3 Rules (2-3 hrs.) Flashcards
Everyone has them, these are for the QME
What is the rule of exclusive remedy?
Worker cannot pursue other civil action, even if employer was negligent, unless the employer is uninsured for work comp
By what percentage is the employee’s compensation increased if an injury resulted from serious and willful misconduct of an employer?
50%
What are the 7 exceptions to claiming something as a work related injury?
- if etoh/drugs were used; 2. intentionally self inflicted harm 3. suicide 4. injury from an altercation in which the employee is an aggressor 5. injuries from a crime 6. injuries during off duty recreational activities 7. psych injuries claimed after termination
For injuries that result from serious and willful misconduct of an injured employee, benefits are reduced by ____ unless_____
50%; unless death or permanent disability of >70%, age <16, or injury resulted from failure of employer to comply with health/safety laws
When first aid is administered, what reports should be filed
Doctors first report (employers first report is not required)
Employers have an obligation to authorize up to $________ within 1 working day after a claim is filed
$10,000
Which 6 components should be included in an occupational history
- all jobs worker has held; 2. length of employment; 3. specific job duties; 4. how much time was spent on each task 5. occupational hazard exposures; 6. what protective equipment was used
What are the 7 exceptions to claiming something as a work related injury? (logical, just think about it)
- if etoh/drugs were used; 2. intentionally self inflicted harm 3. suicide 4. injury from an altercation in which the employee is an aggressor 5. injuries from a crime 6. injuries during off duty recreational activities 7. psych injuries claimed after termination
In which conditions in firefighters, forestry officers, peace officers and correctional employees is the burden of proof on the employer?
hernias, pneumonia, TB, heart dz, cancer
When is a psych injury compensable? “burden of proof”
employment events contribute >50% to injury (or >35% if a violent act was witnessed example Bank Robbery)
When are psych injuries not compensable?
if worker has worked there <6 months in total, if claim is due to personnel matters, or if claim is filed after notice of termination (except in extreme cases)
After how many visits can a chiropractor no longer be the treating physician
24
For injuries occurring after which date are the AMA guides used to evaluate disability?
1/1/2005
What event generally triggers a QME evaluation under LC 4061
permanent disability dispute after the PTP claims worker is P&S and termination of temporary disability
What is a QME evaluation under LC 4060
Helping to determining the compensability of a claim after claim form is filed but before the body part has been accepted by the claims administrator
What disputes fall under LC 4062?
- is worker temporarily disabled? 2. does worker need work restrictions? 3. is there a new/further disability after judicial determination of permanent disability as a result of injury deterioration 4. whether a new body part added to the claim
Since when has disputes over what medical treatment not done by QMEs
since 7/1/2013–now resolved by IMR process if UR is denied
What is the difference between QME forms 105 and 106?
105–unrepresented workers; 106–represented workers
who gets the first opportunity to request a QME panel?
injured worker
Can a worker get a second med-legal evaluation if they later become represented by an attorney?
No
QME evaluations are only available for represented workers for DOI after______?
1/1/2005
Can an evaluator cancel an appointment for lack of medical records?
No (unless psych)
The April 1997 Permanent Disability Rating Schedule (PDRS) can be used for a DOI prior to_____?
1/1/2005
Now we use the AMA Gides 5th Ed for Whole Person Impairment %
How can an unrepresented worker ask for a factual correction to a QME report?
File form QME 37, asking the QME to correct facts; The QME has 10 days to do so.
What is the process for sending records to a QME?
records must first be served to the opposing party 20 days before it is provided to the QME; if the opposing party objects to sending non-medical records within 10 days of its receipt, it will not be provided to the QME
Which records are prohibited from being sent to a QME?
1, any prior report that has been rejected as untimely; 2. an MD report that talks about impairment/disability that is not by a PTP, secondary physician, or QME (unless judge rules it admissible) 3. Any record that has been stricken by a judge
How much $ does a worker receive for total disability?
weekly amount that was determined for temporary disability for life
If the Injured Worker can NOT return to their job, they are a QIW (Quilified Injured Worker) and get $ to retrain called: Supplemental Job Displacement Benefits (SJDB), PAY OUT AMOUNTS
For injuries before 1-1-13 the voucher amount ranges from $4000 to $10,000 depending upon the permanent disability rating
For dates of injury on/after 1-1-13 the voucher will be $6000 across the board, regardless of the permanent disability rating
The voucher will be due 60 days after a treating doctor, AME or QME declares the injured worker permanent and stationary, reports what the worker’s work capabilities are
and the employer does not offer the worker a job
If offered, the job must pay no less than 85% of the worker’s earnings at the time of the injury, and be expected to last at least 12 months
The SJDB voucher can be used for?
Training at a California public school, or other approved provider listed by the state
To pay for licensing or certification and testing fees
Purchase tools required by a training course
Up to $1000 to purchase a computer and/or $500 in miscellaneous expenses
Up to $600 for the services of a licensed placement agency or vocational counselor
What are the voucher amounts for supplemental job displacement benefits?
PDRS<15% $4000; 15-25%: $6000 26-49%: $8000; 50-99%: $10,000
How much $ does a worker receive for partial disability
weekly payments for a number week weeks determined by employer’s disability rating and a small pension for life if >70% disability