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Policy on Lehigh University's Workers' Compensation Program for Work-Related Injuries or Illness

Policy Number: 103
Effective Date: circa 2000
Revisions: 1/1/2005

Policy:

Workers' Compensation Insurance

is a statutory program that provides medical coverage and, in some instances, income maintenance to employees who are disabled as a result of a work related injury or illness. All full-time and part-time faculty, staff, and student employees (salaried or on wages) are eligible for workers' compensation coverage.

Insurance Benefits and Method of Payment

Payment for all medical services, supplies, and medicines that are reasonable and medically necessary for rehabilitation, surgical, and hospital care (as determined by the workers' compensation insurance company) is allowed at no cost to the employee. Also included are the costs of orthopedic appliances and training in their use.

Employees who are disabled for more than seven (7) calendar days as a result of a work-related injury or illness may also be eligible to collect disability income payments at a rate of approximately 66-2/3% of their average weekly wage as defined by the Workers' Compensation Act.

Wage loss is not payable to an employee for the first seven (7) calendar days, unless the disability exceeds fourteen (14) calendar days. This is known as the waiting period. After fourteen (14) continuous calendar days of disability, the employee will retroactively receive approximately 66-2/3% of his/her average weekly wage for the first seven (7) calendar days of disability.

During the first seven (7) days of disability, the employee may apply up to five (5) University provided sick leave days. In the event the disability exceeds (14) calendar days, payment for the first week of disability is made to the injured/ill employee as allowed under the Workers' Compensation Act. The employee will be required to reimburse the University for those sick days for which the employee was paid. The sick days will then be added back to the employee's sick time balance. Questions concerning the use of sick time as a result of a work-related injury should be directed to the Office of Human Resources.

When an employee receives Workers' Compensation disability payments at the rate of approximately 66-2/3% of his/her average weekly wage, his/her university salary will be made whole by accrued University short-term or long-term disability benefits that the employee has available. The employee can also use accumulated sick time to supplement workers' compensation income if neither short-term nor long-term disability income is available to him/her. The amount of compensation paid by the Workers' Compensation insurer to the injured worker is reduced from the employee's University gross payroll amount.

Prescriptions (Express Scripts)

The University's workers' compensation insurer has signed an Agreement to participate in the Express Scripts Workers' Compensation Pharmacy PPO. Employees should not use their group prescription plan card for medicines that are compensable under their workers' compensation claim. Employees should take their prescription to one of the participating pharmacies and provide the pharmacist with their social security number and date of injury. The pharmacist will submit the bill directly to the insurer. In the event a pharmacist receives notice that Express Scripts cannot identify the injured employee or some other issue arises, the employee should pay for the prescription and submit the receipt to the Risk Management Office.

Reporting a Claim Employee Responsibilities Supervisor Responsibilities

Note: Should the employee be disabled for an extended time period (e.g., post-surgery, etc.), the supervisor and/or the employee should make every effort to keep the Risk Management Office informed as to the injured employee's progress. At a minimum, Risk Management must be provided with a status update following each doctor's appointment and be made aware of the next scheduled appointment.

Healthcare Provider Panel

Lehigh University has posted an approved healthcare provider panel, and therefore the Pennsylvania Worker's Compensation Act requires that employees treat with that panel for work-related injuries for 90 days from the first day of treatment. If an employee chooses to treat with a non-panel provider before the 90-day period has expired, the employer is not responsible for paying the non-panel provider for services.

Current Listing of the Healthcare Provider Panel

You must continue to visit one of the physicians or other health care providers on the panel, if you need treatment, for 90 days from the date of your first visit. After this 90-day period, if you still need treatment, you may choose to go to another physician or other health care provider for treatment. If this situation should arise, you must notify Risk Management within 5 days of your first visit.

If you are faced with an immediate medical emergency, you may secure initial assistance from a hospital, physician, or other health care provider of your choice. You must then seek subsequent treatment from a physician or other health care provider listed on the panel for at least the first 90 days from the date of your first treatment. If one of the listed providers recommends invasive surgery, you are entitled to a second opinion from a physician of your choice. Should your physician's opinion differ, and you choose that opinion, the panel physician will bide by same for 90 days.

Any person knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact materials thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Applicability: All Employees
Cross References:

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