Claim Administration & Management © 2014 CopperPoint Mutual Insurance Company. All rights reserved.

Reporting an Injury © 2014 CopperPoint Mutual Insurance Company. All rights reserved. State Regulation Employee reports accident to employer If fails to forthwith report, may have benefits denied Within 10 days, employer files Employers Report of Injury with commission and insurance carrier Within 8 days, physician files Injured Worker Physicians Report with commission and insurance carrier

Reporting an Injury © 2014 CopperPoint Mutual Insurance Company. All rights reserved. State Regulation Employee physician reports accident to employer, insurance carrier and commission Employer may designate in writing physician chosen by employer to make one examination of injured employee to ascertain injury

Reporting an Injury © 2014 CopperPoint Mutual Insurance Company. All rights reserved. State Regulation Employee may not leave state for more than two weeks while necessary medical treatment continues without written approval of commission Failure to obtain written approval will result in the forfeiture of the right to compensation and medical expenses during such time

Reporting an Injury © 2014 CopperPoint Mutual Insurance Company. All rights reserved. What injured worker can expect Process and obligation How benefits are provided Medical Compensation Death/survivor Rehabilitation

Reporting an Injury © 2014 CopperPoint Mutual Insurance Company. All rights reserved. What policyholder can expect Process and obligation Perform internal investigation to complete 101 Employers Report Provide information necessary for claim processing Unless self-insured, employer cannot pay benefits due from carrier – “first aid” claims not allowed in Arizona Involvement and contact with claimant

Claim Investigation © 2014 CopperPoint Mutual Insurance Company. All rights reserved.

Working with Claim Adjusters © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Early intervention for claim mitigation Early pursuit of Return to Work, modified work Make sure injured worker is receiving benefits, seeking appropriate treatment and is compliant

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Securing the scene Interviewing witnesses Determining potential for third-party liability

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Subrogation Preserve evidence Take Pictures Identify potential responsible parties

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Independent medical exams (IME) Employee submits self for medical examination from time to time if requested by commission, employer, or insurance carrier Place convenient for employee, travel expenses and loss of pay reimbursement

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Independent medical exams (IME) Employee can be excused if requests protective order and administrative law judge finds examination unnecessary, cumulative, or could be scheduled with more convenience

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Independent medical exams (IME) If employee leaves state, can arrange in advance for travel expenses, loss of pay Employer/insurance carrier entitled to have employee return to state one time a year or after filing petition to reopen claim

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Independent medical exams (IME) Doctor selection Prepare for right information and right questions Develop a strategic use of IME reports

Investigation Process © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Utilization review Surveillance Should not be performed without just cause or could be construed as harassment

Benefits © 2014 CopperPoint Mutual Insurance Company. All rights reserved.

Medical Benefits © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Upon prompt notice to employer Medical, surgical & hospital benefits or other treatment, nursing, medicine, surgical supplies, crutches & other apparatus Reasonably required During period of disability

Medical Benefits © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Choice of doctor Fully insured Employer may designate in writing physician to make one examination of injured employee Thereafter, employee’s choice Self-Funded Permitted to self-direct medical care

Rehabilitation © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Maintenance Vocational programs State-specific additional benefits

Indemnity/Wage Losses © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Average Monthly Wage (AMW) calculated for indemnity benefits and/or permanent impairment award Temporary wage Statutory maximum AMW Statutory maximum AMW /3% of AMW is payable amount

Indemnity/Wage Losses © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Basis of employee’s average monthly wage at time of injury Based on wages on date of injury Average of previous 30 days of earnings Up to 365 days if 30 days are atypical/incomplete Wage patterns if less than 30 days of history

Indemnity/Wage Losses Wages Used for Calculation of Average Monthly Wage (AMW) Gross earnings Overtime pay Part-time and low-wage workers Can include wages from concurrent employment Boarding/Lodging Tools

Indemnity/Wage Losses © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Shall not be paid for first 7 days after injury If incapacity extends beyond 7 days, compensation begins 8 th day after injury If disability continues for one week beyond these 7 days, will be computed from date of injury First payment to be paid no later than 21 st day after written notification by commission to carrier of filing of claim Thereafter once every two weeks during period of temporary total disability, at least monthly thereafter

Indemnity/Wage Losses © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Partial disability Temporary partial disability 66 2/3 rd of difference between wages earned before injury and wages which injured person is able to earn thereafter Unemployment benefits received during period of temporary partial disability shall be considered wages able to be earned

Indemnity/Wage Losses © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Total disability Temporary total disability 66 2/3 rd of average monthly wage If dependents, additional allowance of $25 per month Permanent total disability 66 2/3 rd of average monthly wage for life Can be rearranged if improvements in health, proof of earnings, change of location

Indemnity/Wage Losses © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Partial disability Permanent partial disability Scheduled Varies depending on impairment and part of body Payable at 50%, 55% or 75% of AMW Unscheduled 55% of difference between pre- and post-injury wages

Death/Survivor Benefits © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Burial benefits $5,000 maximum in Arizona Survivor benefits Beneficiaries Spouse and/or children Can include parents, siblings AZ Calculation 66 2/3 rd of employee’s wage Monthly maximum of AMW

Death/Survivor Benefits © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Survivor benefits Paid until Death or remarriage of spouse Remarriage benefit Children until 18 or married (unless disabled) or age 22 if full-time student in accredited educational institution Parent if dependent Brothers, sisters if dependent

Claim Adjudication © 2014 CopperPoint Mutual Insurance Company. All rights reserved.

Hearings © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Any legally interested party may file a written request with the commission for a hearing concerning a claim Protest of Notice of Claim Status ARS (J) Claim referred to administrative law judge division for determination Judge may dismiss when it appears that disputed issue or issues have been resolved by the parties Otherwise hearing will be scheduled

Claim Closure and Settlement © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Maximum Medical Improvement (MMI) Responsible for bringing back to pre-injury status (unless permanent, or permanently exacerbated, condition) Closed without impairment or supportive medical maintenance Closures with supportive medical maintenance

Claim Closure and Settlement © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Closure with permanent impairment Scheduled awards Unscheduled awards Reopening right of the worker Arizona lifetime right for “New, additional, or previously undiscovered temporary or permanent condition….” Must have supporting statement from a physician Cannot be for subjective pain without a change in objective physical findings, nor solely for additional diagnostics

Claim Closure and Settlement © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Types of settlements Final settlement medical maintenance Upon final settlement, injured worker waives future entitlement to supportive medical maintenance benefits for known conditions Not valid and enforceable until approved by commission

Claim Closure and Settlement © 2014 CopperPoint Mutual Insurance Company. All rights reserved. Types of settlements Settlement of the loss of earnings capacity Reduction in income a worker suffers as result of injury, including returning to work at lowered wages because of incapacity to perform prior job Commutation of compensation to lump sum payment not to exceed $150,000 with carrier consent Can be requested through ICA