Definitions of Common Terms Used In Workers’ Compensation Claims

These are only very general definitions of terms that are commonly used in workers’ compensation claims. There are many legal complexities associated with most of these terms.

Authorized treating physician - attending physician; the medical professional who is recognized as the primary treater of the injured employee.

Carrier - the insurance company administering the workers’ compensation claim.

Claimant - the injured employee, or the surviving dependents of a deceased employee.

Claim rep - claim representative - a skilled hearing representative who is not a lawyer. Can be from an insurance company or from a union.

CMS - Center for Medicare and Medicaid Services. Settlements are often submitted to CMS for approval when the claimant is on Medicare or is expected to be eligible for Medicare in the future.

Compensable - when an injury or illness has a sufficient connection to the employment so that it arises out of and in the course of the employment.

Commissioner’s exam - a physical or mental status exam ordered by a commissioner to resolve differing opinions between the claimant’s treating physician and the employer’s physician. Also known as a 31-294(f) exam, or CME.

Concurrent employment - a job other than the one at which the claimant was injured, at which the claimant was employed during the 52 weeks prior to the date of injury. Wages from concurrent employment are included in to increase the base compensation rate under certain circumstances.

Connecticut Insurance Guaranty Fund - This is a fund that pays claims against insolvent insurers that are Connecticut companies.

Contested claim - when an employer denies liability for the injury or illness, or for some portion of a claim for benefits.

DWR - formerly Division of Workers’ Rehabilitation, now Rehabilitation Services - provides re-training, schooling, job placement and other vocational services to injured workers with accepted or settled claims who can no longer perform their former jobs because of injury.

Date of injury rule - one of the most important principles in workers’ compensation. The rights and liabilities of the parties are fixed as of the date of injury; that is, the law in effect on the date of injury controls all aspects of the claim. There are a few exceptions to this rule which are too complicated to explain in this glossary.

Ex-parte communications - verbal or written communications between parties that are not shared with opposing parties or an opposing party’s lawyer, such as between the respondent’s attorney and the treating physician, or between the claimant’s counsel and the respondent’s medical expert. Ex-parte communications are not permitted with a commissioner, in writing or verbally. Any communication with a commissioner must be shared with the other side.

First Report of Injury - A form that the employer is obliged to complete and submit to the Workers’ Compensation Commission after a workplace injury or illness occurs. A First Report of Injury is not a legally sufficient substitute for formal notice of claim. See Form 30C below. Click here to see a sample First Report of Injury.

Form 30C - written notice of claim to the Commission. This is a form which can be obtained from the Commission’s website, or by mail. Click here for a copy of the form.

Form 36 - the employer’s request to terminate a particular type of benefit. Objections must be filed with the commission within 15 days or the request to terminate will be granted automatically. You can object by calling the commission and asking for a hearing, or by sending a written objection, preferably by fax. Click here to see a sample Form 36.

Form 42 - Physician’s Permanent Impairment Evaluation to be completed by the examining licensed physician to report a claimant's permanent partial loss or loss of use of a body part, as well as the likely date of the claimant's maximum medical improvement. Click here to see a sample Form 42.

Form 43 - the employer’s denial of some aspect of a claim or all of it. Many health insurers require a Form 43 before paying for medical treatment in a contested workers’ compensation claim. Click here to see a sample Form 43.

Formal - a workers’ compensation trial, usually scheduled in three-hour segments several months apart.

FCE - Functional capacity exam - a sometimes discredited method of testing the employee’s physical capabilities to assess his or her ability to perform gainful employment.

Fund - The Second Injury Fund - responsible for claims when the employer is uninsured. Also responsible for some reimbursements to carriers.

Guaranty Fund - the Connecticut Insurance Guaranty Fund. This is a fund that pays claims against insolvent insurers that are Connecticut companies.

IME - independent medical exam - an exam obtained by a respondent to question the treating physician’s opinions and/or decisions, also known as RME - respondent’s medical exam.

Indemnity benefits - compensation for lost wages, as opposed to payment for medical treatment.

Informal - an informal proceeding with all sides present, where a commissioner hears what the issues are and tries to resolve them informally.

Light duty - Work prescribed by a physician to fall within certain physical restrictions while the employee continues to heal from a compensable work-related injury or occupational disease. Modified when you are unable to do your usual job, but you can do alternative work.

Managed care plan - a plan requiring employees with accepted injuries to obtain medical treatment from a specified list of doctors and other health providers. Such a plan must be approved by the Chairman of the Commission, and must have been in effect on the claimant’s date of injury to apply to the claim.

Misclassification - an employer’s classification of those who are actually employees as independent contractors, or classification of manual workers as clerical workers, so as to reduce or avoid workers’ compensation premiums. There are other forms of misclassification.

MMI or maximum medical improvement - when the treating physician has determined that continued treatment will not result in healing or curing the injured worker’s injuries or condition.

Moratorium - a suspension of indemnity and medical workers’ benefits until the amount recovered by the claimant in a third-party civil claim is exhausted.

MSA or Medicare set-aside - an amount allocated in a workers’ compensation settlement agreement for future medical care related to the injury or illness.

Nurse case manager - healthcare professional hired by a respondent to facilitate the injured worker’s medical treatment and to reduce indemnity costs and costs of treatment.

PPD or permanent partial disability - also known as “specific” or “rating” - the permanent impairment to the affected body part is assessed by a physician and a number of weeks of benefits are paid based upon Section 31-308(b) of the statutes. Click here for a detailed article on PPD.

PPO or Preferred Provider Organization - A list of medical providers designated in a plan approved by the Commission for a particular employer which limits the choice of physicians to a network of participating providers.

Pre-formal - hearing after an informal or a series of informals, but prior to a formal.

Pro se - a claimant who doesn’t have an attorney. Can also refer to an uninsured employer.

Protocols - Guidelines issued by the Workers' Compensation Commission regarding appropriate medical treatment; they are advisory only.

Rating - same as PPD above

Recurrence - a flare-up of the original injury or illness. The term has legal significance that affects entitlement to benefits.

Relapse - a flare-up or recurrence of the original injury or illness. The term has legal significance that affects entitlement to benefits.

Respondent - the employer and its insurer, which, absent a conflict of interest, are generally considered the same entity for purposes of workers’ compensation hearings. The term is also used to refer to the Second Injury Fund and the Guaranty Fund when they are parties to a claim.

RME - respondents’ medical exam, also known as IME. See IME above.

Second Injury Fund - responsible for claims when employer is uninsured. Also responsible for some reimbursements to carriers.

Self - insured - an employer that self-insures its workers’ compensation liability, rather than contracting with an insurance company. Self-insured employers often hire insurance companies to administer their workers’ compensation claims.

Specific - same as PPD above

Statute of non-claim - statute of limitations for filing of claim with Commission or asking for a hearing. For accidental injury - one year from date of injury. For repetitive trauma claims, one year from date of last repetitive trauma. For occupational disease claims - three years from date the claimant knew or should have known he had an occupational disease. For heart and hypertension claims, the law is complicated; it's safest to file claim as soon as there is knowledge of a hypertension, heart, or circulatory problem.

Stipulation or stip - a settlement of the workers’ compensation claim, or a partial settlement

Substantial contributing factor - when the work activity is more likely than not a factor in the development or cause of the injury or medical condition. Work activity does not have to be the major contributing factor for the condition to be compensable, but it must be a significant factor. Reference should be made to case law interpretations.

Third-party claim - a civil lawsuit brought against a third-party (i.e., not the employer or the injured employee), whose conduct causes, at least in part, a work-related accident or illness.

TP - temporary partial disability benefits, also known as 31-308(a) benefits - available when the claimant’s work capacity is restricted in some way by the effects of the injury. These benefits are available prior to the time that a claimant reaches maximum medical improvement (MMI) and is rated. These are mandatory benefits as long as the claimant has an impairment attributable to the workplace injury or illness and is actively looking for work. Depending on the circumstances of the claim, these benefits may not be available to those living outside of Connecticut. The law is still not clear as to whether undocumented workers are eligible for these benefits.

TPA - third-party administrator - an insurance company or insurance administration company that handles workers’ compensation claims for self-insured employers

TT - temporary total disability benefits - available when the worker cannot perform any type of work at all because of the injury

Undocumented workers or undocumented aliens - workers born in foreign countries who are in the United States illegally

Uninsured employer - an employer who does not have workers’ compensation insurance coverage as of the date of an injury or illness

Utilization review - a procedure used by the respondent insurance carrier to evaluate the necessity and appropriateness of medical care in workers' compensation cases. This review is subject to significant limitations, and only may be used where the employer has a medical care plan that has been approved by the Chairman of the Commission that is in place as of the date of injury. Utilization review denials should never be accepted without a fight.

VA - also Voluntary Agreement - a contract (usually four copies on colored paper) that identifies the claimant, the employer and insurer, the date of injury, the compensation rate, and other information pertinent to the claim. Both sides sign the VA and it is approved by the Commission. It is not a final settlement. Voluntary agreements should be very carefully scrutinized before signing.

Wage differential - a comparison between the wages an injured worker is able to earn after the injury or illness and the wages he or she would have been able to earn if the injury or illness had not occurred.

Work search - the form on which an injured employee with limitations attributable to a work injury or illness documents efforts to find work within his or her restrictions in order to obtain temporary partial disability or 308a benefits. Click here for a copy of this form.

290a claim - It is illegal to discriminate against an employee for exercising his or her right to claim or receive workers’ compensation benefits. An employee who believes that such discrimination has occurred can bring a claim either in the Workers’ Compensation Commission, or in the Connecticut Superior Court. “290a” refers to the statute that prohibits the discrimination.

299b carrier - the last insurance carrier on the risk for a repetitive trauma claim involving periods of exposure with different insurers; usually the carrier responsible for administering the claim and primary payor of benefits.

308a or Section 31-308a benefits - Also known as post-permanency wage loss benefits. These are similar to temporary partial benefits, but are discretionary, and are awarded after any specific award is paid. For injuries after July, 1, 1993, these benefits are capped at the same number of weeks as the specific award. These benefits may not be available for non-residents of Connecticut, depending on the circumstances of the claim. The law is not yet established as to whether undocumented aliens can receive this type of benefit.

© Copyright by Donna Civitello.  All Rights Reserved.

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Carter & Civitello

Attorneys at Law
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