Injured on the Job?
If you are injured when you are at work, the key to getting back to work is early intervention. It is extremely important to notify your employer of your work-related injury or illness. As your employer’s workers’ comp insurance company, it is our mission at LWCC to help you successfully return to work as quickly and safely as possible.
Getting Medical Care
As part of helping you return to work, LWCC will provide you with reasonable and necessary medical treatment if our investigative claim representative confirms that your injury is covered under Louisiana’s workers’ compensation state law. If so, you should receive benefits as outlined under the law in a timely manner. If your claim is covered and compensable, you will be contacted by a return-to-work (RTW) claims representative within 24 hours after your claim is transferred from the ICR. Your employer and medical provider will be contacted within 48 hours.
Choosing a Physician
Although you are not required to, you may wish to choose a physician in OMNET®, LWCC’s statewide occupational medicine network. This specialized group of doctors, hospitals, physical therapists, and other highly trained occupational medicine professionals will provide you with quality medical care and timely appointments for treating your work-related injury. Here’s how to take advantage of this unique benefit:
- Select a healthcare provider near you by calling 800-85-OMNET. Your employer may already have a relationship with an OMNET® managing care physician, but by law you have a right to choose your physician.
- Tell your physician that your injury is work-related and that LWCC is the insurer, and supply the doctor with the name of your employer.
The cost of medications prescribed to treat your workplace injury is paid by LWCC. We work with Healthesystems, a pharmacy benefits manager (PBM) that helps manage all pharmacy benefits.
Ask your employer for a First Fill form to take to your doctor on your initial visit. This will prevent you from incurring out-of-pocket expenses. Select a Healthesystems network pharmacy so your medications will be evaluated for potentially harmful interactions with other drug therapies and known medical conditions. You can search for a network pharmacy on the Healthesystems website.
You may qualify for convenient mail order pharmacy service and have medications delivered to your door. Call Healthesystems’ 24-hour customer service center at 800-758-5779 for eligibility details, or submit an enrollment request on their website.
WorkAction: LWCC’s Return-to-Work Program
After suffering an injury, the key to getting back to work is early intervention. LWCC’s return-to-work program, WorkAction, capitalizes on the window of opportunity right after an injury occurs. We will help you and your employer create a return-to-work plan that works for you. Here’s what you can expect:
- Site Visit
An LWCC claims representative will visit your worksite to analyze your current job and help identify appropriate transitional duty work.
- Job Analysis
The analysis includes a written report as well as taking photographs or video footage of the job being performed. The job analysis is forwarded to the treating physician for review.
- Physician Review
The physician will review the analysis and make a recommendation about your ability to return to work, along with any restrictions.
LWCC will follow up to help create a transitional duty plan based on the physician's recommendation.
What to Expect When Returning to Work
In the vast majority of the cases LWCC handles, injured employees recover quickly and are back to their regular job duties within a week. Still others, after a short recovery away from work, are able to resume full-duty work. But sometimes when releasing the employee to return to work, depending on the physical requirements of the injured employee’s job and the seriousness of the injury, the treating physician may temporarily limit some types of activities that the employee previously performed in his job.
When that happens, LWCC works with your employer to explore different options that comply with your physician’s restrictions, with the goal of ultimately returning you to your original job. Here are some different options that your employer may consider:
- Light Duty. You are assigned a less physically intense job until the restrictions are lifted.
- Modified Duty. You return to the same job, but it is modified so that you can perform it safely.
- Work Hardening. You return to work part-time and gradually work up to your pre-injury level.
Once your employer offers you a transitional duty job within your doctor’s restrictions, you could risk losing workers’ compensation benefits if you don’t accept it and return to work. If your employer pays you less in any one of these options than in your regular job, don’t worry. If the wages of your new transitional duty assignment are not at least to 90 percent of your average weekly wage (AWW), you are entitled to receive two-thirds of the difference. Remember, transitional duty is a temporary arrangement designed to ease you back into your regular job. Depending upon your employer’s business needs and your recovery progress, the job could last from 14 days to 120 days or more. In addition, your transitional duty may change as your physician lifts restrictions. Eventually, you should be able to resume regular duties.
Average Weekly Wage (AWW)
AWW is determined by averaging your pay from the last four full weeks of work immediately before your injury. If you are injured in the middle of a pay period, the previous week is used to calculate four full weeks prior to your injury. A full-time employee’s wages are based on 40 hours, regardless of how many hours the employer defines as full time. Overtime, commissions, and other taxable pay are also included in the calculation, subject to limitations. This is the most common method of determining your AWW, but there are other ways depending upon how you are paid (for example, annual, monthly, unit, commission, or other basis, as well as seasonal employment). Note: We will obtain your wage information from your employer; however, you may tell your claims rep of any and all forms of compensation you receive to ensure you are paid correctly. The amount of your weekly TTD benefit is subject to a minimum and maximum dollar amount as determined by the Louisiana Workforce Commissions’s Office of Workers’ Compensation Administration.
Compensation Rate for Temporary Total Disability (TTD)
For an injury resulting in TTD, the rate is 662/3 percent of the AWW, subject to the minimum/maximum weekly benefits allowed at the time of the injury. Employees will receive the greater of the minimum weekly benefit or the full two-thirds of their AWW, but no more than the maximum weekly benefit.
Supplemental Earnings Benefit (SEB)
If you are able to return to a job or begin earning any income that is less than 90 percent of your pre-injury wages, you may be entitled to two-thirds of the difference to supplement your earnings. This type of payment is called supplemental earnings benefit (SEB).
You can receive SEBs until you are released to full duty, are earning pre-injury wages or hit the maximum of 520 weeks, whichever occurs first. (Temporary total disability wage replacement benefits are included in the 520-week maximum.) SEB checks are mailed monthly.
If the same work-related injury causes a second period of disability, you may be eligible for additional benefits, provided it has been less than one year since you received your last benefit check.
If the same work-related injury causes you later to earn less income, you may be eligible for additional SEB benefits, provided it has been less than two years since you last received an SEB payment.
Frequently Asked Questions
This is only a general explanation of Louisiana’s workers’ compensation system and how it affects employers and employees. Details on specific regulations, coverage, benefits and other technical aspects are not included.
- What is workers’ compensation?
- Who receives benefits?
- What benefits are payable?
- How is my weekly lost wages (indemnity) benefit amount calculated?
- When and how often will I receive a check?
- Can I choose my own doctor?
- How does LWCC handle pharmacy benefits?
- What are the Medical Treatment Guidelines (MTG)?
- Where can I obtain a copy of the Medical Treatment Guidelines?
- Who is required to use the Medical Treatment Guidelines?
- What is the LWC-WC Form 1010 (First Request) and when is it initiated?
- What is the LWC-WC Form 1010A (First Request) and when is it initiated?
- How is a claim for denied services submitted to the OWCA medical director?
- Who can file the LWC-WC Form 1009 (Disputed Claim for Medical Treatment)?
- When filing the LWC-WC Form 1009, what other information is required?
- What if any of the parties disagree with the determination issued by the OWCA medical director?
- If the medical provider is in compliance with the MTG, are they still required to obtain approval from the (C/SIF) to exceed the statutory limit of $750?
- What form do I need to complete to receive workers’ compensation indemnity (lost-time wages) benefits?
- Where can I find the required OWCA forms?
- Who is LWCC?
- What is the Louisiana Office of Workers’ Compensation Administration (OWCA)?
- What is the Louisiana Department of Insurance?
1. What is workers’ compensation?
Workers’ comp is a type of insurance that provides health-care and disability benefits when you experience a job-related injury. Premiums for this coverage are paid totally by your employer. Because these benefits are outlined under state law, you should receive them timely without needing to hire an attorney, even if the accident was your fault. (As with any law, there are a few exceptions, such as if the injury was due to your intoxication, horseplay, or fist fighting.)
2. Who receives benefits?
Just about all employees who are injured on the job may be eligible for workers’ compensation benefits. The key question is whether the condition happened while you were at work and because of your employment. This broad definition covers many common workplace injuries. Some employers are not required to provide workers’ comp insurance.
3. What benefits are payable?
Four basic types of benefits may be provided if you are injured on the job:
- All reasonable and necessary medical care. This includes reasonable and necessary doctor bills, medicine, hospital charges, lab tests, x-rays, crutches, and mileage expenses incurred for treatment—in short, everything medically necessary to treat the effects of the injury. There is no deductible or dollar limit for you for covered treatment.*
- Disability benefits. These are tax-free weekly payments that partially replace lost wages if you are injured and cannot return to work because of your injury. Supplemental earnings benefits (SEBs) are calculated at two-thirds of the your average weekly wage. Benefits also are paid if you are unable to earn 90% of your pre-injury wages because of the injury.
- Death benefits. If you die within two years of the last treatment as the result of any job-related accident, your surviving spouse and/or dependent child(ren) (or other dependents) may be entitled to weekly indemnity benefits pursuant to the Louisiana Workers’ Compensation Act. If you have no surviving dependents, your surviving parents are entitled to a one-time benefit of $75,000 each. The employer or its workers’ compensation insurer shall also pay, in addition to any other benefits, reasonable burial expenses not to exceed $8,500.
- Rehabilitation services. The goal of rehabilitation services is to return a disabled employee to work, with a minimum of retraining, as soon as possible after an injury occurs. The first appropriate option among the following must be chosen for the employee:
- Return to the same position
- Return to a modified position
- Return to a related occupation suited to the claimant’s education and marketable skills
- On-the-job training
- Short-term retraining program (less than twenty-six weeks)
- Long-term retraining program (more than twenty-six weeks but not more than one year)
4. How is my weekly lost wages (indemnity) benefit amount calculated?
To determine how much your wage replacement will be, you must first determine your average weekly wage (AWW). For most people, their AWW equals the average gross wages during the four full weeks before their accident. You will be paid 66% of your AWW. This is referred to as your compensation rate (CR).
Gross wages are the total amount of your pay before deductions for taxes, social security, retirement plans, health insurance, etc. It may also include taxable fringe benefits. If you are supposed to pay income taxes on it (or if it is a pre-tax retirement account like a 401K), then it should be figured into the calculation of your gross wages.
AWW is based upon your gross income in the “four full weeks” before your accident. If you were a full-time employee and usually worked 40 hours per week, the calculation may need to be adjusted if any one of the following occurred in the four weeks immediately before your accident:
- You had a full or partial week’s vacation
- You worked less than 40 hours during the week due to a holiday
- You were laid off for part or all of a week
- You were required by your employer to work a reduced schedule
If any of the conditions listed above affected your work schedule during the four full weeks before your accident, the Louisiana workers’ compensation law says that you should be credited with a full 40 hours of income for that week when calculating your AWW.
If you worked two jobs at the time of your injury, your AWW equals (1) the hourly rate you earned at the job in which you were injured, multiplied by (2) the total hours you worked each week in both jobs, or 40 hours per week, “whichever is less.” Thus, if you were working in two jobs at the time of your injury, your AWW is not necessarily based upon the higher paying job and will include a maximum of 40 hours per week.
If you have a work-related illness (rather than an “injury”), the date of your “accident” is considered to be either the last day you worked for the employer, or the last date upon which you had a harmful exposure to the condition in your employment that cased your illness, whichever is later. You would then calculate your AWW using that date as your “accident date.”
5. When and how often will I receive a check?
For claims that fall under the state’s jurisdiction, there is a seven-day waiting period before benefits start. If your disability exceeds two weeks, the waiting period will be paid to you.
6. Can I choose my own doctor?
By law, if you suffer a compensable work-related injury or illness, you may choose a treating physician for an initial evaluation or consultation and may switch providers without seeking approval from your employer or the insurer. However, you must seek permission to switch from one medical provider to another within the same field or specialty.
LWCC encourages you to choose a health-care provider in our occupational medicine network, OMNET®. OMNET® is a statewide network of over 2,000 medical providers that specialize in occupational medicine. If you choose an OMNET® provider, you will receive the best care possible for a faster recovery and return to work. You are also guaranteed appointments with specialists within 72 hours.
While you are free to select a treating physician who is not an OMNET® provider, the physician must gain approval from the payor (insurance carrier or self-insured employer) to continue diagnostic testing or treatment beyond $750 worth of care, unless it is provided under emergency circumstances. Requests for authorization to exceed the $750 limit for medical services may be made by submitting the Louisiana Workforce Commission’s Office of Workers’ Compensation Administration’s (OWCA) LWC-WC Form 1010 (Request for Authorization/Carrier or Self-Insured Employer Response).
Once you choose a treating physician and an initial evaluation is given, the OWCA’s medical treatment guidelines (MTG) and utilization review (UR) rules should be followed when the treating physician requests care above the $750 nonemergency medical care cap.
7. How does LWCC handle pharmacy benefits?
LWCC has partnered with Healthesystems to provide retail and mail-order pharmacy benefits to our injured workers. You will receive a pharmacy card for ongoing prescriptions and refills. The card may be used at local participating Healthesystems network pharmacies.
To access a list of participating pharmacies, visit www.healthesystems.com, or call the customer service center at 800-758-5779.
8. What are the medical treatment guidelines (MTG)?
In 2009, the Louisiana Legislature passed R.S. 23:1203.1 which provided the process of adopting a medical treatment schedule with the purpose of assisting with the decision making process regarding proposed medical treatment for the injured worker. The medical treatment guidelines became effective July 13, 2011.
9. Where can I obtain a copy of the medical treatment guidelines?
A copy of the MTG can be located on the Louisiana Workforce Commission’s website at www.laworks.net. Click on the menu item “Businesses” then click on “Workers’ Compensation.” There you will find a link to the guidelines.
10. Who is required to use the medical treatment guidelines?
All medical providers and insurance carriers are expected to comply with the MTG.
11. What is the LWC-WC Form 1010 (First Request) and when is it initiated?
The health-care provider (HCP), when seeking authorization to exceed the $750 statutory limit for medical services, completes the LWC-WC Form 1010. Section #1 and #2 of the LWC-WC Form 1010 must be completed by the requesting HCP. The LWC-WC Form 1010 and all supporting medical documentation are faxed to the insurance carrier/self-insured employer (C/SIF) and/or the designated utilization review (UR) representative. The C/SIF must respond within five business days by returning the LWC-WC Form 1010 to the requesting HCP with their decision determination designated in Section #3 of the form.
12. What is the LWC-WC Form 1010A (First Request) and when is it initiated?
The C/SIF or UR representative will initiate the LWC-WC Form 1010A when the medical documentation submitted with the LWC-WC Form 1010 does not sufficiently provide the necessary information to complete the review of the requested medical services. The HCP must respond to the request within 10 business days from the date of receipt. Failure to submit the requested information shall result in a withdrawal of the request for authorization.
13. How is a claim for denied services submitted to the OWCA medical director?
For any dispute as to whether the recommended care, services, or treatment is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is reasonably required, any aggrieved party shall file a LWC-WC Form 1009 (Disputed Claim for Medical Treatment) appeal with the Office of Workers Compensation Administration medical director.
The LWC-WC Form 1009 must be completed and submitted, via mail, to the OWCA Medical Director along with the LWC-WC Form 1010, LWC-WC Form 1010A (if applicable), and supporting medical documentation.
The LWC-WC Form 1009 must be filed within 15 calendar days of the date of denial by the C/SIF or the date the denial was received. The medical director shall render a decision as soon as is practicable, but in no event, not more than thirty calendar days from the date of filing.
IMPORTANT: A copy of the completed LWC-WC Form 1009 must be mailed to all involved parties.
14. Who can file the LWC-WC Form 1009 (Disputed Claim for Medical Treatment)?
The statute states “any aggrieved party” shall file, within 15 calendar days, an appeal with the OWCA medical director. Aggrieved party is defined as “a person whose personal or property rights are adversely affected by a judgment or decree of a court.”
The LWC-WC Form 1009 must be received in the OWCA Medical Services Section no later than 15 calendar days from the date on the written denial letter issued by the C/SIF.
15. When filing the LWC-WC Form 1009, what other information is required?
In addition to the completed LWC-WC Form 1009, the following information is necessary:
- A copy of the LWC-WC Form(s) 1010 and 1010A
- A copy of the Peer Review denial from the C/SIF
- Copy of the medical record(s) substantiating the medical necessity of the requested services
Requests submitted without the supporting documentation as stated above will be returned to the requesting party.
Any LWC-WC Form 1009 with incomplete information will also be returned to the requesting party.
16. What if any of the parties disagree with the determination issued by the OWCA medical director?
Any party feeling aggrieved by the determination of the medical director shall seek a judicial review by filing Form LWC-WC 1008 (Disputed Claim for Compensation) with the appropriate hearing office within 15 days of the date said determination is mailed to the parties. The filed LWC-WC 1008 shall include the following:
- Copy of the Form LWC-WC 1009 (Disputed Claim for Medical Treatment)
- Copy of the decision of the medical director
A party filing such appeal must simultaneously notify the other party that an appeal of the medical director’s decision has been filed.
The decision of the medical director may be overturned when it is shown by clear and convincing evidence that the decision of the medical director was not in accordance with the provisions of the Louisiana Workers’ Compensation’ MTG.
17. If the medical provider is in compliance with the MTG, are they still required to obtain approval from the (C/SIF) to exceed the statutory limit of $750?
Yes. Even if the recommended medical treatment is in compliance with the MTG, all medical services exceeding the statutory limit of $750 will require the prior approval from the C/SIF as is stated in the Workers’ Compensation Statute (R.S. 23:1142).
18. What form do I need to complete to receive workers’ compensation indemnity (lost-time wages) benefits?
You must submit a completed LWC-WC Form 1020 (Employee’s Monthly Report of Earnings) within 30 days following your job-related injury, and every 30 days as long as you receive indemnity benefits. Your benefit payment may be suspended if you do not timely submit this report. The form is not required if you only received medical benefits.
19. Where can I find the required OWCA forms?
The forms are posted on the website, www.laworks.net. You can access the form from the numerical listing by clicking on “Downloads,” then “Workers’ Compensation,” then “Forms–Numerical.”
20. Who is LWCC?
LWCC is a private, nonprofit workers’ compensation insurance company. Through licensed insurance agents, we sell workers’ compensation insurance policies to thousands of Louisiana businesses. LWCC is not a state agency and does not set the laws regarding workers’ compensation. LWCC does pay workers’ compensation benefits according to the law to the injured employees of those businesses who have purchased a workers’ comp policy with us.
21. What is the Louisiana Office of Workers’ Compensation Administration (OWCA)?
The OWCA is part of the Louisiana Workforce Commission (LWC) and is not affiliated with LWCC, which is a private insurance company. The OWCA is responsible for regulating workers’ compensation, self-insurance, and overseeing compliance. In addition, OWCA hearing officers settle disputed claims statewide. The Medical Services Section resolves conflicts over the necessity, advisability, and cost of certain healthcare services and treatment. The agency also encourages employers to adopt safety and health policies and procedures.
22. What is the Louisiana Department of Insurance?
The Louisiana Department of Insurance is responsible for watching the financial stability of insurance companies operating in the state. These companies are required to meet strict statutory financial requirements and are audited regularly. The department also investigates consumer complaints concerning specific companies. If the problem concerns casualty insurance, the Consumer Affairs Division can be reached at 800-259-5300. If the problem is about life and health insurance, call 800-259-5301. The department does not sell or place insurance.
*There is one exception when the injured employee chooses a brand-name drug in filling a prescription when a generic is both available and allowed by the prescribing physician. In these cases, the employee is required to pay the difference in cost between the generic and the brand-name drug.