GQ Corner
Q. We received a bill from a hospital; however we have no claim. We reached out to the City asking them to send us a claim so we can investigate, as our ‘clock’ started when we got the bill. The City said that it was not workers’ comp and the claimant did not present a claim to them. Since the City does not want to send us a claim to do this, can we send a letter back to the provider that we do not have a record of a claim and to contact the claimant for proper billing? If we do this and claimant later pursues (after 60th day), will we have to let the City know we waived our right to deny compensability?
A. First, a medical bill can serve as the carrier’s first written notice of an injury. It must simply name the injured employee, identify the employer, provide an approximate date of injury and provide information which asserts that the injury is work related. If a carrier or in this case, the entity responsible for administering the claim for the political subdivision, receives notice and has not received an Employer’s First Report of Injury, the TPA is required to contact the City regarding the injury within seven (7) days of notification. As you noted, if you do not create a claim and take no action, you face the very real possibility that the claimant will pursue the claim and raise a waiver issue. Moreover, the carrier may not only be facing a possible waiver issue, but also an administrative violation for failing to either initiate TIBs or to dispute disability timely. Thus, we recommend that if you have been given the four elements of notice of injury, set up a claim and take the appropriate action.
Q. Do we owe TIBs if a claimant retires? I have included a few scenarios below:
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- While TIBs are being paid due to claimant being off work for the injury?
- While partial TIBs are being paid due to the claimant having loss of earnings?
- If claimant is working elsewhere after retirement from the claim employer?
- If claimant is not working at all after retirement with the claim employer?
- Does claimant have to report his retirement earnings to us?
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A. Retirement does not preclude a finding of disability, though it can be a factor that is considered in determining whether a claimant has disability. If the claimant is off work completely, is receiving TIBs, and then retires, TIBs would not be suspended. If the claimant is working and earning partial TIBs, and then retires, I would continue the partial TIBs with the argument against full TIBs being that the claimant could have continued working and earning some PIE had he/she not elected to retire. If the claimant retires from the claim employer and then gets a job elsewhere, the earnings at the new job are PIE and would serve to reduce/eliminate the amount of TIBs due. If the claimant is not working anywhere after retirement, then TIBs potentially continue based upon the circumstances. If the retirement was planned prior to the injury, then I think you have a better argument against no TIBs following retirement. However, if the claimant indicates that he/she planned to retire from the claim employer prior to the injury, and then planned to work for someone else, but that plan got derailed based upon the injury, I think you could get stuck paying TIBs. Retirement pay is not PIE, and thus, the claimant does not need to report that to you.
FOLIO
