TPD 3/10/13 - 3/16/11 cont.) • Pre-injury AWW $800 • Determine the WCR – 2/3 of AWW (WCR $533.33). • Post-injury weekly earnings $300 • Determine the WCR – 2/3 of $300.00 (WCR $200.00). • Employee’s TPD benefits for the transition week = $333.33 • The difference between the pre-injury rate and the post-injury rate is the partial benefit amount. • Less TTD paid during the transition week ($304.76) • Employee owed $28.57 TPD in addition to the $304.76 TTD already paid

  27. Modifications from TTD to TPD or TPD to TTD Example 2: Jack is Injured 3/5/13, not paid ½ day • Pay period Sunday - Saturday • Pre-injury AWW $750 • OOW 3/5/13 - 3/13/13, RTW 3/14/13 with restrictions • Post-injury actual earnings $350

  28. Compensation for partial incapacitySection 213 and Rule 8.8

  29. Compensation for partial incapacitySection 213 and Rule 8.8 Example 2 (cont.) • Pre-injury AWW $750 • WCR $500.00/Daily Rate $71.43 • TTD 3/5/13 - 3/13/11 • Calculate TTD 3/5/13 - 3/13/13 (one week plus 2 days = $642.86) • Do not pay 7 day waiting period 3/5/13 - 3/11/13 ($500.00) • Pay TTD 3/12/13 - 3/13/13 ($71.43 x 2 days = $142.86) • Calculate Partial benefits for week ending 7/16/11

  30. Modifications from TTD to TPD or TPD to TTD Example 2 (cont.) • Pre-injury AWW $750 • Determine the WCR – 2/3 of the AWW (WCR $500.00). • Post-injury weekly earnings $350 • Determine the WCR – 2/3 of $350 (WCR $233.33). • Employee’s TPD benefits for the transition week = $266.67 • The difference between the pre-injury rate and the post-injury rate is the partial benefit amount. • Less TTD owed during the transition week (4 days or $285.72). • $266.67 (TPD due) minus $285.72 (TTD due) is less than zero, so no additional benefits are due.

  31. Modifications from TTD to TPD or TPD to TTD Example 2 (cont.) • Pre-injury AWW $750 • Determine the WCR – 2/3 of the AWW (WCR $500.00). • Post-injury weekly earnings $350 • Determine the WCR – 2/3 of $350 (WCR $233.33). • Employee’s TPD benefits for the w/e 3/23/13 = $266.67 • The difference between the pre-injury rate and the post-injury rate is the partial benefit amount. • Be sure to pay for the waiting period in addition to TPD the following week if incapacity continues for more than 14 days (2 x WCR).

  32. Waiting period; when compensation payable Example 2 Calculations (cont.) WCR = $500.00, 2 x WCR = $1000.00)

  33. QUESTIONS???

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