Foundational Knowledge
Before WC laws were passed in the early 1900s, employees had to prove this as their only recourse for a workplace injury.
What is negligence?
This is the most consistent benefit provided from state to state. It's an unlimited benefit, subject to the test of reasonable and necessary treatment.
What is medical?
This governs the "We Will Pay" or insuring agreement portion of the the WC policy.
What is the state WC law?
The title of Part 2 and the term that describes coverage for an employer found to be legally liable.
What is Employers Liability?
The numerator in the EMR calculation.
What is actual losses?
The no fault WC system has become known as this for the employee.
What is the "sole/exclusive remedy"?
This benefit has the greatest variance from state to state and is designed to prevent injured workers from exaggerating injuries that delay return to work.
What is disability income, indemnity, or lost wages?
The two coverage triggers for workers' compensation
What is accident and disease?
These claims under part two can be brought forth by the injured employee's spouse or children.
What is care and loss of services?
The number of years included in the EMR calculation.
What is three?
An employer who fails to provide WC will usually be subject to this.
What is fines and penalties?
This term serves as a deductible for WC.
What is the waiting period?
This section is valuable to have in Part One because disputes do occur regarding benefits payable.
What is "we will defend" or defense costs?
These are claims made against the employer by others who have initially been held liable for an ee injury.
What are third party claims?
Errors related to this can make expected losses (denominator) inaccurate.
This is often considered the most important factor when determining independent contractor status.
What is behavioral control or degree of control?
This benefit makes up a small percentage of total claims, but is very significant in terms of large payments.
What is the death and survivor benefit?
Any one of these could be considered an exclusion (payment you must make) in Part One
What is willful misconduct, violation of law, fines/penalties, or discharge/discrimination?
This occurs when an ee is injured; the employer is sued in a capacity other than as the employer.
What is dual capacity?
These errors can throw off actual losses and unnecessarily increase the EMR?
What are loss reserves and closed claims? (check reserves on mod worksheet against loss runs)
This has been a major driver of thousands of court cases involving WC?
What is covered injuries or arising out of and in the course and scope of employment?
Most of the time, the amount of disability is determined by this person's evaluation.
Who is a physician?
This means that the insurer has the employer's rights, and the rights of persons entitled to the benefits of this insurance, to recover payments from anyone liable for the injury.
What is Recovery from Others or subrogation?
The names for the three limits provided in part two
What are bodily injury by accident, bodily injury by disease - each employee, and bodily injury by disease - policy limit.
Experience rating plans tend to punish these types of claims.
What is frequency or smaller more frequent claims?