Claim Closure with Brian Groesser

A claimant injures his back lifting an item.  You run an ISO Report and see a prior back claim.  You talk with the insured and confirm that claimant denied prior back issues upon being hired.  Do you have a defense to deny the claim.  Maybe.  But you have some heavy lifting of your own to do first.  I'll discuss further in this episode a little-known and little-used defense that may save you a lot of money.  

Claimant has a positive drug screen and is fired for violating the employer's drug-free work zone.  Automatic denial, right?   Maybe, but will it ultimately hold up in court?  Maybe not.  Intoxication is an affirmative defense in North Carolina meaning that you as the employer and carrier need to prove it.  What exactly do you need to do to prove intoxication?  Take a shot of this episode and find out.  

Generally, when a worker is not covered by workers' compensation when she is going to or from work.  However, like most things in life, there are exceptions.  I will discuss those four exceptions to the Coming and Going Rule and what to look for in your cases when an employee gets injured but has yet to "arrive" or "clock in or out" at work.  

The Supremes came out with a published decision - a rare treat in North Carolina workers' compensation cases.  Although this was more of a procedural rebuke of the Court of Appeals, there is a decent discussion of burdens of proof when it comes to a notice defense under N.C. Gen. Stat. 97-22.  Think you are safe when an employee notifies you of an accident and says she's fine, then opts to treat on her own without telling you to the point of needing fusion surgery over a year later?  Think again.  

Today I do a deep dive into an unpublished opinion on the Parsons Presumption.  I discuss the presumption, but more importantly I point out how attorneys and doctors engage in depositions, the testimony one needs to rebut the presumption, handling pre-existing injuries and how the Commission and Court of Appeals deals with testimony when they render their opinions.  This episode is a must-listen in terms of "inside baseball" as to the litigation process playing out.  

The time, place and circumstances of an injury matter.  It can be from an accident that arose out of the employment, but the employee still has to prove that it occurred within the course and scope of the employment for the injury to be compensable.  We will discuss how a claimant can meet that burden.  

Today, the General Assembly approved of Governor Cooper's appointment of Chairman Baddour to another six-year term as Chair of the Full Commission.  This is a good opportunity to discuss the hearing process.  Who makes up the Commission and the 20 Deputy Commissioners spread across the state?  What does it take for a claim to get to be heard by a Deputy Commissioner?  The Full Commission?  And how long does it take for an Opinion and Award to be rendered on a case?  I will discuss in full in today's episode.  

A claimant is walking down the hallway and falls.  It matters as to whether she tripped over an object, her leg just gave way, she rolled her ankle or she has no idea how she fell.  Some of these are compensable claims.  Some are not.  I will discuss the concept of an idiopathic condition and how it plays a role in a compensability analysis.  

A special treat of three published Court of Appeals cases in one week.  Baker discusses the requirement for a Pleasant case to survive summary judgment in a civil proceeding.  Brewer discusses the burden when it comes to the Parsons presumption.  And Marlow allowed a civil case to survive summary judgment with a finding that the accident did not arise out of the employment - despite the employer already accepting the accident as compensable on a Form 60.  Listen in to learn how these cases can impact your claim handling.  

12 hours after the last episode published, the Court of Appeals came out with its revised decision in Sturdivant.  The verdict?  The 500-week cap on indemnity benefits is gone.  I will discuss this decision and take a deep dive into what is actually left of the alleged pro-employer amendments that were made to the Act in 2011.  I will also discuss what a veto-proof General Assembly can do to immediately address the problems that have arisen since those amendments were enacted 12 years ago.  

This one has been 12 years in the making.  Ever since the Act was changed in 2011 and a 500-week cap installed regarding entitlement to indemnity benefits, employers and employees have been waiting for the Court of Appeals to decide what it actually takes to have benefits extended beyond 500 weeks.  And now we have our answer.  Or do we?  The Court of Appeals actually vacated its own decision and will reassess after essentially eliminating the 500-week cap by its original decision.  We will discuss this case along with a Woodson analysis of what it takes for an employer to be sued in civil court and not have the exclusive remedy protection typically afforded under the Act.  

Employee injures his ankle playing volleyball at a company picnic.  Not compensable.  Employee injures her ankle dancing at the company Christmas party.  Compensable.  Say what?  Injuries that occur during social activities hinge not on the injury, itself, but the voluntariness of the activity the injury occurred during.  There are a set of guideposts to follow when receiving these fact patterns, and this episode will cover all of them.  

This published Court of Appeals decision addresses the correct method for determining the average weekly wage of a temporary worker who dies prior to the end of his employment period.  Further, I will discuss the implications of a death at work and the presumption that work caused the death.  

Employee gets injured goofing off with another employee.  Automatic denial, right?  No necessarily.  This episode will delve into the history of horseplay and how such injuries have actually generally been found to be compensable unless certain exceptions apply.  People who work together tend to play together.  

An employee gets physically attacked at work.  Whether by a co-worker or a third-party, the analysis remains the same.  This episode will explore looking for the causal connection to work and how small distinctions can make all the difference between a compensable and non-compensable assault claim.  

Just because an injury by accident occurred, that does not mean that there is a causal connection to the employment.   A claimant must prove that the injury arose out of the employment for it to be compensable.  This episode will provide an initial overview as to how an injury arises out of the employment in North Carolina.  Future episodes will apply that standard to specific instances, including workplace assaults, horseplay, social activities, idiopathic conditions and pre-existing conditions.  This episode will serve as a primer for those discussions.  

Work injuries happen.  But not all work injuries are the result of an accident.  And if there is no accident, then it is not a compensable claim.  Too often adjusters make the mistake of accept injuries that do not stem from accidents.  This episode will go over what constitutes an injury by accident and how to identify it in your initial investigation of a claim.  

Pay your worker on a 1099?  Could still be an employee.  The worker is undocumented?  Could still be covered as an employee.  The worker is an 8-year-old helping around the store?  Could still be responsible for an injury.  Who exactly is an employee and therefore covered under workers' compensation?  This episode will help address that preliminary question.  

What makes a claim a NORTH CAROLINA workers' compensation claim?  When an injury happens outside of the state, that does not mean the claimant cannot file in North Carolina.  In fact, claimants often do file in North Carolina based on it being easier to keep benefits going than in neighboring states.  This episode will discuss how you can recognize whether or not North Carolina has jurisdiction over a claim.  

The FINAL episode discussing the Industrial Commission forms.  The claimant has returned to work.   That's only the beginning of the process.   Filing the correct forms depends on a variety of scenarios and the road map can be a bit confusing.  This episode walks you through the statutory and rule requirements for a conventional and trial return to work.  

This form is a major pain to most employers tasked with filling it out.  I receive questions weekly from adjusters as to how to use it.  The form is complicated on its face and not conducive to most payroll records.  This episode will help employers and adjusters learn how to not only fill it out correctly, but calculate the average weekly wage from it.  

This is the form used to a deny a claim.  But specificity and timeliness are required in order to actually utilize the defenses at your disposal.  We will discuss both and prepare you for understanding the various defenses that exist in a workers' compensation case.  

The Form 63 is arguably the most controversial form at the Industrial Commission.  However, it is also THE form to file if you are looking to proactively investigate the claim.  It allows for medical treatment to go forward and for the claimant to receive benefits while you conduct your investigation.  What makes it controversial?  Tune in for a full discussion and how that controversy can be negated.  

This episode discusses the Form 60, which formally accepts the claim.  It is also a form I do NOT recommend filing, as you have a Form 63 at your disposal.  Why is that important?  We will discuss all of the implications if a Form 60 is filed and how it handcuffs employers and carriers from thoroughly investigating the claim from the outset.  

The employee has filed a claim.  What should you look for on the form?  What defenses may arise?  How should you respond?  We cover the many implications of a claim filing and ways for the employer and carrier to handle it.  

An employee gets injured at work.  Now what?  This episode discusses the initial steps that an employer and carrier need to take when an employee reports a work injury.  This often overlooked form can have significant implications on a claim later on in the litigation process.  

Welcome to a new concept that will forever change workers' compensation claim handling in North Carolina: a podcast.  Rather than waiting for an in-person seminar or a periodic webinar, this podcast will allow listeners to access a digital resource available to them at any time.  Listen at your desk at work, while driving in your car, working out at the gym or sipping some coffee at home.  We will cover frequently used forms, common issues and topics and monthly case law updates.  This novel approach is a must-have resource for adjusters, risk managers, case managers and employers involved in workers' compensation claims.