WEST virginia legislature
2016 regular session
Introduced
Senate Bill 76
By Senator Yost
[Introduced January 13, 2016;
Referred to the Committee on Banking and Insurance; then to the Committee on
the Judiciary; and then to the Committee on Finance.]
A BILL to amend and reenact §23-4-1c of the Code of West Virginia, 1931, as amended, relating to workers’ compensation; requiring covered employee to be paid maximum temporary total disability benefits for lost time without penalty to employee; and eliminating any offset to employers for employees who have a wage replacement plan.
Be it enacted by the Legislature of West Virginia:
That §23-4-1c of the Code of West Virginia, 1931, as amended, be amended and reenacted to read as follows:
ARTICLE 4. DISABILITY AND DEATH BENEFITS.
§23-4-1c. Payment of temporary total disability benefits directly to claimant; payment of medical benefits; payments of benefits during protest; right of commission, successor to the commission, private carriers and self-insured employers to collect payments improperly made.
(a) In any claim for
benefits under this chapter, the Insurance Commissioner private carrier or
self-insured employer, whichever is applicable, shall determine whether the
claimant has sustained a compensable injury within the meaning of section one
of this article and enter an order giving all parties immediate notice of the
decision.
(1) The Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, may enter an order conditionally approving the claimant's
application if it finds that obtaining additional medical evidence or
evaluations or other evidence related to the issue of compensability would aid
the Insurance Commissioner, private carrier or self-insured employer, whichever
is applicable, in making a correct final decision. Benefits shall be paid
during the period of conditional approval; however, if the final decision is
one that rejects the claim, the payments shall be considered an overpayment.
The Insurance Commissioner, private carrier or self-insured employer, whichever
is applicable, may only recover the amount of the overpayment as provided for
in subsection (h) of this section.
(2) In making a determination regarding the compensability of a newly filed claim or upon a filing for the reopening of a prior claim pursuant to the provisions of section sixteen of this article based upon an allegation of recurrence, reinjury, aggravation or progression of the previous compensable injury or in the case of a filing of a request for any other benefits under the provisions of this chapter, the Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall consider the date of the filing of the claim for benefits for a determination of the following:
(A) Whether the claimant had a scheduled shutdown beginning within one week of the date of the filing;
(B) Whether the claimant received notice within sixty days of the filing that his or her employment position was to be eliminated, including, but not limited to, the claimant's worksite, a layoff or the elimination of the claimant's employment position;
(C) Whether the claimant is receiving unemployment compensation benefits at the time of the filing; or
(D) Whether the claimant has received unemployment compensation benefits within sixty days of the filing. In the event of an affirmative finding upon any of these four factors, the finding shall be given probative weight in the overall determination of the compensability of the claim or of the merits of the reopening request.
(3) Any party may object to the order of the Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, and obtain an evidentiary hearing as provided in section one, article five of this chapter: Provided, That if the successor to the commissioner, other private carrier or self-insured, whichever is applicable, fails to timely issue a ruling upon any application or motion as provided by law, or if the claimant files a timely protest to the ruling of a self-insured employer, private carrier or other issuing entity, denying the compensability of the claim, denying temporary total disability benefits or denying medical authorization, the office of judges shall provide a hearing on the protest on an expedited basis as determined by rule of the office of judges.
(b) Where it appears from
the employer's report, or from proper medical evidence, that a compensable
injury will result in a disability which will last longer than three days as
provided in section five of this article, the Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, may immediately
enter an order commencing the payment of temporary total disability benefits to
the claimant in the amounts provided for in sections six and fourteen of
this article, and the payment of the expenses provided for in subsection
(a), section three of this article, relating to the injury, without waiting for
the expiration of the thirty-day period during which objections may be filed to
the findings as provided in section one, article five of this chapter. The
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, shall enter an order commencing the payment of temporary total
disability or medical benefits within fifteen working days of receipt of either
the employee's or employer's report of injury, whichever is received sooner,
and also upon receipt of either a proper physician's report or any information
necessary for a determination. The Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, shall give to the parties
immediate notice of any order granting temporary total disability or medical
benefits. When an order granting temporary total disability benefits is made,
the claimant's return-to-work potential shall be assessed. The Insurance
Commissioner may schedule medical and vocational evaluation of the claimant and
assign appropriate personnel to expedite the claimant's return to work as soon
as reasonably possible.
(c) The Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may enter orders granting temporary total disability benefits upon receipt of medical evidence justifying the payment of the benefits. The Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may not enter an order granting prospective temporary total disability benefits for a period of more than ninety days: Provided, That when the Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, determines that the claimant remains disabled beyond the period specified in the prior order granting temporary total disability benefits, the Insurance Commissioner, private carrier or self-insured employer shall enter an order continuing the payment of temporary total disability benefits for an additional period not to exceed ninety days and shall give immediate notice to all parties of the decision.
(d) Upon receipt of the
first report of injury in a claim, the Insurance Commissioner, private carrier
or self-insured employer, whichever is applicable, shall request from the
employer or employers any wage information necessary for determining the rate
of benefits to which the employee is entitled. If an employer does not furnish
this information within fifteen days from the date the Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, received the
first report of injury in the case, the employee shall be paid the maximum
temporary total disability benefits at the rate the commission obtains for
lost time without penalty to the employee. from reports made pursuant to
subsection (b), section two, article two of this chapter If no wages have
been reported, the Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, shall make the payments at the rate the
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, finds would be justified by the usual rate of pay for the
occupation of the injured employee the maximum temporary total
disability benefits for lost time without penalty to the employee. The rate
of benefits shall be adjusted both retroactively and prospectively upon
receipt of proper wage information. The Insurance Commissioner shall have
access to all wage information in the possession of any state agency.
(e) Subject to the
limitations set forth in section sixteen of this article, upon a finding of the
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, that a claimant who has sustained a previous compensable injury
which has been closed by order, or by the claimant's return to work, suffers
further temporary total disability or requires further medical or hospital
treatment resulting from the compensable injury, payment of temporary total
disability benefits to the claimant in the amount provided for in sections
six and fourteen of this article shall immediately commence, and the expenses
provided for in subsection (a), section three of this article, relating to the
disability, without waiting for the expiration of the thirty-day period during
which objections may be filed. Immediate notice to the parties of the decision
shall be given.
(f) The Insurance Commissioner, private carrier or self-insured employer shall deliver amounts due for temporary total disability benefits directly to the claimant.
(g) Where the employer has elected to carry its own risk under section nine, article two of this chapter, and upon the findings aforesaid, the self-insured employer shall immediately pay the amounts due the claimant for temporary total disability benefits. A copy of the notice shall be sent to the claimant.
(h) In the event that an employer files a timely objection to any order of the Insurance Commissioner, private carrier or self-insured, whichever is applicable, with respect to compensability, or any order denying an application for modification with respect to temporary total disability benefits, or with respect to those expenses outlined in subsection (a), section three of this article, the division shall continue to pay to the claimant such benefits and expenses during the period of such disability. Where it is subsequently found by the Insurance Commissioner, private carrier or self-insured, whichever is applicable, that the claimant was not entitled to receive such temporary total disability benefits or expenses, or any part thereof, so paid, the Insurance Commissioner, private carrier or self-insured, whichever is applicable, shall credit said employer's account with the amount of the overpayment. When the employer has protested the compensability or applied for modification of a temporary total disability benefit award or expenses and the final decision in that case determines that the claimant was not entitled to the benefits or expenses, the amount of benefits or expenses is considered overpaid. For all awards made or nonawarded partial benefits paid the Insurance Commissioner, private carriers or self-insured employer may recover the amount of overpaid benefits or expenses by withholding, in whole or in part, future disability benefits payable to the individual in the same or other claims and credit the amount against the overpayment until it is repaid in full.
(i) In the event that the Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, finds that, based upon the employer's report of injury, the claim is not compensable, the Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall provide a copy of the employer's report to the claimant in addition to the order denying the claim.
(j) If a claimant is
receiving benefits paid through a wage replacement plan, salary continuation
plan or other benefit plan provided by the employer to which the employee has
not contributed, and that plan does not provide an offset for temporary total
disability benefits to which the claimant is also entitled under this chapter
as a result of the same injury or disease, the employer shall notify the
Insurance Commissioner, private carrier or self-insured of the duplication of
the benefits paid to the claimant. Upon receipt of the notice, the Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, shall reduce the temporary total disability benefits provided under
this chapter by an amount sufficient to ensure that the claimant does not
receive monthly benefits in excess of the amount provided by the employer's
plan or the temporary total disability benefit, whichever is greater: Provided,
That this subsection does not apply to benefits being paid under the terms and conditions
of a collective bargaining agreement.
NOTE: The purpose of this bill is to require a covered employee to be paid the maximum temporary total disability benefits for lost time without penalty to the employee. The bill requires a covered employee to be paid the maximum temporary total disability benefits for lost time without penalty to the employee. The bill eliminates any offset to employers for employees who have a wage replacement plan.
Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.