Controversial Opt Out Panels
The blogging live controversial Opt Out panels in WCRI
Two Presenters –
Trey Gillespie – Property and Casualty Insurers Association of America
Bill Minick – PartnerSource
Opt outs as a form of Workers Compensation coverage has been in Texas for quite some time. Texas’s program has been successful. Oklahoma is still the fulcrum of a recent controversial decision.
Opt out is ERISA based.
No admission of liability .
Many common exclusions.
Many of the cause of injury aspects in the regular insurance market look very similar to the Oklahoma Workers Compensation Opt out rules.
However, there are Conditions and Limitations:
- Benefits stop if employee leaves the company
- FMLA protections to 12 weeks
- Reporting requirements (24 hour delay max)
- NCCI say only 20% of Lost Time injuries are reported within 24 hours.
- 93% of costs are allocated to Lost Time vs. Medical Only claims
- Medical plans are made by plan administrator
- Medical benefits may be terminated before care ends- this varies greatly from regular WC coverage
- Medically necessary – the cheapest way to treat, if no treatment in 60 day = termination of benefits
- Continuing medical maintenance differs greatly from regular WC coverage. Palliative care – whether required or not is not covered
- Voluntary settlements are based on Plan Administrator evaluation
- Often refers to “Dillard Decision”
- Limited appeal rights
- No payment of PPD (Permanent Disability) benefits are not covered.
- Quote From Dillard’s decision – Injured workers not treated equally under opt out
Bill Minick presentation-
- Same mutual goals
- Determining Good Public Policy
- Experiments -rigorous assessments
- No anecdotal experiences
- 1.5 million workers covered
- 50,000 claims resolved annually
- $0 spent by regulatory industries
- $125 million annual claims cost
- $1 Billion in direct written premiums over the past decade.
- 1,000 private sector jobs
Benefits are mandated
Financial Security Requirements
Employee protections – safety such as OSHA
- Written plan document
- Definitely determinable benefits
- Acting in employee’s interest
Enforcement- there are civil and criminal penalties
There is no perfect grand bargain
93 Texas settlements in Excess of $1 million
ERISA requires that Opt Out benefits are communicated to the employees in a language that they can understand – Workers Comp has an issue with being mysterious
Immediate reporting requirement leads to better outcomes
Medical providers should be held accountable
Evidence based medicine
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