CALA Workers Compensation Claims 3 — Questions and Answers
Question 1: An employee with a pre-existing back condition suffers a work-related back injury that aggravates the condition. How is this typically handled under workers compensation?
- The work injury is compensable for the aggravation, and benefits cover the worsening of the condition (Correct answer)
- The claim is denied entirely because the injury is pre-existing
- Benefits are reduced by 50% to account for the pre-existing condition
- The employer is only liable after the pre-existing condition is resolved
Correct answer: The work injury is compensable for the aggravation, and benefits cover the worsening of the condition
Workers compensation covers aggravation of pre-existing conditions caused by work injury, making the entire worsened condition compensable.
Question 2: What is the purpose of a vocational rehabilitation benefit in workers compensation?
- To help injured workers return to gainful employment through retraining or job placement services (Correct answer)
- To compensate workers for permanent disfigurement from a work injury
- To provide counseling services for work-related stress claims
- To reimburse employers for training replacement workers
Correct answer: To help injured workers return to gainful employment through retraining or job placement services
Vocational rehabilitation helps injured workers who cannot return to their prior occupation by providing retraining, education, or job placement assistance.
Question 3: A workers compensation claimant refuses authorized medical treatment that would likely improve their condition. This may result in:
- Suspension or reduction of indemnity benefits (Correct answer)
- Criminal charges for insurance fraud
- The claim being classified as fraudulent
- Immediate termination of the employer's workers compensation policy
Correct answer: Suspension or reduction of indemnity benefits
Most states allow suspension or reduction of workers compensation benefits if a claimant unreasonably refuses authorized medical treatment that could improve their condition.
Question 4: Which party is typically responsible for selecting the treating physician in states with employer-directed medical care?
- The employer or insurer selects the authorized treating physician (Correct answer)
- The employee has free choice of any licensed physician
- The state workers compensation board appoints a neutral physician
- The claimant's attorney selects the physician
Correct answer: The employer or insurer selects the authorized treating physician
In employer-directed medical states, the employer or insurer controls the selection of the authorized treating physician for the injured worker.
Question 5: What does 'apportionment' mean in the context of a workers compensation permanent disability rating?
- Dividing the disability between the current work injury and pre-existing conditions or prior injuries (Correct answer)
- Splitting benefit payments between the employee and their dependents
- Allocating claim costs between primary and excess insurers
- Distributing medical expenses across multiple treating physicians
Correct answer: Dividing the disability between the current work injury and pre-existing conditions or prior injuries
Apportionment allocates permanent disability percentages between a current work injury and pre-existing conditions to determine the employer's actual liability.
Question 6: A claimant is found to have committed workers compensation fraud by exaggerating their disability. The most common consequence is:
- Criminal prosecution, repayment of fraudulently obtained benefits, and claim denial (Correct answer)
- A warning letter and reduction of future benefits
- Automatic disqualification from all state benefits for life
- The insurer absorbs the loss with no recourse against the claimant
Correct answer: Criminal prosecution, repayment of fraudulently obtained benefits, and claim denial
Workers compensation fraud typically results in criminal charges, requirement to repay benefits, and denial of the fraudulent claim.
Question 7: Under workers compensation, 'indemnity benefits' refer to:
- Wage replacement payments made to injured workers who cannot work due to their injury (Correct answer)
- Payments for medical treatment and rehabilitation services
- Lump-sum settlements paid at claim closure
- Reimbursements to the employer for business losses during the worker's absence
Correct answer: Wage replacement payments made to injured workers who cannot work due to their injury
Indemnity benefits are income replacement payments designed to compensate injured workers for lost wages while they are unable to work.
CALA Workers Compensation Claims 3
An employee with a pre-existing back condition suffers a work-related back injury that aggravates the condition.
How is this typically handled under workers compensation?