Jeramy
Jeramy had surgery 3 months ago and has been now provided restrictions. The insured is able to accommodate at his full hours and wages. Jeramy had a prior commitment to join a reality show and stated he did not feel comfortable returning within his restrictions. Would TPD be due?
No, if the offer is clearly documented Jeramy declined and removed himself from the workforce.
Chelsea has been released to full duty and returned to work. The insured indicates she continues to report pain and refuse some of her prior job duties. What should be done?
The insured and examiner should reach out to Chelsea and advised that all benefits are based on medical reporting and that if she does not feel she is able to work at full capacity she should return for care to have her work status re-evaluated.
Kenneth is currently receiving salary continuation (SC) at 40 hours per week while on restrictions the insured is unable to accommodate. He typically works an addition 10 hours per week of overtime, which is not included in the SC. Is Kenneth experiencing wage loss?
Yes
Sarah Ann is a Jet ski instructor and works Mon-Friday 40 hours per week. She was released to modified duty with no use of the right hand. The insured is able to accommodate with a position in office 20 hours per week. Sarah Ann feels this is unfair and she wants to continue working with Jet skis. She has refused to work the 20 hours offered. Would we owe TPD?
Yes, based on the offer we would owe as only 20 hours were offered however, we would not pay for the hours offered as she declined.
The insured is able to accommodate Jimmy's current restrictions at his normal hours of 40 hours per week at $20 per hour however at a lower pay rate of $15 per hour. Would he be due TPD?
yes
Jeramy feels he should be paid for this time off and is in disagreement. The offer is formally documents. What benefit notice should issue?
Temporary partial disability denial
Chelsea returned to the doctor and was placed on restrictions. The insured is frustrated as they do not understand the decline in progress and are aware she has been very involved in planning for her upcoming wedding. They are willing to offer a part time position as a trial of modified duty. Would TPD be due?
Yes, offer of hours and rate to be documented and confirmation restrictions continue to be accommodated regularly confirmed with insured.
What should we do?
Contact the insured, determine if they wish to consider increasing their rate to account for the overtime. If they do not wish to, we would owe TPD.
The insured is very frustrated with her attitude and lack of cooperation. How should they handle this?
There is a formal offer and this would be an employment issue to handle internally. Request they remain in communication should any personnel action be taken.
Jimmy's performance has declined within his new role. The insured requested if they must continue to accommodate his restrictions?
No, however if not accommodated while he is on restrictions we will have to pay for his lost time.
The performance issues should be handled as an employment issue.
Bonus question for those that watch the show. What was key in Laura confirming Jeramy was being dishonest?
Documentation
Chelsea's restrictions were reduced and the insured is now able to offer her normal hours and wages. She has taken time off stating due to medical appointments but has posted on social media cake tasting and flower shopping. Her wages are reduced on paper, would we owe TPD?
No, we do not pay for time lost due to medical appointments.
Also we might want some surveillance and a social media canvas.
Kenneth has been released to full duty but his school is closed for spring break and work is not available for two weeks. The insured was accommodating reduced earnings prior, would benefits be due.
This is typically an unpaid leave.
No as it is the normal course and scope of employment and not due to his restrictions.
He might be entitled to other benefits (hint) but not TPD)
Bonus: Math time! (Extra credit). What is Sarah Ann's TPD rate? She makes $20 per hour, 40 hours per week pre-injury. Modified duty offer is $20 per hour 20 hours per week.
AWW:
New gross earnings:
Wage loss:
Rate (2/3):
$266.67
The insured has agreed to continue to work with Jimmy on his performance. They have now decided to bring him back to his original position with normal time and wages. Jimmy preferred the new role and requested to stay within that position. Would TPD continue to be owed?
No, he has declined the full offer of normal hours and wages. TPD is based on offer provided by the insured.
What if the insured was unable to accommodate the restrictions but Jeramy reported this planned commitment? What questions would you have for the insured?
- Was PTO/time off requested prior to injury?
- Was this a previously documented pre-planned absence?
-What are the barriers to modified duty offer?
Chelsea has been deemed permanent and stationary with permanent restrictions. The insured is unable to offer a permanent position. Would she continue to be owed benefits?
Most likely
Kenneth is currently on restrictions of seated work only. The insured is able to accommodate his normal hours and wages. Kenneth is a really hard worker and has seemed to be working outside of his restrictions. The insured is concerned he may further injure himself. What should they do?
They should ensure the offer of modified duty has been clearly documented. They should remind Kenneth that he should be working with in his restrictions and should he feel his is able to do more than assigned, he should be directed to return to the doctor to have his restrictions re-evaluated. Examiner should also reach out and echo the same.
The insured has submitted a formal offer of modified duty for Friday night - Tuesday night shift. Is this a reasonable offer?
No based on the original terms of her employment, this would not be a reasonable offer from the insured as this would not have been expected pre-injury.
Jimmy is still on restrictions and not performing well. He is continuously distracted by his new engagement and has been counseled several times. The insured has decided to terminate his employment based on his performance. Would we still owe benefits?
No as the insured would have continued to accommodate his restrictions but for his termination for cause.
What questions would you have for Jeramy?
- Is this a paid opportunity with tax reportable income?
- Will he be available for medical care?
- remind updated work status is needed every 45 days
What kind of benefits?
Since she has been deemed P&S, she would now be entitled permanent disability benefits based on the report. Best practice is to always advance a good faith estimate if permanent disability is anticipated.
Bonus: What action may the examiner want to take with this information?
Consider reaching out to the doctor to clarify restrictions and if Kenneth is able to consider full duty release or reduced restrictions.
Check medical reporting for Kenneth's subjective complaints if they match the insured's observations in consideration for additional investigation.
Assuming Sarah Ann declines the offer to be a night time Jet ski instructor which was in combination with office work of 20 hours per week. Would benefits be due? and which?
Yes, TPD as their remains a formal and reasonable offer for office work position.
Bonus: What if they were only accommodating his partial wages at the time of his termination? Would we owe and what type of benefits?
Yes, TPD would be due based on the original offer but no additional as the insured would have accommodated those restrictions.
Side note: if termination was not for cause this is a different story