Workers' Compensation Benefits Summary
For dates of injury occurring on or after July 1, 2004 through June 30, 2005
Employment Relations Division
Department of Labor and Industry
PO Box 8011
Helena, MT 59604-8011
Phone: (406) 444-7751 or 444-3089
INTRODUCTION
The information in this pamphlet is a summary of the most commonly requested information on workers' compensation wage loss and medical benefits available to covered employees injured on the job. It is not all-inclusive.
GENERAL INFORMATION
What is Workers' Compensation?
Workers' compensation is a program designed to:
· provide, without regard to fault, wage loss benefits
and medical benefits to workers suffering from a work-related
injury or occupational disease;
· return the worker to the work force as soon as possible;
· be easy to access without professional help; and
· provide coverage at reasonably constant rates to employers.
Who is covered?
Workers' compensation insurance is required for most types of
employment. If you are injured on the job, you may be eligible
for workers' compensation benefits provided you submit the proper
claim form on time.
REPORTING REQUIREMENTS
What do I have to do?
Report all on-the-job injuries to your supervisor, insurer or
employer as soon as possible. You must report the accident within
30 days. We recommend you report minor injuries to your
employer whether or not you receive medical treatment.
You must submit a written and signed first report of injury (FROI) within 12 months from the date of the accident. You can submit this form to your employer, the workers' compensation insurer or the Department of Labor and Industry. After you report the injury, your employer has 6 days to notify the insurer. Upon receipt of your signed FROI, the insurer has 30 days to either accept or deny your claim. If denied, you and the Department of Labor and Industry must be informed in writing.
What if I give false information?
When you sign your first report of injury, you are confirming
the information on the claim is true. If you obtain benefits to
which you are not entitled, you may be guilty of theft and criminal
proceedings can be initiated. Helping someone else to fraudulently
obtain benefits is also a crime.
Can I report suspected fraud?
Yes, you can report suspected fraud by calling the fraud hotline
at 1-800-922-2873. You do not have to give your name.
MEDICAL BENEFITS
What medical benefits are provided?
Once the insurer accepts your injury or occupational disease claim,
you are entitled to reasonable doctor, hospital, prescription
and medical care costs. Allowable charges are paid according to
a medical fee schedule. You do not have to pay the balance between
what the medical provider charges and the insurance company pays.
Workers' compensation insurance policies don't allow you complete freedom of choice of medical providers. An insurer contracting with a Managed Care Organization (MCO) can direct you to the MCO for medical care.
Also, insurers will be able to direct you to preferred provider organizations (PPOs) in addition to, or in conjunction with, managed care organizations. After the date your insurer gives you written notice of a preferred provider, the insurer is no longer liable for charges if you continue to see the non-preferred provider.
Prior authorization from the insurer is required for the following:
· a change of physician, or
· any treatment after you have reached maximum medical improvement
(MMI), or
· when there has been no treatment for 6 months, or
· for specialized medical care
What charges do I have to pay?
After your first visit to an emergency room, you are responsible
for $25 of the cost of each following visit to an emergency room.
You may also be required to pay the difference between name-brand drugs and the generic product if you choose to use the name-brand product. If the generic product is not a therapeutic equivalent or is not available, you will not have to pay the difference. Physicians can no longer specify "no substitutions" for name-brand products.
If I have to travel for treatment of my injury, who pays
for the travel?
The insurer is required to pay reasonable travel expense. Your
first 100 miles per month are subtracted and you must submit the
travel claim within 90 days. Travel to a medical provider in your
community is not reimbursable.
WAGE LOSS COMPENSATION
If your physician doesn't permit you to return to work because of your injury, and your claim has been accepted by the insurer, you may be eligible for wage loss benefits.
If you are eligible for compensation benefits, no compensation
may be paid for the first 32 hours or 4 days loss of wages, whichever
is less. You are eligible for compensation starting with the 5th
day.
What if I can't work at all for a while?
If you suffer a total loss of wages due to your injury, you may
be eligible for temporary total disability (TTD) benefits until
your physician determines you have reached maximum medical improvement
or you are released to return to the employment in which you were
injured or a job with similar physical requirements. You may receive
weekly compensation of 66 2/3% of your gross wages at the time
of injury – up to the maximum rate of $504 a week. These
benefits are payable after 4 days or 32 hours of wage loss, whichever
is less. If you also receive social security disability benefits,
your weekly compensation benefits may be reduced by up to ½
of your social security payment.
If I can work with a temporary work restriction, am I eligible
for benefits?
Possibly. If, prior to reaching maximum healing, you have a physical
restriction, suffer an actual wage loss and are approved to return
to modified or alternative employment, you may be eligible for
temporary partial disability benefits. The benefits:
· are the difference between your average weekly wage at the time
of injury, subject to the maximum of 40 hours a week, and the
actual wages you earn in the modified or alternative employment;
· may not exceed your temporary total disability rate or $504
a week; and
· are limited to 26 weeks with an extension available from the
insurer.
If you continue to be disabled you may requalify for temporary total disability (TTD) benefits if a modified or alternate position is no longer available. (Some restrictions apply)
What happens if I am partially disabled because of the injury?
If your physician determines you have reached maximum medical
improvement (MMI), you may be eligible for permanent partial
disability (PPD) benefits if you have an actual wage loss
resulting from the injury and a permanent impairment rating greater
than zero. If you have no wage loss, you remain eligible for an
impairment award only. Contact your insurer for more information.
What if I can no longer work because of the injury?
If, your physician determines you have reached maximum medical
improvement (MMI) and you can't return to any regular employment,
you may be eligible for permanent total disability (PTD)
benefits. Regular employment means recurring work performed for
remuneration in a trade, business, profession or other occupation
in the state.
The benefit rate is the same as for temporary total disability (TTD). Benefits are available until you are eligible to receive social security retirement benefits. Benefits are subject to a cost of living increase. If you also receive social security disability payments, your weekly compensation payments may be reduced by up to ½ of your social security payment.
DEATH BENEFITS
If an on-the-job injury or an occupational disease is the cause of death, your spouse and unmarried children may receive weekly compensation benefits at the temporary total disability (TTD) rate. Your spouse receives benefits for 500 weeks or until remarried. Unmarried children receive benefits until age 18, or age 22 if attending an accredited school or apprenticeship program. If you have no spouse or unmarried children, dependent parents, brothers or sisters may be eligible for weekly benefits. Burial expenses, not to exceed $4,000, are also payable.
REHABILITATION BENEFITS
You may be eligible for rehabilitation benefits if;
· you have a permanent medical impairment resulting from your
injury and cannot return to your time of injury job or a job with
similar physical requirements and;
· you have a medical impairment rating 15% or greater, or
· you suffer an actual wage loss.
RIGHTS & REMEDIES
If you disagree with a decision made by your insurer, you may request a forum depending on the type of dispute.
| DISPUTE | FORUM |
| Attorney Fee | Administrative Review 444-6539 |
| All Benefit Issues | Mediation 444-6534 |
| Administrative review,
mediation and contested case hearing decisions can be appealed to the Court. Appeals from the Court go directly to the Montana Supreme Court. |
Workers' Compensation
Court 444-7794 |
If you have any questions, please call the Employment Relations Division at (406)444-7751 or (406)444-3089.
Forms are now available online at our website.
The address is: erd.dli.mt.gov/wcclaims/wcchome.asp
