Temporary Total and Temporary Partial Incapacity Benefits - The Basics Rev 3/4/2013.

Temporary Total and Temporary Partial Incapacity Benefits - The Basics

Rev 3/4/2013

Compensation for Incapacity

Order or award of compensation.

OR Employer/Insurer accepts the claim. MOP Box 20(A)

Creates a compensation payment scheme.

Payment with Prejudice

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.

Section 204: 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

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 –

ongoingWhen is the 7 day waiting period met?


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.


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


Example 2 Calculations

First day of compensability after waiting period is met (MOP Box 22): 4/6/13


Partial Weekly Benefit

Rate

Cumulative Partial Weekly Benefit

Rate

Weekly Benefits

Due

3/10-3/16/13

133.33

3/17-3/23/13

133.33 266.66

3/24-3/30/13

133.33 399.99

3/31-4/6/13

133.33 533.32 99.99

In case incapacity continues for more than 14 days, compensation is allowed from the date of incapacity.

Must pay for the waiting period.


Example 2 Calculations (cont.) (WCR $433.33) (2 x WCR $866.66)



Rate

Cumulative


Rate

Weekly Benefits

Due

3/10 - 3/16/13

133.33

3/17 - 3/23/13

133.33 266.66

3/24 - 3/30/13

133.33 399.99

3/31 - 4/6/13

133.33 533.32 99.99

4/7 - 4/13/13

133.33 666.65 133.33

4/14 - 4/20/13

133.33 799.98 133.33

4/21 - 4/27/13

133.33 933.31 566.66

4/28 - 5/4/13

133.33 1066.64 133.33

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.

Benefit payment Section 205 and Rule 1.1

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.

Benefit paymentSection 205 and Rule 8.4

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.

Discontinuance or reduction of payments

Section 205.9 and Rule 8.11

Section B – all circumstances other than the employee’s return to work with the employer of injury.

1. Payment without prejudice (voluntary payment) – must file WCB-8.

2. Payment with prejudice (order or award of compensation or compensation payment scheme) – must petition the Board.


Section 205.9

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.

Discontinuance or reduction of payments Section 205.9 and Rule 8.15

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

Discontinuance or reduction of paymentsExamples

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)


Examples (continued)

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

Maximum benefit levelsSection 211

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).

Compensation for total incapacity

Section 212

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.

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.


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.

Modifications from TTD to TPD or from 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

Modifications from TTD to TPD or TPD to TTD

March 2013Sun

Mon Tue Wed Thu Fri Sat

1 2Paid ½ day

3TTD

4TTD

5TTD

6TTD

7TTD

8TTD

9TTD

10TTD

11TTD

12TTD

13TTD

14TPD

15TPD

16TPD


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


Example (TPD 3/10/13 - 3/16/11 cont.) Pre-injury AWW $800

1. Determine the WCR – 2/3 of AWW (WCR $533.33). Post-injury weekly earnings $300

2. Determine the WCR – 2/3 of $300.00 (WCR $200.00). Employee’s TPD benefits for the transition week =

$333.333. 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


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


March 2013Sun

Mon Tue Wed Thu Fri Sat

1 2

3 4 5Not Paid ½ day

6TTD

7TTD

8TTD

9TTD

10TTD

11TTD

12TTD

13TTD

14TPD

15TPD

16TPD

17TPD

18TPD

19TPD

20TPD

21TPD

22TPD

23TPD


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



1. Determine the WCR – 2/3 of the AWW (WCR $500.00). Post-injury weekly earnings $350

2. Determine the WCR – 2/3 of $350 (WCR $233.33). Employee’s TPD benefits for the transition week =

$266.673. 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.



1. Determine the WCR – 2/3 of the AWW (WCR $500.00).

Post-injury weekly earnings $350 2. Determine the WCR – 2/3 of $350 (WCR $233.33).

Employee’s TPD benefits for the w/e 3/23/13 = $266.67

3. 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).


Example 2 Calculations (cont.) WCR = $500.00, 2 x WCR = $1000.00)


Partial Weekl

y Benefit Rate*

Cumulative


Rate

Weekly

Benefits Due

Notes

3/5/13 - 3/9/13

357.14 *TTD Benefits

3/10/13 - 3/13/13

285.72 642.86 142.86 *TTD Benefits

3/10/13 - 3/16/13

0 642.86 0 No additional due

3/17/13 - 3/23/13

266.67 909.53 266.67

3/24/13 - 3/30/13

266.67 1176.20 766.67 $500.00 + $266.67

3/31/13 - 4/6/13

266.67 1442.87 266.67

QUESTIONS???

Temporary Total and Temporary Partial Incapacity Benefits - The Basics Rev 3/4/2013.

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Transcript of Temporary Total and Temporary Partial Incapacity Benefits - The Basics Rev 3/4/2013.