12.01.02 - Workers' Compensation Claims
CITY OF BOYNTON BEACH, FLORIDA ADMINISTRATIVE POLICY MANUAL CHAPTER: 12 Risk Management Policy No. 12.01.02 SECTION: 01 Risk Management Policy Manual Page: 1 of 11 SUBJECT: 02 Workers’
Compensation Claims A. CONCEPT AND RESPONSIBILITIES: 1. The City of Boynton Beach self-insures its own insurance coverage for employee work-related injuries and illnesses. The City has
assigned the administration of the self-insurance program to the Risk Management Department and provides in its organization the resources necessary to assure employees of the appropriate
medical treatment if injured, to minimize hardships created by the injury, to facilitate their return to duty, and to promote and provide safe working environments and practices. 2.
The City Commission, in approving the City’s Workers’ Compensation Program, adopted a policy, which guarantees that Workers’ Compensation laws will be liberally construed in favor of
the employee; no employee will be discharged or otherwise discriminated against because he reports any work-related injury or otherwise applies for Workers’ Compensation benefits. B.
DEFINITIONS 1. Occupational Injury is defined as a personal injury arising out of and in the course of, employment and includes an injury caused by the willful act of a third person
directed against an employee because of his employment. Treatment for these injuries is outlined below and supervisory personnel shall ensure compliance. 2. Occupational Illness is defined
as a disease caused by certain hazardous conditions or materials when there is a direct causal connection between the condition under which the work is performed and the occupational
disease. 3. Preferred Governmental Claims Services (PGCS) is the workers’ compensation claims adjuster. C. EMERGENCY MEDICAL TREATMENT 1
1. Serious injuries requiring immediate emergency medical treatment, such as profuse bleeding, broken bones, unconsciousness, shock, etc., shall warrant immediate emergency treatment.
2. In emergencies, use the nearest Hospital Emergency Room, which, in the City of Boynton Beach and immediate surrounding areas, is Bethesda Memorial Hospital. In cases of serious injury,
when a listed City-authorized healthcare provider is not immediately available, the nearest medical facility may be used. This exception, however, should be necessary only in rare instances.
(Except in bonafide emergencies, the City denies financial responsibility for medical treatment obtained from doctors or medical facilities other than those on the City-authorized healthcare
provider list). 3. Private or City vehicles should be used to transport a seriously injured employee only when an ambulance or paramedic is not readily available or is unobtainable.
The facility nearest the accident scene shall be used. a. For all emergencies, call for EMS assistance and transport to the local Hospital Emergency Room. b. Administer first aid until
help arrives. Every City facility work site shall have at least one person qualified in first aid and CPR per shift, and a functional first aid kit. (Personnel qualifications will be
monitored through annual employee evaluations; and, first aid kits will be monitored through monthly departmental safety inspections.) c. The injured person’s supervisor or rescue personnel
shall, when possible, advise the hospital emergency room personnel of the nature of injuries of the patient being sent to them. This can be done by telephone. d. Injuries within this
emergency category shall be reported by telephone to Risk Management (THIS DOES NOT ELIMINATE THE NEED FOR WRITTEN REPORTS described under Record Keeping Requirements.) D. INJURIES NOT
CONSTITUTING AN EMERGENCY BUT REQUIRING PHYSICIAN’S CARE 1. The employee or supervisor will call Risk Management to report the incident and secure authorization for treatment and referral
for treatment to a City-authorized healthcare provider. The injuries shall be initially treated by a physician or medical facility from the City-authorized healthcare provider list.
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2. Failure to comply with this provision will result in the employee being responsible for payment for services provided. 3. Upon the notification that an employee has been injured on
the job, the supervisor shall ensure that: a. First aid is administered. b. If treatment by a medical doctor is required, insure that Risk Management is contacted for authorization and
referral to a City-authorized healthcare provider. c. The injured employee shall be taken to the City-authorized healthcare provider as authorized and referred by Risk Management. E.
ESTABLISHING A WORKERS’ COMPENSATION CLAIM It is not necessary for a physician to treat an injury to validate an injury claim. A minor injury such as a small cut, puncture, scratch or
bruise should be treated in the field by someone qualified to administer first aid from a kit. As long as the injury is reported to the supervisor and Risk Management, the employee will
be covered for medical treatment later if the need should arise. F. FIRST AID TREATMENT IN THE FIELD FIELD OR OFFICE Superficial injuries such as minor cuts, bruises, small punctures,
scratches, etc., can be treated in the field or office by an employee, qualified to administer first aid, with a first aid kit. Such injuries shall be made a matter of record by the
supervisor by reporting to Risk Management. HOSPITAL EMERGENCY ROOMS ARE NOT AUTHORIZED FOR SUPERFICIAL INJURIES. G. FALSE CLAIMS An individual who makes a false statement of a material
matter which is willfully made with an intent to deceive, or an individual who collaborates in making a false claim, is committing a criminal act and shall be subject to the full penalties
provided by the law. H. REPORTING PROCEDURE FOR INJURIES 1. Timely reporting of any incident is mandatory. Ensuring full employee benefits and reasonable liability benefits and reasonable
liability adjustments at lowest cost to the City is totally dependent upon proper reporting. It is the responsibility of each employee and supervisors to report all incidents in accordance
with this reporting procedure. 3
2. Reporting of Injuries – Regardless of the degree of injury, the employee shall report its occurrence to his supervisor immediately thereafter, or as soon thereafter during the current
shift as is practicable. Any employee who fails to do this will be subject to disciplinary action. 3. Florida Law requires that every employer who is insured against any liability imposed
by the State shall file with the insurance carrier a complete report of every injury arising out of, or in the course of, employment. The report shall be filed within seven days after
the injury has been reported. The City of Boynton Beach is self-insured. 4. Reporting Injuries requiring Treatment by a Doctor 4.1 All injuries must be reported immediately by telephone
to Risk Management. The employee or supervisor will ensure that all information required for the First Notice of Injury shall be provided to Risk Management. 4.2 Within 24 hours, the
supervisor of the injured employee shall forward the Supervisor’s Report of Incident Form (RM-102) to the Risk Management Department. a. The supervisor shall thoroughly investigate the
cause of each injury occurring within his area of operations and record his findings and recommendations on the Form. b. The original shall be forwarded to the Risk Management Department.
c. The supervisor shall retain a copy of this form for his records. 4.3 All employees who file a workers’ compensation claim must report to the Risk Management Office, as soon thereafter
as possible, to review and sign the First Notice of Injury or Illness Form (LESDWC01). This is to insure the accuracy of the claim information and to develop better communication between
the employee, Risk Management and the Third Party Administrator. 5. Recurrence of a Previous Injury 5.1 Should an employee experience recurrence of a previously reported work-related
injury, he shall report it to his supervisor immediately. 4
5.2 The supervisor or the employee shall call Risk Management immediately. 6. Industrial Sick Time (IST) Time lost because of a new injury is compensable when PGCS determines it is a
valid claim within the meaning of the Workers’ Compensation law. 7. Compensation 7.1 Whenever an employee is totally disabled from duty for a period of no more than seven (7) calendar
days because of an injury determined to be compensated under the provisions of the Worker’s Compensation Act, he/she shall be entitled to full regular pay. 7.2 If the period of disability
is greater than seven (7) calendar days, the employee will be eligible to receive a sum of money up to an amount equal to the difference between his/her worker’s compensation check and
his normal net take home pay. The injured employee will be eligible to receive the salary supplement for a period not to exceed three (3) months from date of injury. 7.3 At the end of
the three months, or sooner, the City Manager, Department Head, and Human Resources Director will review the case for a determination of pay status. If continuation of the salary supplement
is granted it can be at any rate determined equitable by the reviewing committee, but not to exceed an amount equal to the net take home pay. In no case will the salary supplement be
greater than six (6) months within an 18-month period commencing with the date of injury or illness. 7.4 After six (6) months of supplemental pay within an 18 month period, the injured
employee may elect to receive accrued sick leave and after exhausted, vacation leave, in accordance with his/her regular hourly wage, to the extent that his/her combined sick leave or
vacation leave, City supplement (if less than the full amount authorized) and workers’ compensation benefits equal his/her regular weekly net take home salary. The employee must contact
the payroll clerk to qualify for the combined check. 7.5 It is incumbent on the employee to make application for disability in accordance with the pension plan they are members of, or
the insurance plan they are covered under. Failure to do this automatically cancels the additional City benefits. 5
7.6 If the appropriate disability plan denies the claim, the additional City salary supplement benefit will be canceled. If the appropriate disability plan accepts the claim, the salary
supplement will be canceled after issuance of the disability pension check or at the end of the time duration outlined above, which ever comes first. 7.7 If an employee who is receiving
Workers’ Compensation payment along with City supplement, sick or vacation leave, is found to be working or receiving compensation for his/her services elsewhere during this period,
he/she will be required to reimburse the City for all medical expenses and supplement sick or vacation pay taken and be subject to dismissal. 7.8 Workers’ Compensation paid time will
only be authorized by Risk Management when medically verified by the physician to be off work or when placed on light duty or modified duty, if there is no work available within the
employee’s restrictions. I. FATALITY REPORTING The death of an employee as a result of an injury by incident arising out of, and in the course of employment, shall be reported to the
Risk Management Department immediately by telephone. The supervisor in charge shall be responsible for making the call and providing as much initial information as possible. J. SUDDEN
SEVERE ILLNESS REPORTING Sudden illness occurring to employees during duty hours requiring emergency medical treatment such as possible heart attacks, strokes, seizures, fainting, etc.,
shall be reported to Risk Management by telephone ads soon as possible. K. INCIDENT/NEAR MISS REPORT 1. Close calls or near incident information is frequently as valuable as incident
reports in flagging hazardous procedures or conditions. 2. Supervisors shall encourage employees to report on incidents that nearly produced an injury. 3. Information gained from such
reports will then be disseminated to all that can benefit from the lesson. 4. Complete the Supervisor’s Report of Incident (RM-102 Form) and check “near incident” and send to the Risk
Management Department. Department. 6
L. HAZARD REPORT 1. Equipment or facilities which are poorly designed for the task at hand, and in themselves constitute additional hazards to personnel, shall be reported if attempts
to make corrections have failed. 2. Information furnished by such a report can be used to advantage when future procurement of equipment or construction of buildings is anticipated.
3. Tools and other equipment can frequently be modified to eliminate most of the undesired features when exposed by this Hazard Report. 4. Use plain paper or memo sheet using the subject
“HAZARD REPORT” and send to the Risk Management Department. M. INVESTIGATION OF OCCUPATIONAL INJURIES 1. Investigation of any incident is a valuable tool in controlling losses. Each
incident must be considered a “total loss” unless its true cause is objectively determined and all contributing deficiencies are corrected. Thorough investigation, reporting, recording
and corrective follow-up of each incident can be time-consuming, but the time used for such a purpose contributes relatively little to the total time wasted from the disruption that
invariably follows. Devoting necessary time and effort to prevent the recurrence of each incident is an investment that pays compounded benefits to employees and management as their
number decreases. 2. Procedures for Investigation of Occupational Injuries – Each injury shall be investigated by the supervisor of the person injured as soon as possible after it has
occurred and the following procedures shall be adhered to as closely as possible. 2.1 Check the Scene a. Begin where the incident occurred. The first step is to carefully examine where
the injury occurred. b. Reconstruct, as much as possible, the chain of events leading up to the injury and attempt to determine the single event that caused the injury. c. Draw a diagram
of the location if it will be helpful in arriving at a conclusion. 7
d. Sketch in machinery, equipment and any other nearby physical objects, together with the places where witnesses were standing. 2.2 Write It Down a. Complete the Incident Investigation
Report (RM-105) to document all facts that may relate to the cause of the injury. As an example, employee had complained of dizziness, or employee had not used proper equipment, etc.
(RM-105 to be completed by Supervisor investigating incident.) b. Write down any procedure used, misuse of equipment or other factors not in accordance with published work rules or safety
policies. c. Write down any unsafe conditions in work area, defective tools or faulty equipment noted. d. Write down such other items as the time of your investigation, the lighting
conditions, the weather conditions, if pertinent, a description of supplementary evidence, and conversations having a bearing on the case. 2.3 Collect the Evidence If an injury or near
miss occurs when machine parts or structure fail, it is essential to determine what failed and why. This can frequently be done without laboratory analysis and corrective action can
be initiated. However, if a detailed study is determined to be essential, then all components shall be collected and submitted for study immediately. 2.4 Interview Witnesses It is important
to interview witnesses at the scene immediately or as soon thereafter as possible. Make brief notes and identify who gave the information. 2.5 Interview the Employee a. Timing is important.
If the injury is minor, the interview should be made as soon as the investigation of the scene and a review of the medical report are complete. 8
b. If the injury is serious, selecting the right time is a judgement factor. Too soon afterward – the employee may be confused and inaccurate; waiting too long may cause the employee
to be cautious and evasive. Let the employee tell his story as he wishes without actual interrogation, but a complete picture should be encouraged. The interview must be complete, and
it may be necessary to question the employee or witnesses several times. 2.6 Weigh the Evidence a. It is essential to eliminate any inconsistencies in the testimony of the injured or
witness, even if further questioning is required. b. All facts should be reviewed for completeness before submission to the Risk Management Department. N. DOCTOR AND PRESCRIPTION BILLS
1. After treatment of an injury, bills for medical treatment and medicines are normally sent directly to PGCS for payment. However, bills are sometimes inadvertently sent to the employee
for payment and the employee frequently ignores them until threatening letters are received from some collection agency. Employees have a responsibility to forward such bills to the
Risk Management Department for processing, immediately upon receipt, in order to avoid unpleasant and unnecessary complications. 2. Employees are entitled to reimbursement for mileage
for medical treatment and for prescriptions. It is the responsibility of the employee to submit mileage claims to Risk Management. Claim forms may be obtained from the Risk Management
Department. Prescription requests should be referred to Risk Management. O. EMPLOYEE RETURN TO WORK AFTER INJURY A supervisor shall not allow an employee to return to work after an occupational
injury or illness unless he receives a signed RELEASE TO RETURN TO FULL DUTY from the treating physician. P. LIMITED DUTY ASSIGNMENTS If the injury results in permanent disability, the
Risk Management Department, working with the Human Resources Department, will work to assign the employee to a project which can be handled without danger of reinjury or 9
aggravation of the disability. This may involve an adjustment of regular duties, reassignment to another position, or training to prepare the employee for a different job. A limited
duty assignment is for short term duration and is not meant to be a full-time alternative position. Q. EMPLOYEE’S RESPONSIBILITY FOR NOTIFICATIONS 1. The employee shall be responsible
for notifying his supervisor of all healthcare provider appointments, in advance; and, providing supervisor with healthcare provider’s report. 2. The employee shall be responsible for
notifying his supervisor of absences related to the workers’ compensation claim. Absences must be documented by the Primary Care Physician or other authorized healthcare provider, and
be submitted to the supervisor. 2.1 Employees shall only utilize healthcare providers authorized by Risk Management. 2.2 In true emergency situations, the employee should go to the nearest
Emergency Room. ER Registration staff should be advised that this could be related to a workers compensation claim and the appropriate information should be provided by the employee.
It is the employee’s responsibility to notify, or arrange for notification, to his supervisor as soon as possible. The employee is also responsible for notifying Risk Management as soon
as possible, of the ER visit to arrange follow-up with an authorized healthcare provider. 3. The Employee and physician are responsible for providing written notice of physical restrictions
if employee is to be taken out of work or placed on limited duty. Kurt Bressner City Manager Developed by: Risk Management Department EFFECTIVE DATE: January 24, 1990 REVISED DATE: January
15, 1997 REVISED DATE: September 3, 1997 REVISED DATE: August 1, 2000 10
11 REVISED DATE: January 1, 2003 REVISED DATE: December 15, 2005 REVISED DATE: March 8, 2007 REVIEWED – no changes May 27, 2008