Workers' Compensation
Insurance Adjuster
How to...
-
establish a claim with the
division
An Employer’s First Report of Injury form (First Report) must be
filed with the Division within 10 days of notice or knowledge that a
work-related accident results in any of the following:
- Lost time in excess of three shifts or calendar days
- Permanent impairment, or
Contraction of an occupational disease
that has been listed by the Director by rule.
A First Report must be filed with the Division immediately upon
notice or knowledge that a work-related accident resulted in:
Death, or
Injury to three or more employees
See C.R.S. § §
8-43-101,
8-43-103
and
Rule 5-2(B)(2).
When filing is required pursuant to the above, the carrier,
third-party administrator or self-insured employer electronically
transmits or mails to the Division, an Employer’s First Report of
Injury (WC1) along with a First Report Transmittal form (WC106).
If a claim is established with the Division through a Worker’s
Claim for Compensation (Worker’s Claim-WC15) or Dependents’ Notice
and Claim for Compensation (Dependents’ Claim-WC18), the carrier,
self-insured employer or non-insured employer identified from
Division records, is provided a copy of the claim by mail.
Upon acceptance of a First Report, Worker’s or Dependents’ Claim,
the Division assigns a Worker’s Compensation number (WC#).
Whenever a First Report is filed with the Division, a position on
liability must be stated within 20 days after the date the First
Report is filed or should have been filed with the Division.
In the case of a Worker’s or Dependents’ Claim, a position
statement must be filed within 20 days after the Division mails a
copy of the claim to the insurer.
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-
file a position statement
Notice of Contest:
A Notice
of Contest (WC74) is filed to deny liability for a
worker's
compensation claim.
Timeline
A
position statement must be filed within 20 days after the date the
Employer’s First Report of Injury is filed or should have been
filed with the Division. In the case of a Worker’s or
Dependents’ Claim, a position statement must be filed within
20 days
after the Division mails a copy of the claim to the insurer.
DO NOT
file a Notice of Contest on a previously admitted claim.
See
Tips.
Tips
-
To limit liability on an already-admitted claim, DO NOT
file a Notice of Contest. This could be construed as withdrawing
from a previously-filed admission. The remarks
section on a General Admission may be used to limit an
insurer's admission of liability. For example, denial of
liability for injury to a specific body part or medical
treatment determined to be unrelated to a claim may be
addressed in this manner. The provider must also be notified
of any contested bills.
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General Admission
A General Admission of Liability (WC2) is filed to admit liability
for a worker's compensation claim. The General Admission states
acceptance of the claim as compensable and admits liability for
reasonable and necessary medical expenses related to the injury. The
General Admission may be notification of the admitted average weekly
wage, the time period and rate of temporary disability benefits,
medical benefits, and other benefits. See C.R.S. §
8-43-203(2)(b)(I).
Timeline
A
position statement, either an admission or a Notice of
Contest, must be filed within 20 days after the date the
Employer’s First Report of Injury is filed or should have been
filed with the Division. In the case of a Worker’s or
Dependents’ Claim, a position statement must be filed within 20
days after the Division mails a copy of the claim to the insurer.
A
subsequent admission is filed immediately with supporting
documentation when temporary benefits are terminated or modified
(if a bi-weekly check is not sent, an admission terminating
benefits must be filed). See
Rule 5-5(C).
A
subsequent admission must be filed within 30 days of
resumption of or increase in temporary benefits.
Tips
- Supporting documentation for termination/modification
See How to...terminate
or modify temporary benefits, for discussion of
the supporting documentation that must be filed with the General
Admission when temporary benefits are terminated or modified.
ü
Claimant is at MMI at the time of the initial filing
If the claimant has reached maximum medical improvement
(MMI) at the time of the initial position statement and
permanent impairment has been addressed, a Final
Admission of Liability may be filed to both establish
liability and conclude the case. In this instance, a General
Admission need not be filed. DO NOT file both a General
and Final Admission simultaneously.
ü
Limiting liability to a specific body part/condition
Use the remarks section for any explanations regarding the
admission of liability including limiting liability to a
particular body part and to clarify benefits.
ü
Filing subsequent admissions
Subsequent admissions must be submitted with a Division
assigned WC#. The First Report Transmittal sheet is faxed
back to the carrier or TPA as soon as the WC# has been
assigned. The WC# for a claim transmitted via EDI is
assigned and submitted to the carrier electronically. Check
internal company procedures regarding how to access the
assigned WC#. All subsequent admissions must reflect
all benefits previously admitted and paid.
ü
Benefits admitted and paid may not be recovered
unilaterally by admission
An Administrative Law Judge (ALJ) may under certain
specific sets of facts, such as a finding that benefits were
fraudulently attained, order retroactive recovery. A carrier
may Petition to Modify future benefits under Rule
6-4.
See
How to...terminate
or modify temporary benefits, for discussion of the supporting documentation that must be
filed with the General Admission when temporary benefits are terminated
or modified.
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Final Admission
A Final Admission of Liability (WC4) is filed at the conclusion
of a worker's compensation claim to summarize benefits
admitted. The Final Admission notifies the claimant of what
action must be taken if the claimant disagrees with the
admission including applicable deadlines. If the claimant does
not timely object, then the claim closes. The Final Admission
also sets forth the carrier's position on liability for future
benefits including permanent disability benefits, medical
impairment benefits, and medical benefits after MMI. See
C.R.S. §
8-43-203(2)(b)(II).
Timeline
Scheduled injuries,
§
8-42-107(2)
For scheduled
injuries, within 30 days after the date of mailing
or delivery of a determination of no impairment by the
authorized treating physician providing primary care, a Final
Admission consistent with the physician's opinion or application
for hearing must be filed. See Rule
5-5(H)(2).
For scheduled injuries, within 30 days after the date of mailing
or delivery of a determination of impairment by an authorized
level II accredited physician, a Final Admission consistent with
the physician's opinion or application for hearing must be filed.
See Rule
5-5(H)(2).
Non-scheduled injuries,
§
8-42-107(8)
For
injuries not on the schedule, within 30 days after the date of
mailing or delivery of a determination of no impairment by
the authorized treating physician providing primary care, a Final
Admission consistent with the physician's opinion must be filed
or application for a Division Independent Medical Examination
must be filed. See Rule
5-5(H)(2).
For
injuries not on the schedule, within 30 days after the date of
mailing or delivery of a determination of medical impairment
by an authorized level II accredited physician, a Final
Admission consistent with the physician's opinion or application
for a Division Independent Medical Examination must be filed.
See Rule
5-5(H)(2).
Tips
ü
Certificate of Mailing
The Certificate of Mailing attests to the date the Final
Admission was placed in the U.S. mail and postmarked or
delivered to the parties listed. The date must be completed
along with the signature of the person certifying the date the Final
Admission actually was placed in the U.S. mail and
postmarked or delivered. Correct certification is important
since the claimant has by statute 30 days from this date
to object to the Final Admission. The claim will automatically close
if no written objection and application for hearing or IME is made
within 30 days of the date of the Final Admission.
ü
Re-filing a Final Admission
If an admission is re-filed, the new admission carries the
same weight as the original admission. The Certificate of
Mailing must be completed with the current (new) date of
mailing. Information on an admission cannot be changed or
additional documentation provided without re-certifying the
admission and providing all attachments including the previously
filed report of MMI, as this may affect the claimant's period to
object and closure of the claim.
ü
Recouping overpayments
Temporary disability benefits paid beyond the date of MMI
may be credited toward permanent impairment benefits
pursuant to Rule
5-6(D). Any overpayment should be explained in the
remarks section. Any claimed overpayment may not be subject to
recovery unless the issue is reserved or explicitly stated on the
Final Admission.
ü
Final Payment Notice vs. Final Admission
Pursuant to Rule
5-11(B), a Final Payment Notice (WC25) must be filed
after all compensation issues have been resolved by final admission,
final order or stipulation. The final payment notice must be filed
60 days after the claim is closed. NOTE: A Final Payment Notice cannot be substituted for a Final Admission of Liability since the form does not notify the
claimant of his or her right to object. The filing of a Final
Payment Notice will not close a claim.
ü
Amending a Final Admission pursuant to
Rule 5-9
Within the time limits for objecting to the Final Admission,
the Director may allow a carrier to amend the admission for
permanency, by notifying the parties that an error exists due
to miscalculation, omission, clerical error, or misapplication
of the statute. See Rule
5-9(A). For possible relief, notify
the Division's Claims Services Section within the time limits for
objecting to the admission when such an error is discovered.
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Form
Completion
Final Admission Checklist - in the order the items appear on the
Final Admission form:
Use the following
checklist to assure completeness:
ü
Complete the form completely and accurately.
ü
State the MMI date accurately (the start date of PPD benefits is the
date of MMI).
ü
Check all benefits admitted and include totals admitted in
the Benefit Summary section.
ü
If a stipulation has been reached and approved, do not list it
in the benefit history. It should be noted on the line listed as
Stipulation in the benefit summary only.
ü
When completing the Benefit Summary, the total medical
paid should only include medical expenses, not legal fees
paid or any non-medical expenses.
ü
Verify the PPD rating is by a Level II-accredited physician
or a statement of no impairment is by the authorized
treating physician providing primary care.
ü
Reflect the impairment rating properly in the PPD section
check whether Whole Person or Scheduled Impairment and
include percentage. Include age on the date of MMI if a
Whole Person rating is admitted. Include Part of Body
Code if a Scheduled rating is admitted.
ü
State position on medical benefits after MMI in easily
understood language. See Rule
5-5(A).
ü
State any offsets or overpayments in the Remarks section.
ü
Reference the medical report upon which the Final
Admission is based, including the physician's name and date of the
report under "Remarks and basis of permanent disability award." See
Rule
5-5(A). It is helpful to include the calculations for the
award. See
How to...calculate indemnity benefits.
ü
If
an admission is for intermittent benefits, indicate intermittent TTD
or TPD under the Type of Benefits section, state beginning and
ending date and attach supporting documentation.
ü
List all admitted permanent impairment benefits completely,
including time periods, rates and totals in the Benefit History
section. Only the benefits to which the carrier actually admits and
intends to pay should be listed in this section.
ü
If
benefits are limited per §
8-42-107.5, benefits should equal the applicable cap in the
Benefit History and the remarks should state the cap being applied.
ü
Even if the PPD has been paid in a lump sum, the information on the
benefit history needs to include time periods, rates, and totals.
This is required as the statute of limitations runs from the last
day PPD is due and payable if paid biweekly.
ü
If there was an overpayment, list the amount on the Amount
Overpaid line and use remarks to explain how the amount will be
recovered, if applicable.
ü
Identify the Claims Representative's name, local phone number,
toll-free telephone number and address.
ü
Certify the actual date the document is placed in the U.S.
mail or delivered.
ü
List the names and addresses of the parties being provided
the admission.
ü
Provide the signature of the individual certifying mailing or
delivery of the document.
ü
Provide all required attachments:
·
The Final Admission is a four-page document; send all four
pages to all parties.
·
Provide support for termination or modification of
temporary benefits if not filed with previous admissions.
·
Attach the MMI report and physician's worksheets.
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Fatal Admission
The
Fatal Case-General Admission (WC151) is filed to admit liability or
update a change to dependents' benefits in the case of a
work-related injury resulting in death.
The
Fatal Case-Final Admission (WC153) is filed when all issues have
been addressed as to liability and to provide notice of appeal
rights. It is filed when the deceased worker leaves no statutory
dependents and payment of $15,000.00 is made to the Subsequent
Injury Fund or after all dependents' benefits have been paid out.
Timeline
The employer is
required to give immediate notice to the
Director in a case of death resulting from an injury.
See C.R.S. §
8-43-103 (1).
Notice should be given by calling the Division of Workers'
Compensation at 303.318.8700. The following information
must be provided:
·
Deceased’s Last Name
·
Social Security Number
·
Date of Injury
·
Date of Death
·
Age
·
Gender (M or F)
·
Carrier
·
Third Party Administrator (if applicable)
·
Employer
·
Location of accident
·
Description of injury
A position
statement, either an admission or a Notice of
Contest, must be filed within 20 days after the date the
Employer’s First Report of Injury is filed or should have been
filed with the Division. In the case of a Worker’s or
Dependents’ Claim, a position statement must be filed within 20
days after the Division mails a copy of the claim to the insurer.
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Establishing a claim
for death benefits with the Division
The carrier must file a First Report of Injury (WC1) in accordance with
C.R.S. §
8-43-101(1). The box on the First Report asking: Did injury
cause death should be marked "yes," with the corresponding date of
death.
Dependents may file a Dependents' Notice and Claim for Compensation
(WC18). The Division provides this form to the estate of the deceased
upon notice of the fatality. The carrier may also provide this form to
the estate to expedite adjustment of the claim.
Whenever a Dependents' Notice and Claim for Compensation is
received on a claim where there is a preexisting injury claim and
allegation of a causal connection between the injury and subsequent
fatality, a separate claim must be established with
the Division and assigned a distinct workers' compensation claim
number. If multiple Dependents' Notice and Claims are filed for the
same fatality, all will be filed under the same WC# assigned to the
claim for death benefits.
Amount of death
benefits
Benefits are
calculated as sixty-six and two-thirds percent of the
deceased employee's average weekly wage The maximum
benefit rate in effect at the time of death applies to dependent’s
claims. The amount of death benefits is fixed as of the date of
death. If the deceased was a minor with dependents, the
maximum rate applies.
Death benefits are
unique in that there is a provision for
payment of a minimum death benefit equal to 25% of the
maximum weekly benefit in effect at the time of death. For
example, if the deceased earned an AWW of $210.00 per week
at the time of death, the compensation rate for an injury claim
would be $140.00 per week. However, in the case of a
dependent's claim, if the maximum compensation rate for the
State of Colorado was $593.81 at the time of death, a minimum
death benefit of $148.45 (or 25% of $593.81) would be payable
to dependents of the deceased.
The Director of the
Division of Workers' Compensation or an
Administrative Law Judge of the Office of Administrative
Courts may apportion benefits among dependents as is
determined to be "just and equitable" in accordance with C.R.S.
§
8-42-121.
Otherwise, benefits are apportioned on a "share
and share alike" basis among persons wholly dependent. C.R.S.
§
8-41-501
defines those persons who are presumed to be
wholly dependent. Payment of benefits to persons partially
dependent may occur only when there are no persons wholly
dependent and cannot exceed a period of six years from the date
of death.
No dependents:
payment to the Subsequent Injury Fund
Whenever a compensable
injury results in death where there are
no persons wholly or partially dependent, payment must be
made to the Subsequent Injury Fund (SIF) in the amount of
$15,000.00 unless the deceased is a minor with no dependents.
In such cases, $15,000.00 shall be paid to the parents of the
deceased for deaths occurring on or after February 1, 2000.
The fatal final
admission form must be filed for either payment
to SIF or payment to the minor’s parents. The form contains a
check box to indicate payment owed SIF. See C.R.S. §
8-46-102(1).
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Offsets
For injuries occurring on or after May 29, 1991, benefits are
reduced by 50% of federal survivor's benefits payable to
dependents. For injuries occurring prior to May 29, 1991, the
offset rate is 100%. Offsets are applied only to those dependents
who receive federal survivor's benefits. Hoffman v.
Hoffman, 872 P.2d 1367 (Colo. App.1994).
Closure of a claim for
dependents' benefits
Closure on a fatal claim will generally follow the same process
as closure for an injury claim. Whenever a Final Admission of
Liability is filed which adheres to all the filing requirements, the
Notice to Claimant section defines the requirements for timely
objection to an admission. A final order in which all
remaining issues are adjudicated and to which no timely appeal is
received also serves to close a claim.
Claims may also be closed following a request to the Director
for an Order to Show Cause why the claim should not be closed
for failure to prosecute for a period of at least six months. See
Rule 7-1(B). Questions with regard to closures of these claims
may be forwarded to the Division's Customer Service Unit.
Tips
ü
Claim established prior to death
If a claim has already been established with benefits paid
for the date of injury and the claimant dies, a separate WC#
must be established when filing an admission for death
benefits. This is because the claimant is no longer receiving
the admitted benefits and different (fatal) benefits are now
being paid to dependents. If death occurs subsequent to the
filing of a First Report, and a General Admission has been
filed admitting for temporary disability benefits, termination
of benefits may occur in accordance with
Rule 6-1(A)(6).
That is, a Final Admission may be filed to terminate
temporary disability benefits, whether or not death was a
proximate result of the work related injury/disease. The Final
Admission must be accompanied by a letter or death certificate
advising of the death of the claimant with a
statement by the carrier on liability for death benefits.
ü
Claimant receiving TTD benefits at the time of death
Compensation that a claimant would have been entitled to
receive up to the date of death, is payable to dependents as
may be determined by the Director or ALJ. If there are no
dependents, the Director may order unpaid benefits be applied to
other expenses, preferably funeral expense. See
C.R.S. §
8-41-503. If liability is admitted for dependents' death
benefits, then a separate claim is established following the above
procedures.
ü
Claimant receiving PPD benefits at the time of death
Where death is not the proximate result of the injury and
PPD benefits have been admitted, the unpaid portion of
PPD benefits is due any dependents. See §§
8-42-116(b)
and
8-42-117(b).
Where death resulted from the injury, See
§
8-42-115
regarding distribution of benefits.
ü
Claimant receiving PTD benefits at the time of death
In the case of an admitted claim for PTD benefits where
death is not the proximate result of the work related injury
or disease, a Final Admission may be filed to terminate
PTD benefits and to state a position on residual death
benefits. See
Rule 5-8(B). If the deceased leaves persons
wholly dependent upon the deceased for support, death
benefits consist of "the unpaid and unaccrued portion of the
permanent total disability benefits which the employee
would have received had the employee lived until receiving
compensation at the employee's regular rate for a period of
six years." See C.R.S. §
8-42-116(1)
(a).
If liability is admitted for dependents' death benefits, then a separate
claim is established following the above procedures.
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Temporary Disability Benefits
There are two types of temporary disability benefits, temporary
total and temporary partial. Both types are calculated based on
the Average Weekly Wage (AWW) at the time of injury. Temporary
total disability benefits are due when a claimant is unable to work
as a result of the injury and temporary partial disability benefits
are due when the claimant is earning reduced wages due to the
injury. For a discussion of what is included in the calculation of
the AWW, see C.R.S §
8-40-201(19).
The AWW worksheet may be used to document the admitted AWW.
See Average Weekly Wage under the Desk Aids section of the Division
website. If the AWW on the First Report of Injury or Worker's Claim
for Compensation is different from the admission, the admitted AWW
must be documented. Actual
wage records should be issued to determine the AWW.
Temporary Total Disability
The claimant is considered to be totally disabled when, due to
disability as the result of the work injury, no wages are earned.
All benefits are calculated and paid based on a seven-day week.
The temporary total disability (TTD) benefit rate is calculated
as sixty-six and two-thirds percent of the claimant's AWW up to
the maximum rate established by the Director each year on July
1st. There is no minimum rate. See C.R.S. §
8-42-105(1).
A weekly TTD rate is calculated by multiplying the AWW by
66-2/3%.
For a discussion of AWW, see C.R.S. §§
8-40-201(19)
and
8-42-102.
In order to calculate a partial week of TTD, divide the weekly
TTD rate by 7 and multiply the result by the number of days of
TTD owed.
Temporary Partial Disability
Temporary partial disability (TPD) benefits are due when a
claimant returns to work before reaching MMI, is not released
to usual duties, and is earning less than the admitted AWW.
Also, TPD benefits are due if the claimant has never left work,
and due to disability is unable to earn the admitted AWW.
The TPD rate should be calculated on a weekly basis by subtracting
the weekly gross earnings from the admitted AWW and multiplying the
result by 66-2/3 %.
The maximum rate is the same as the TTD rate established yearly by
the Director. There is no minimum rate. Partial weeks are calculated
on the basis of a seven day week. See C.R.S. §
8-42-106(1).
Permanent Impairment Benefits
There are two types of permanent impairment benefits,
scheduled impairment benefits and non-scheduled (whole person)
impairment benefits. Pursuant to statute, each type of benefit is
calculated differently. For purposes of this guide, permanent
medical impairment benefits may also be referred to as PPD
(permanent partial disability).
Scheduled Impairment
Scheduled impairment is defined by C.R.S. §
8-42-107(2)
to
specific extremities and to sight and hearing. See exceptions at
C.R.S. §
8-42-107(5),
(7), and (8) (c.5).
For dates of injury prior to July 1, 1999, the statutory rate used
in the calculation of impairment of scheduled injuries is
$150.00 per week. For dates of injury July 1, 1999 through
June 30, 2000, the rate is $176.00 per week. Beginning July 1,
2000 and every year thereafter, the Director of the Division of
Workers' Compensation establishes the statutory rate. A listing
of the Maximum Benefit Rates is available under the Desk Aids
section of the Division web site.
To calculate medical
impairment benefits for injuries on the
schedule:
·
determine the body part and locate the number of weeks on
the schedule.
·
determine the impairment rating from the physician's report
of MMI and impairment.
·
determine the rate to be used in the calculation based on the
date of injury.
Number of weeks specified on the schedule for the body part
x impairment rating x statutory rate = PPD award.
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Tips
In calculating partial loss-of-use benefits, the most distal
permanent impairment rating provided by the physician shall be
multiplied by the number of weeks corresponding to the scheduled
injury for the appropriate entire finger, whole hand, or whole upper
extremity, or the appropriate entire toe, whole foot, or whole lower
extremity, then multiplied by the amountpursuant to C.R.S. §
8-42-107(6). See
Rule 12-6.
Non-Scheduled (Whole Person) Impairment
When an injury results in permanent medical impairment not set forth
in the schedule, the benefits are calculated pursuant to C.R.S. §
8-42-107(8)(d).
Permanent medical impairment benefits of non-scheduled injuries are
calculated as:
Medical impairment
rating x age factor x 400 weeks x TTD rate = PPD award.
To determine the age factor found at C.R.S. §
8-42-107(8)(e),
use the age of the claimant on the date of MMI. (The Age
Factor Chart is available under the Desk Aids section of the
Division web site.)
The TTD rate is 66-2/3 % of the AWW on the date of injury, up
to the maximum.
·
For injuries occurring on or after 7/1/99
- When a claimant sustains both scheduled and non-scheduled
injuries, the losses are compensated on the schedule for scheduled
injuries and the non-scheduled injuries are compensated as medical
impairment benefits. See C.R.S. §
8-42-107(7)(b).
·
For injuries occurring prior to 7/1/99
- When a claimant
sustains both scheduled and non-scheduled injuries, the losses are
converted to whole person and compensated as
combined medical impairment benefits.
Mountain City Meat Co. v. Oqueda,
919 P.2d 246 (Colo. 1996).
Indemnity Benefits for Minors
A minor is defined as
any person who has not attained the age of twenty-one years. See
C.R.S. § 2-4-401(6). The age on the date of injury is the factor
used to determine if the claimant is considered a minor for the
entire claim. Benefits are paid in the same time frames as in the
case of adults.
Where an employee is a minor and the disability is temporary, the
average weekly wage of such minor shall be determined by the
division as in cases of disability of adults. Where the disability
of such minor is permanent or if benefits under articles 40 to 47 of
this title accrue because of the death of such minor, compensation
to said minor or death benefits to said minor's dependents shall be
paid at the maximum rate of compensation payable under said articles
at the time of the determination of such permanency or of such
death.
C.R.S. §
8-42-102(4)
Temporary Disability Benefits for Minors
The AWW is determined and TTD and TPD benefits are calculated as in
the case of adults.
Permanent Impairment Benefits for Minors
·
Scheduled Impairment—Minors
The fixed rate for scheduled injuries is determined based on the
date of injury per statute. Calculation is the same
as for adults. See Williams v. Industrial Claims Appeals Office,
932 P.2d 869 (1997).
Number of weeks
specified on the schedule for the body part x
impairment rating x statutory amount = PPD award.
·
Non-Scheduled (Whole Person) Impairment - Minors
For dates of injury on or after July 1, 1991, the PPD award
is calculated using the maximum TTD rate in effect at the time of
MMI (not the maximum TTD rate in effect on the date of injury as in
adult cases).
The age factor used is the age of the claimant on the date of MMI.
(Note: The claimant's status as a minor at the time of injury does
not change although the claimant may be 21
years or older at the time of MMI.)
Calculation of medical impairment benefits of injuries not on the
schedule:
Medical impairment rating x age factor x 400 weeks x maximum TTD
rate at the time of MMI = PPD award.
See Arkansas Valley
Seeds v. Industrial Claims Appeals Office, 972 P.2d. 695 (1998).
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Statutory Offsets
Offsets are allowed so that a claimant does not receive duplicate
benefits designed for the same purpose. See C.R.S. §
8-42-103 and
Rule 6-5. Offsets may not reduce benefits below
zero. Based on certain conditions, offsets may be taken for
disability, retirement, unemployment, and workers' compensation
benefits received from another state or the federal government.
ü
Disability Benefit Offsets
Offsets for disability payments may be taken against TTD,
TPD, PPD, and PTD benefits. See C.R.S.
8-42-103(1). Generally, reduction in benefits equal to 50%
of Social Security disability benefits is allowed. The offset
percentage for an employer paid disability plan is the percentage of
the employer's contribution.
ü
Social Security Disability Benefit Offset
Only the original Social Security award is subject to offset. The
social security cost-of-living increases should not be included when
determining the amount of the weekly benefit awarded. When a
claimant receives a retroactive lump sum of Social Security
benefits, only the net amount of the award, after subtracting the
attorney fees, may be offset. The weekly benefit amount of the
Social Security award is multiplied by
50%. This amount is then deducted from the claimant's
weekly compensation payment.
Initial monthly (SSDI award x 12) ÷ 52 x 50% = Amount of
offset per week
Weekly TTD, PPD, or PTD Benefit - Amount of offset =
Weekly benefit rate
·
Employer-paid Disability Benefit Offset
The disability offset is calculated by multiplying the claimant's
weekly disability benefits by the percentage of the employer's
contribution to the disability plan. This amount is then
deducted from the weekly worker's compensation payment.
·
Firefighters’ and Police Officers’ Pension Reform Act
(FPPA) Offset
Workers’ compensation benefits may be eligible for offset or
reductions by FPPA disability pension paid pursuant to article 30.5
or 31, of title 31 C.R.S. The reduction shall not reduce the
combined weekly disability benefits below a sum equal to one hundred
percent of the state average weekly wage as defined in
§
8-47-206 and applicable to the year in which the weekly
disability benefits are being paid. Whether benefits are subject to
offset should be re-evaluated every July 1 when there is a change in
the state average weekly wage and whenever there is a change in the
FPPA award.
ü
Retirement Benefit Offsets
Offsets for retirement payments may only be taken against
PTD benefits, and the claimant must have reached the age
of forty-five years at the time of the injury on which the PTD award
was based. See C.R.S. §
8-42-103(1)(c). Note the deletion of reference to a specific age
of retirement for purposes of the offset against permanent total
disability benefits in 2000. See HB00-1383, modifying C.R.S. §
8-42-103.
The offset percentage for an employer-paid retirement plan is the
percentage of the employer's contribution.
·
Social Security Retirement Benefit Offset
The
initial weekly benefit amount of the Social Security
retirement benefit is multiplied by 50%. This amount is then
deducted from the claimant's weekly PTD benefit payment.
Initial monthly Social Security retirement benefit x 12 ÷ 52
x 50% = Amount of offset per week
Weekly PTD Benefit - Amount of offset =
Weekly benefit rate
·
Employer-paid Retirement Benefit Offset
The
retirement offset is calculated by multiplying the
claimant's weekly retirement benefits by the percentage of the
employer-paid retirement benefits. This amount is then deducted from
the claimant's weekly PTD benefit payment.
Employer's contribution during covered employment ÷
Total contribution during covered employment
=
Employer's percentage of contribution;
Employer's percentage
of contribution x weekly retirement benefit = Amount of offset per week;
Weekly PTD Benefit - Amount of offset = Weekly
benefit rate
There is an exception in PTD cases that all employer contributions are
considered to be made by the employee if the result of collective
bargaining. See
C.R.S. §
8-42-103(1)(c)(II)(B).
ü
Supplemental Security Income (SSI)
SSI benefits are not offsetable against any workers’ compensation
benefits. SSI is a federal income program funded by general tax
revenues not Social Security taxes. The program helps aged, blind, and
disabled persons who have little or no income by providing monthly
payments to meet basic needs.
ü
Unemployment Compensation Offset
An offset may be taken against permanent total disability and temporary
disability benefits for the amount of unemployment benefits received,
but benefits may not be reduced below zero. If the claimant's
unemployment benefits have already been reduced by reason of receipt of
temporary disability benefits, then the temporary disability benefits
may not be reduced. There is no offset against PPD benefits. See C.R.S. §
8-42-103(1)(f).
ü
Offset due to Workers’ Compensation Benefits from
Another State or Federal Government
An
offset may be taken to the full extent of workers' compensation
benefits received under the law of another state or the federal
government. See
C.R.S. §
8-42-103(1)(e).
Tips
ü
Calculation of Permanency when Social Security
Disability Insurance (SSDI) Benefits Apply
An SSDI offset against whole person impairment should be calculated as
follows in accordance with Armijo v. ICAO, 989 P.2d 198 (Colo. App.
1999).
1.
Determine the pre-offset PPD award pursuant to §
8-42-107(8)(d)
by multiplying the medical impairment rating by the age factor by 400
weeks by the TTD rate.
2.
Determine the weekly offset amount by multiplying the original
SSDI monthly award by 12, divide by 52 and multiply by 50%.
3.
Determine the number of weeks of the payout period by dividing
the PPD award by the PPD payout rate. The PPD payout rate is the TTD
rate but not less than $150 per week and not more than 50% of the state
AWW for the date of injury.
4.
Deduct the SSDI weekly offset amount from the weekly PPD payout
rate to determine the weekly benefit amount.
5.
Multiply the weekly benefit amount by the number of weeks of the
payout period.
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Temporary Benefits
The initial payment of temporary benefits
must be paid immediately
upon admission for benefits. See C.R.S. §8-43-203(2)(b)(I).
Benefits should be paid at least through the date of the check
unless benefits were terminated in accordance with
Rule 6, to
avoid potential disputes over whether payment is in arrears.
Benefits must be paid at least once every two weeks. See
C.R.S. §
8-42-105(2)(a).
The waiting period must be paid when a claimant's period of
disability lasts longer than two weeks from the day the claimant
leaves work as a result of the injury. See C.R.S. §
8-42-
103(1)(b). Benefits are calculated based on a 7-day week.
Tips
ü
The initial payment of temporary benefits awarded by
admission is due on the date of the admission and through
the date of the check unless benefits were terminated
pursuant to
Rule 6.
ü
Pursuant to
Rule 6, temporary benefits may be terminated, ..
modified, or suspended without a hearing only if certain
conditions are met and an admission is filed with applicable
supporting documentation. An admission with supporting
documentation must be filed by the date the periodic
payment is due or payment must continue. See
Rule 6. See, also,
Rule
5-5(C).
ü
Reaching the statutory limits does not trigger the condition
allowing termination of temporary benefits. Temporary
benefits are limited at either $60,000.00 or $120,000.00 for
dates of injury occurring 7/1/91 through 12/31/05 and
$75,000.00 or $150,000.00 for dates of injury occurring on
or after January 1, 2006--only when the claimant has
reached MMI and the amount of permanent impairment has
been determined. This limitation applies to combined
temporary and permanent impairment benefits, and
permanent impairment can only be determined upon MMI.
See C.R.S. §
8-42-107.5.
Permanent Impairment Benefits
·
Benefits for permanent impairment (PPD) are due on
the date of the admission and every two weeks
thereafter until paid in full.
·
Benefits for PPD should commence on the date of MMI.
·
The initial PPD payment should use the date of MMI as the
first date of the time period and pay at least through the date of the
admission to bring the payment current.
·
Periodic payments of impairment benefits may not stop if
the automatic lump sum of $10,000.00 is paid, pursuant to
C.R.S. §
8-42-107(8)(d).
·
Credits are applied at the end of the payout period.
Rates for Permanent
Impairment
Maximum Benefit Rates are available under the
Desk Aids section
of the Division web site.
Scheduled injuries are paid at the fixed compensation rate
determined by the Director of the Division of Workers'
Compensation each July 1st for dates of injury during that year.
For dates of injury prior to July 1, 1999, the statutory rate for
scheduled injuries is $150.00 per week. For dates of injury July
1, 1999 through June 30, 2000, the rate is $176.00 per week.
Beginning July 1, 2000 and every year thereafter, the statutory
rate is established by the Director.
Non-scheduled injuries are paid at the TTD rate, but not less
than $150.00 per week and not more than 50% of the State
AWW in effect on the date of injury. When up to $10,000.00 is
requested by the claimant and paid in a lump sum less the 4%
discount, the remaining periodic payments are paid at the TTD
rate but not less than $150.00 per week and not more than 50%
of the State AWW at the time of injury, beginning on the date of
MMI. See C.R.S. §
8-42-107(8)(d). The 4% discount is not a
straight 4%. See Lump Sum Payments and Calculation of
Discount, Chapter VIII.
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Disfigurement Benefits
·
Colorado provides for disfigurement benefits if the claimant has permanent scarring or disfigurement on a
body part normally exposed to public view. Disfigurement benefits may be
awarded
up to a maximum of $2,000.00 for injuries occurring prior to
July 1, 2007, and up to $4,000.00 for injuries on or after that
date. The maximum award for extensive disfigurement is
$8,000.00 for injuries sustained on or after July 1, 2007. See
C.R.S. §
8-42-108.
·
Permanent disfigurement is indicated if a scar or
disfigurement exists at least six months after the date of injury or
last surgery.
·
Public view is normally indicated by a scar or
disfigurement that is visible when an individual is wearing a swimsuit.
Determination of the
amount of Disfigurement Benefits
A claimant should contact the insurance carrier (or employer if there is
no insurer) to request disfigurement benefits. If the claimant and
insurer are unable to agree on an amount of disfigurement benefits, the
claimant may submit photographs showing the scar or disfigurement to an
administrative law judge for determination of disfigurement benefits.
An explanation of this procedure and the form used for submission of
disfigurement benefits may be obtained from the Office of
Administrative Courts.
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-
terminate or modify temporary benefits
Unilateral Termination of Temporary Benefits Pursuant to Rule 6
When temporary disability benefits are terminated or modified
an admission must be filed immediately. See Rule
5-5(C).
Supporting documentation pursuant to
Rule 6 must accompany
the admission for unilateral termination or reduction of
temporary benefits.
Attach documents to the admission that satisfy all components of
ONE of the following subsections of Rule 6 to support terminating or
reducing temporary benefits:
ü
Signed statement by employer or employee of return to work
at reduced wages and admission for TPD benefits. Rule 6-1(A)(3).
ü
Signed statement by employer or employee of return to
work at full wages.
Rule
6-1(A)(3).
ü
Medical release to return to regular employment.
Rule
6-1(A)(2)
ü
Written offer of modified duty that:
·
was sent by certified mail or confirmation of the delivery
of the offer by a signed certificate of service;
·
set forth duties, wages, hours; and
·
was accompanied by a statement by an authorized
treating physician stating the modified employment is within the
claimant's physical restrictions.
ü
Letter rescheduling a missed medical appointment with the authorized
treating physician that:
·
was sent by certified mail or confirmation of the delivery
of the notice by a signed certificate of service;
·
stated temporary benefits would be suspended if the
claimant failed to appear at a rescheduled medical appointment with the
authorized treating physician (date and time of rescheduled
appointment given); and
·
documentation from the physician that the claimant failed
to appear. Rule 6-1(A)(5).
ü
Report of MMI and impairment by an authorized treating
physician provided the carrier states a position on permanency
consistent with the physician's report.
Rule 6-1(A)(1)
ü
Death certificate or letter and statement of position on
liability for death benefits.
Rule 6-1(A)(6).
ü
Documentation that substantiates any offset and
calculations showing how the amount of the offset was determined
pursuant to
C.R.S. §
8-42-103(c).
Rule 6-5. See Statutory Offsets;
ü
Certified copy of a mittimus or court document
establishing confinement due to conviction.
Rule 6-6.
ü
Copy of a fully executed third-party settlement agreement
that establishes the claimant has agreed to a monetary settlement for
damages from a third party.
Rule 6-7.
ü
For employees of a temporary agency with dates of injury
on or after July 1, 1996:
·
a copy of the initial written offer of modified employment
provided to the claimant, which clearly states that future offers of
employment need not be in writing, a description of the policy of the
temporary help contracting firm regarding how and when employees are
expected to learn of such future offers, and a statement that benefits
shall be terminated if an employee fails to timely respond to an offer
of modified employment;
