Each state has a workers’ compensation law that provides benefits to employees injured at work. These laws require employees suffering an injury on the job receive compensation to replace lost wages and cover medical expenses.  

Workers’ compensation is a no fault system. No matter what caused the injury—worker’s negligence, employer’s negligence or a combination of the two—workers injured on the job and/or in the course of their employment may be eligible to receive benefits under the various state laws.

As the terms imply, a worker may be disabled only partially or totally, and temporarily or permanently. The law treats each of these conditions differently and each state has its own schedules and time limits.

Temporary Partial Disability (TPD): Temporary, but only partial, incapacity from work of an employee with a compensable work-related injury or occupational disease. During a period of partial incapacity, an employee can perform SOME types of work and may be eligible for Temporary Partial Disability benefits.

Permanent Partial Disability (PPD): Permanent loss of, or loss of use of, one or more body part(s) of an employee with a compensable work-related injury or occupational disease. If it is determined by the attending physician at the time of the employee’s maximum medical improvement that a Permanent Partial Disability exists, that employee is eligible to receive Permanent Partial Disability benefits.

Temporary Total Disability (TTD): Temporary, but total, incapacity from work of an employee with a compensable work-related injury or occupational disease. During a period of total incapacity, an employee is unable to perform ANY type of work and is eligible for Temporary Total Disability benefits.

Permanent Total Disability Benefits: These benefits are paid in catastrophic injury cases where the employee is regarded as totally and permanently unable to perform gainful employment. These benefits may be payable for the life of the injured worker. These are generally subject to the same maximum and minimum benefit rates as Temporary Total Disability Benefits.

Examples are injuries caused by:

• intoxication or the influence of controlled substances
• attempted suicide or homicide
• commission of crimes while on the job
• injured while engaged in horseplay on the job
• deviation from employment without the employers expressed approval for deviation
• an accident in which the employee failed to refuse to use safety appliances provided by the employer
• Some medical conditions that occur during working hours may not be compensable. For example, just because an employee sustains a heart attack at work does not necessarily mean that it is a compensable claim.

We handle workers’ compensation claims for all non-monopolistic states out of a single office using four dedicated geographical regions.

• Each region is assigned an experienced unit supervisor, at least one indemnity adjuster who specializes in preliminary investigations, several experienced long-term indemnity adjusters, a medical-only adjuster and a dedicated claims support representative.
• The regional split allows our adjusters to become experts in their territories and develop strong relationships with the defense attorneys in their regions. It also allows insureds to know exactly who to contact for a claim in a specific state.
• We have a developed network of defense attorneys, nurse case managers and surveillance services in all 50 states that is comprised of experts who are familiar with the workers’ compensation system and our dedication to excellence in claims handling.

Each claim is put through an internal triage process to make sure the most appropriate adjuster is assigned to that claim. We take into consideration the type of injury, jurisdiction and any red flag indicators such as potential fraud and pre-existing conditions. Once assigned, three-point contact with the claimant, employer and medical provider is made within 24 hours. From there, you and the claimant can expect:

• Customer communication on a regular basis to provide proactive status reports, modified duty opportunities, litigation plans, surveillance consideration and claim resolution.
• Claimant contact on a weekly basis for the first eight weeks of disability, biweekly during weeks nine through 16 and monthly contact until a successful return to work is achieved or the claim is settled.
• Supervisors review claims on day seven to confirm that three-point contact has been made and on day 15 to verify compliance with state filing and disability payment requirements. To ensure the claim is moving toward resolution, it is reviewed every 30 to 45 days thereafter by the adjuster and the unit supervisor.
• A nurse case manager triages all indemnity claims on day 14 to ensure medical management is progressing and every 30 days thereafter depending on the severity of the injuries.
• Compensability will typically be determined within 14 days.

• Dedicated nurse case managers who triage all indemnity claims and are available for ongoing medical management
• Full-time in-house attorneys
• Full-time in-house special analysts and litigation managers who are also attorneys
• Full-time in-house paralegals
• A fully-staffed Legal Department
• A Loss Prevention & Safety Services Department dedicated to reducing and preventing claim expenses
• A subrogation team committed to recovering losses caused by third parties
• A dedicated special investigation unit committed to preventing fraudulent claims
• A nationwide network of carefully vetted and selected vendors used to reduce costs
  Includes bill review, pharmacy, physical therapy, attorneys and in-state representatives if required by law
• Roundtable meetings where compensability issues, medical and legal management, impairment ratings and settlement proposals are discussed

Protective has partnered with CorVel’s CorCare^® Network to offer our policyholders access to a world class Medical Provider Network (MPN). Our MPN provides access to an extensive network of highly skilled physicians who are dedicated to facilitating speedy recovery. Utilizing the MPN has proven to reduce overall workers’ compensation claim payouts by providing greater control over medical fees and obtaining more favorable medical treatment outcomes.

An experience mod is:

• A credit or debit factor that is applied to workers’ compensation premium. 
• Issued by the state rating bureau or its administrator, the National Council on Compensation Insurance (NCCI).
• Determined by comparing an individual business’ claims experience with other businesses of similar size and operations.
• Updated each year by the state rating bureau or NCCI.
• Applicable only to businesses with a certain amount of premium.

Data used in calculating an experience mod:

• Claims frequency and severity are both considered, but frequency has a greater impact than severity. Multiple small claims could impact the experience mod more than a single large claim.
• The claims and payroll data used in determining the experience mod is based on a rolling three-year period ending with the year prior to the most recently expired policy.
  • Example: If current policy period is 6/1/17 – 6/1/18, the experience mod period would include policies effective:
  • 6/1/15 – 6/1/16
  • 6/1/14 – 6/1/15
  • 6/1/13 – 6/1/14
  • Example: If a claim occurred on 10/17/17, or at any time within the 6/1/17 – 6/1/18 policy period, it would first be included in the experience mod issued 6/1/19. The claim would “fall off” as of 6/1/22.

Important info to know about experience mods:

• The experience mod follows the business from insurance carrier to insurance carrier.
• If a business purchases or transfers partial assets to another business, an evaluation will be completed by the state rating bureau or NCCI and the experience mod may be impacted.
• Having a safety program in place may help prevent work place accidents or injuries, which has a positive impact to the business’ experience mod.

Learn more about controlling your experience mod.