Workers Compensation Terms | Intact Insurance Specialty Solutions

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A

Average Weekly Wage (AWW): AWW is used to determine the employee’s rate of temporary total or partial disability or permanent total disability. It is usually determined by dividing the employee’s total wages for the previous year by 52.
Applicant Attorney (AA): Attorney for the claimant or injured worker.

B

Benefit Review Conference (BRC): Some states offer BRCs to help resolve issues and disputes resulting from on-the-job injuries. BRCs vary by state, but typically involve an informal mediation conference administered by a neutral hearing officer or ombudsman. If a dispute is resolved at a BRC, an agreement may be written and signed by the injured employee and a representative of the employer (or the employer’s insurance carrier or third-party administrator).

C

Claims Representative (CR)
Case manager (CM), Nurse Case Manager (NCM), Field Case Managers (FCM) or Telephonic Case Managers (TCM): CMs are sometimes assigned by third-party administrators or workers compensation carriers to monitor and assist with the coordination of medical and disability aspects of workers compensation claims. CMs are generally nurses or social workers. Some are employees of the third-party administrator or workers compensation carrier, while others are essentially independent contractors. On occasion, CMs attend medical appointments with injured workers, particularly in cases involving serious injury.
Carpal Tunnel Syndrome (CTS): CTS is a nerve condition in the wrist and is frequently the subject of workers comp claims.
Complex Regional Pain Syndrome (CRPS): Chronic pain that usually affects the arms or legs, that typically develops after an injury, surgery, stroke but the pain is usually out of proportion to the severity of the original injury.

D

Date of Injury (DOI), Date of Accident (DOA) or Date of Loss (DOL)
Defense Counsel (DC): Attorney representing the employer or insurance carrier.

E

Employee (EE)
Employer (ER): Attorney representing the employer or insurance carrier.

F

Functional Capacity Evaluation (FCE): An FCE is a series of tests administered to a workers compensation claimant by a physical therapist or other health care professional. They can be beneficial in determining an injured worker’s capabilities and restrictions. FCE evaluators can review job descriptions and make a determination regarding whether the injured employee is capable of performing certain jobs. After a claimant undergoes an FCE, the evaluator typically provides a detailed report on the results, including the claimant’s capabilities and restrictions.
Full Duty (FD)
First Report of Injury (FROI): Following an on-the-job injury, employers are usually required to file an FROI with the state administrative agency that oversees workers comp.
Future Medical Care (FMC): Employers are typically responsible for payment of medical expenses associated with their employees’ on-the-job injuries. Medical benefits are often lifetime benefits (i.e., employers are generally on the hook for future meds for the injured employee’s lifetime as long as the medical expenses are related to the underlying job injury). In some states, the employee’s right to future meds can be terminated when the employee and employer agree to the terms and a judge or appropriate administrative authority approves the agreement.

I

Independent Medical Examination (IME): As the name suggests, an IME is an assessment of a person’s physical condition (i.e., an evaluation) made by an independent physician. Many states authorize the use of IMEs in the context of workers compensation claims. An IME can be a valuable tool in your arsenal, particularly if you are suspicious about possible fraud or some other abuse of the workers compensation system.
Impairment Rating (IR): An IR (sometimes called a physical impairment rating) is a medical assessment of a claimant’s injury represented by a percentage value. A physician may assign an IR to the body as a whole or to a specific body part. The rating may then be used to calculate the workers comp benefits owed to a claimant. Impairment ratings are particularly important in determining permanent partial disability benefits.
Injured Worker (IW) or Injured Employee (IE)

L

Light Duty (LD)
Impairment Rating (IR): An IR (sometimes called a physical impairment rating) is a medical assessment of a claimant’s injury represented by a percentage value. A physician may assign an IR to the body as a whole or to a specific body part. The rating may then be used to calculate the workers compensation benefits owed to a claimant. Impairment ratings are particularly important in determining permanent partial disability benefits.
Life Expectancy (LE): LE is sometimes a factor in determining the value of benefits owed to an injured employee, particularly in claims for permanent total disability.

M

Maximum Medical Improvement (MMI): Generally, to resolve a workers compensation claim, the claimant must reach MMI. Typically, MMI is assigned by a treating physician when an injured employee’s condition has stabilized to the point that no major change is expected in his medical condition, despite continuing medical treatment. After MMI is assigned, the payment of temporary workers compensation benefits may be suspended.
Medicare Set-aside Agreement (MSA): MSAs sometimes come into play when a workers compensation case is settled to include the closing of future meds and the claimant is a Medicare beneficiary or is expected to become one in the near future. As part of the settlement, money for projected medical expenses associated with the workers compensation injury is “set aside” into a bank account. The set-aside funds are used solely to pay for medical expenses related to the injury that would otherwise be paid by the employer. MSAs are designed to ensure that the federal government doesn’t get saddled with medical expenses (via Medicare) that should be paid in accordance with state workers compensation laws.
Medical Provider Network (MPN): Specific to California is a network of healthcare providers approved by the CA DWC to treat workers injured on the job. These providers are required to follow all treatment guidelines established by the DWC.

O

Occupational Therapy (OT): Assessments and treatment used to develop or maintain daily living or work skills for people with physical, mental or cognitive injury.
On-the-Job (OTJ)

P

Permanent Partial Disability (PPD): When a worker has been assigned MMI and is capable of returning to gainful employment but has some loss of function or residual problems as a result of an on-the-job injury, he is entitled to PPD benefits. In short, PPD describes a disability that is less than total. PPD benefits are calculated in different ways in different states, often in accordance with statutorily prescribed formulas. PPD may vary depending on the body part that is injured.
Permanent Total Disability (PTD): PTD benefits are payable to employees who are never able to return to gainful employment. An employee who is determined to be permanently and totally disabled because of an on-the-job injury is entitled to PTD benefits. In many states, PTD benefits are payable for the life of the injured employee. The rate is typically two-thirds of the employee’s AWW.
Physical Therapy (PT): PT is the treatment of a physical injury by use of therapeutic exercise. It can be a valuable tool in getting an injured employee back to work.
Preferred Provider Organization (PPO): A network of medical providers that are knowledgeable and focused on workplace accidents which offers workers compensation cost and care management solutions.

R

Retaliatory Discharge (RD) or Wrongful Termination (WT): These terms are synonymous. Many states have laws in place to make sure you don’t terminate employees in retaliation for filing workers compensation claims. An employee who believes his employer violated those laws may file a claim for RD or WT.
Return to Work (RTW)
RX: Medical prescriptions.

S

Social Security Disability Insurance (SSDI): This benefit is tied to Social Security retirement program but is for workers who become disabled before retirement age.

T

Third-Party Administrator (TPA): In the workers compensation context, a TPA is an organization that processes claims on an employer’s behalf. A large company may be self- insured for workers compensation claims, but may outsource the administration of its claims to a TPA.
Temporary Partial Disability (TPD): When an employee returns to work following an on-the-job injury but hasn’t achieved MMI and is earning less than his preinjury AWW, he is entitled to TPD benefits. Typically, TPD benefits are payable at two-thirds of the difference between what the employee earned at the time of the injury and his current earnings. TPD is perhaps the least common type of workers comp benefit.
Temporary Total Disability (TTD): When an employee is injured on the job and can’t return to work, he is temporarily totally disabled and entitled to receive TTD benefits during his convalescence. TTD benefits are generally paid weekly at the rate of two-thirds of the employee’s AWW, subject to a maximum or minimum rate. For example, an employee who usually makes $600 per week would be entitled to receive $400 per week for the period that he is temporarily and totally disabled. TTD benefits may be discontinued after the claimant reaches MMI.

U

Utilization Review (UR): Many states have procedures for UR. UR is the process used by employers or claims administrators to review whether treatment is medically necessary.

V

Vocational Benefits (voc benefits): In many states, voc benefits are available to injured employees. If an injured employee can’t return to his regular job, he may be a candidate for vocational rehabilitation. In many states, the employer may be on the hook for expenses associated with vocational retraining of an injured employee.
Vocational Expert (voc expert): Either party may obtain the services of a voc expert. Voc experts are often retained when an employee hasn’t returned to work following a job injury or has returned at a lower wage. A voc expert may opine about jobs that the injured employee is capable of performing within his medical restrictions. Often, they will prepare a report and provide a voc rating based on the injured employee’s loss of earning capacity. The voc rating may be used as (1) a tool to determine PPD benefits owed to an injured employee, (2) a settlement negotiation tactic, or (3) persuasive evidence to a fact-finder.

W

Workers Compensation (WC)
Workers Compensation Rate (WC rate): Also referred to as the “comp rate” or “work comp rate,” the WC rate is typically two-thirds of the employee’s AWW or jurisdictionally mandated and is often used to calculate an injured employee’s temporary or permanent benefits.

Intact Insurance Specialty Solutions is the marketing brand for the insurance company subsidiaries of Intact Insurance Group USA LLC. Coverages may be underwritten by one of the following insurance companies: Atlantic Specialty Insurance Company, a New York insurer; Homeland Insurance Company of New York, a New York insurer; Homeland Insurance Company of Delaware, a Delaware insurer; OBI America Insurance Company, a Pennsylvania insurer; OBI National Insurance Company, a Pennsylvania insurer; or The Guarantee Company of North America USA, a Michigan insurer. Each of these insurers maintains its principal place of business at 605 Highway 169 N, Plymouth, MN 55441, except The Guarantee Company of North America USA, which is located at One Towne Square, Southfield, MI 48076. This material is intended as a general description of certain types of insurance coverages and services. Coverages and availability vary by state; exclusions and deductibles may apply. Please refer to your insurance policy or consult with your independent insurance advisor for information about coverages, terms and conditions. Some coverage may be written by a surplus lines insurer through a licensed surplus lines broker. Surplus lines insurers do not generally participate in state guaranty funds and insureds are therefore not protected by such funds.