Policies and Procedures — Section #1
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Policies and Procedures — Section #1
Steps in filing a claim
Employees are required to report any injury or illness to their supervisor or the Program
Manager immediately, and in no event later than fourteen (14) working days from the
date of occurrence. Failure to report such on-the-job injury shall result in the worker
forfeiting benefits under this act, unless the claimant can demonstrate an extraordinary
reason that prevented the reporting of the injury or occupational disease in a timely
manner.
The supervisor must submit a supervisor’s report to Risk Management within seven (7)
days of receipt from the receipt of the claim by the injured worker. Once that report has
been made, the employee has thirty (30) days from the date of the injury/illness to file a
claim. Time Loss payments and medical bills associated with the injury will not be issued
or paid until a claim has been filed.
If medical attention is necessary, the supervisor will supply the injured employee with the
following forms:
e Employee Application for Compensation and Report of Injury or Occupational
Disease
e Disability Claim Attending Physician Statement
»® Supervisor’s Accident Report of Injury
These forms can be obtained at the Risk Management/Benefits Office or downloaded
from the Tribal website. (www.colvilletribes.com)
It is imperative that these forms are completed in a timely manner in order to submit and
initiate a claim. This is especially important if the injured employee is missing work due
to the injury/illness.
Completed forms must be forwarded to the Risk Management/Benefits Office. The
injured employee will be assigned a Workers’ Compensation Case Coordinator who will
manage all forms and documents as well as assist the claimant through the process.
Upon receipt of the completed forms the case coordinator will create a claim file and
initiate time loss if needed. The injured employee will not return to work until réleased to
do so by their attending physician. The goal in each case is the restoration of the injured
employee to maximum bodily function and gainful employment as soon as possible.
If you have questions, contact the Risk Management/Benefits Office at (509) 634-2028.
Policies and Procedures — Section #2
Accepting or denying a claim
The following issues will be examined to determine if a claim will be allowed or denied.
* Was the alleged injury a result of an incident, accident or occupational disease?
* Did the claim arise out of the covered person’s employment?
¢ Did the claim arise while in the course and scope of employment and proximately
out of covered employment?
e Did it arise while in the furtherance of the employer’s interests?
Once a claim has been filed in a timely manner, it is then necessary to determine if the
employee was acting in the course of employment at the time the injury is alleged to have
occurred. For the claim to be accepted the employee must be acting at his/her employer’s
direction or in the furtherance of the employer’s interests.
The circumstances surrounding the filed claim must involve one of the following:
Injury - Injury shall mean any physical impairment, including, without limitation, death
and/or occupational disease. “Arising out of and in the course of employment” excludes
any injury resulting primarily from the natural aging process, or normal daily activities,
or an injury sustained during voluntary recreational or social activities. The injury must
arise out of the course of employment, requiring medical services ot resulting in
disability or death; and further defined as a specific, traumatic incident at a definite time
and place, while in the course of employment, that produces an immediate onset of pain
and is established by medical evidence supported by objective findings.
Occupational Disease — Shall be only those diseases which arise out of and in the course
and scope of the worker’s employment. Such diseases shall have a direct casual
connection with the employment and must have followed as a natural incident thereto
from injurious exposure occasioned by the nature of employment. The disease must be
incidental to the character of the business, occupation or process in which the worker was
employed and not independent of the employment. The disease need not have been
foreseen or expected but after its contraction it must appear to have had its origin in a risk
connected with the employment and to have resulted from the source as an incident and
rational consequence, A disease which follows from a hazard to which a worker has or
would have been equally exposed outside of said occupation is not compensable as an
occupational disease.
Mental Trauma Injuries- Mental traumas, disorders, and/or conditions, even if manifested
in physical symptoms and/or related to stress, are not compensable injuries under this act,
except that mental trauma is only recoverable if resulting from accidental physical injury
traceable to a definite time, place, and cause rather than from repetitive mental trauma. A
mental trauma or emotional injury that arises principally from a personnel action,
including, without limitation, a transfer, promotion, demotion, or termination is not
a compensable injury under this act,
Policies and Procedures — Section #3
Medical Services Provided
An injured employee is entitled to the following:
e Medical treatment that meets diagnosis-specific standards
« Help understanding the complexities of medical treatment
e A Treatment plan that includes return to work as part of a worker’s recovery
process
* Timely identification and access to healthcare providers who are qualified to treat
the worker’s illness or injury
e Encouragement to comply with treatment plans
Accurate and timely descriptions of a worker’s progressive functional capabilities
e Efficient and effective communication of necessary information with all
appropriate parties
The attending physician will be notified at the beginning of a claim and informed of the
accepted condition(s),
All medical treatment will be based on “objective findings”, Any doubts about objective
findings, will be clarified either with the attending physician or through an Independent
Medical Examination (IME). The report of the IME shall be sent to the attending
physician for comments. If the attending physician disagrees with the IME conclusion,
they must provide the objective findings on which they base their disagreement.
If the Risk Management Department concludes there are no objective findings, they will
advise the worker of the following in writing:
e They have been unable to obtain documentation of objective findings.
* Medical treatment on the claims will not be authorized.
The injured worker can discuss these concerns with their attending physician and,
perhaps, obtain a more complete report. The Risk Management Department will consider
any further reports provided by the attending physician.
The Risk Management Department will pay for “proper and necessary” health care
services that are related to the diagnosis and treatment of an accepted condition. "Proper
and necessary" refers to those health care services which are:
Reflective of accepted standards of good practice, within the scope of practice of
the provider's license or certification;
Curative or rehabilitative care must be of a type to cure the effects of a workrelated injury or illness, or it must be rehabilitative. Curative treatment produces
permanent changes, which eliminate or lessen the clinical effects of an accepted
condition. Rehabilitative treatment allows an injured or ill worker to regain
functional activity in the presence of an interfering accepted condition. Curative
and rehabilitative care produce long-term changes;
Not delivered primarily for the convenience of the claimant, the claimant's
attending doctor, or any other provider; and
Provided at the least cost and in the least intensive setting of care consistent with
the other provisions of this definition.
The Risk Management Department will cover the following treatments without prior
authorization:
A maximum of twenty office calls for the treatment of the industrial condition,
during the first sixty days, following injury. Subsequent office calis must be
authorized. Reports of treatment rendered must be filed at sixty-day intervals to
include number of office visits to date.
Initial diagnostic x-rays necessary for evaluation and treatment of the industrial
injury or condition,
The first twelve physical therapy treatments, upon consultation by the attending
doctor or under his direct supervision. Additional physical therapy treatment must
be authorized and the request substantiated by evidence of improvement.
Routine laboratory studies reasonably necessary for diagnosis and/or treatment of
the industrial condition. Other special laboratory studies require authorization.
Routine standard treatment measures rendered on an emergency basis or in
connection with minor injuries not otherwise requiring authorization.
Consultation with specialist when indicated.
The Risk Management Department will not cover the following treatments without prior
authorization:
Office calls in excess of the first twenty visits or sixty days whichever occurs first.
X-ray and radium therapy.
Diagnostic studies other than routine x-ray and blood or urinalysis laboratory
studies.
Physical therapy treatment beyond initial twelve treatments.
Diagnostic or therapeutic injection.
Home nursing, attendant services or convalescent center care.
Provision of prosthetics, orthotics, surgical appliances, special equipment for
home or transportation vehicle; custom made shoes for ankle/foot injuries
resulting in permanent deformity or malfunction of a foot; TNS units; masking
devices; hearing aids; etc.
e Biofeedback program; pain clinic; weight loss program; psychotherapy;
rehabilitation programs; and other programs designed to treat special problems.
e Prescription or injection of vitamins for specific therapeutic treatment of the
industrial condition(s).
* Injections of anesthetic and/or anti-inflammatory agents into the vertebral facet
joints.
e The long term prescription of medication.
® Diagnostic and surgical procedures which can be performed in other than a
hospital inpatient setting.
The Risk Management Department will not pay for services performed by the following
practitioners:
e Acupuncturists
e Herbalists
e Christian Science practitioners or theological healers
Homoeopathists
The Risk Management Department will not allow nor pay for following treatment:
e Treatment to improve or maintain general health (.c., prescriptions and/or
injection of vitamins or referrals to special programs such as health spas, swim
programs, exercise programs, athletic-fitness clubs, diet programs, social
counseling). :
e Continued treatment beyond stabilization of the industrial condition(s), i.e.,
maintenance care, except where necessary to monitor prescription of medication
necessary to maintain stabilization i.e., anti-convulsive, anti-spasmodic, etc.
e Any treatment measure deemed to be dangerous or inappropriate for the injured
worker in question.
e Treatment measures of an unusual, controversial, obsolete, or experimental nature.
The Risk Management Department will take any or all of the following steps when
concerned about the amount or appropriateness of drugs the patient is receiving:
e Notify the attending physician of concerns regarding the medications such as drug
interactions, adverse reactions, prescriptions by other providers;
e Require that the attending physician send a treatment plan addressing the drug
concerns;
e Request a consultation from an appropriate specialist;
e Request that the attending physician consider reducing the prescription, and
provide information on chemical dependency programs;
e Limit payment for drugs on a claim to one prescribing doctor.
If the attending physician or worker does not comply with these requests, or if the
probability of imminent harm to the worker is high, the Risk Management Department
may discontinue payment for the drug after adequate prior notification has been given to
the worker, pharmacy and physician.
Physician failure to reduce or terminate prescription of controlled substances, habit
forming or addicting medications, or dependency inducing medications, after requested to
do so for an injured worker may result in a transfer of the worker to another physician of
the worker's choice.
Drugs are listed in the following categories:
Allowed - Drugs used routinely for treating accepted industrial injuries and occupational
illnesses. Example: Nonscheduled drugs and other medications during the acute phase of
treatment for the industrial injury or condition.
Prior authorization required - Drugs used routinely to treat conditions not normally
accepted as work related injuries, drugs which are used to treat unrelated conditions
retarding recovery from the accepted condition on the claim, and drugs for which less
expensive alternatives exist. Example: All drugs to treat hypertension because
hypertension is not normally an accepted industrial condition.
Denied - Drugs not normally used for treating industrial injuries or not normally
dispensed by outpatient pharmacies. Example: Most hormones, most nutritional
supplements.
In the event of complication, controversy, or dispute over the treatment aspects of any
claim, the Risk Management Department will not authorize treatment until the attending
doctor has arranged a consultation with a qualified doctor with experience and expertise
on the subject. The Risk Management Department will make a decision once they receive
notification of the findings and recommendations of the consultant.
Consultations may also be required in the following situations:
e All non-emergent major surgery on a patient with serious medical, emotional or
social problems which are likely to complicate recovery.
e All procedures of a controversial nature or type not in common use for the
specific condition. a .
e Surgical cases where there are complications or unfavorable circumstances such
as age, preexisting conditions or interference with occupational requirements, etc.
s Ifthe attending doctor, the Risk Management Department, or authorized
department representative requests a consultation.
* Conservative care, (.g., nonsurgical cases) extending past one hundred twenty
days following initial visit.
Conditions preexisting the injury or occupational disease are not the responsibility of the
Risk Management Department. When an unrelated condition is being treated
concurrently with the industrial condition, the attending doctor must notify the
department immediately and submit the following:
* Diagnosis and/or nature of unrelated condition.
e ‘Treatment being rendered.
e The effect, if any, on industrial condition.
Temporary treatment of an unrelated condition may be allowed provided these conditions
directly retard recovery of the accepted condition. The Risk Management Department
will not approve or pay for treatment for a known preexisting unrelated condition for
which the claimant was receiving treatment prior to his industrial injury or occupational
disease, which is not retarding recovery of his industrial condition.
The Risk Management Department will not pay for treatment of an unrelated condition
when it no longer exerts any influence upon the accepted industrial condition, When
treatment of an unrelated condition is being rendered, reports must be submitted monthly
outlining the effect of treatment on both the unrelated and the accepted industrial
conditions.
All transfers from one doctor to another must be approved by the Risk Management
Department. Normally transfers will be allowed only after the worker has been under the
care of the attending doctor for sufficient time for the doctor to: Complete necessary
diagnostic studies, establish an appropriate treatment regimen, and evaluate the efficacy
of the therapeutic program. No reasonable request for transfer will be denied. The worker
will be advised when and why a transfer is denied.
When a transfer is approved, the new attending doctor must be provided with a copy of
the worker's treatment record by the previous attending doctor. X-rays in the possession
of the previous attending doctor must be immediately forwarded to the new attending
doctor for his or her retention as long as the worker remains under his or her care. Copies
of x-rays and other records may be provided in lieu of originals.
The Risk Management Department reserves the right to require a worker to select another
doctor or specialist for treatment, under the following conditions:
@ When more conveniently located doctors, qualified to provide the necessary
treatment, are available.
* When the attending doctor fails to cooperate in observance and compliance with
the Risk Management Department rules.
® Jn time loss cases where reasonable progress towards return to work is not shown.
6 Cases requiring specialized treatment, which the attending doctor is not qualified
to render, or is outside the scope of the attending doctor's license to practice.
e Where the Risk Management Department finds a transfer of doctor to be
appropriate and has requested the worker to transfer in accordance with this rule,
the Risk Management Department may select a new attending doctor if the
worker unreasonably refuses or delays in selecting another attending doctor.
e In cases where the attending doctor is not qualified to treat each of several
accepted conditions.
* No transfer will be approved to a consultant or special examiner without the
approval of the attending doctor and the worker.
Transfers will be authorized for the foregoing reasons or where the Risk Management
Department in its discretion finds that a transfer is in the best interest of returning the
worker to a productive role in society.
When a worker's care is transferred to another doctor each doctor must submit a separate
bill to the Risk Management Department for their portion of the care.
In some cases, treatment by more than one practitioner may be allowed. The Risk
Management Department will consider concurrent treatment when the accepted
conditions resulting from the injury involve more than one system and/or require
specialty or multidisciplinary care.
When requesting consideration for concurrent treatment, the attending doctor must
provide the Risk Management Department with the following:
» The name, address, discipline, and specialty of all other practitioners assisting in
the treatment of the injured worker and an outline of their responsibility in the
case and an estimate of the length of the period of concurrent care.
When concurrent treatment is allowed, the Risk Management Department will recognize
one primary attending doctor, who will be responsible for prescribing all medications;
directing the over-all treatment program; providing copies of all reports and other data
received from the involved practitioners and, in time loss cases, providing adequate
certification evidence of the worker's inability to work.
The Risk Management Department will approve concurrent care on a case-by-case basis.
Consideration will be given to all factors in the case including availability of providers in
the worker's geographic location.
Elective surgery for an unrelated condition is not normally permitted during
hospitalization for an industrial condition. Under some circumstances unrelated elective
surgery may be permitted through prior agreement and approval by the Risk Management
Department provided the unrelated surgery is not more extensive than the procedure for
the industrial condition, The requesting doctor must submit a written request and identify
which services are needed due to the industrial injury and which are needed due to
unrelated conditions, along with an estimate of what effect, if any, the unrelated surgery
will have on the accepted conditions and recovery time from surgery.
Massage therapy treatment will be permitted when given by a licensed massage
practitioner only upon written orders from the worker's attending doctor.
A progress report must be submitted to the attending doctor and the Risk Management
Department following six treatment visits or one month, whichever comes first. Massage
therapy treatment beyond the initial six treatments will be authorized only upon
substantiation of improvement in the worker's condition in terms of functional modalities,
ie., range of motion; sitting and standing tolerance; reduction in medication; etc. In
addition, an outline of the proposed treatment program, the expected restoration goals,
and the expected length of treatment will be required.
Massage therapy in the home and/or places other than the practitioners usual and
customary business facilities will be allowed only upon prior justification and
authorization by the Risk Management Department.
Massage therapy treatments exceeding once per day must be justified by attending doctor.
Policies and Procedures — Section #4
Return to Work
The goal of the Risk Management Department is to return an injured worker to work with
the employer-of-injury or current employer as soon as it is safe. Our return-to-work
program shifts the focus from disability to return-to-work: judiciously, timely and costeffectively. Our goal is to prevent the barriers that develop from prolonged disability and
removal from the labor force. We will accomplish this by accommodating the temporary
physical limitations that a worker has while still undergoing medical treatment and
recovering from their industrial injury, or occupational disease.
Benefits to the worker include:
@ Increased physical activities that when preformed within the limits set by the
attending physician, help speed up the worker’s medical recovery.
e Getting the injured worker out of his or her home and back to a work routine,
ending the worker’s isolation from co-workers, this will improve the worker’s
mental state.
se ‘The worker’s financial position will improve, because light duty work pays better
than Time Loss.
® The worker health and welfare benefits will continue at the level provided at the
time of injury (in accordance with benefit plans).
The Risk Management Department also benefits from this type of program as it reduces
lost workdays while keeping the trained and skilled workers at work. This reduces claim
costs and the possibility of loosing a valued employee.
Due to the physical restrictions imposed by the injury, an adjustment to the way a job is
performed might be made to accommodate the worker’s limitations during the recovery
phase. These adjustments, which may be temporary or permanent, might be
accomplished in one or more of the following ways:
Job restructuring:
e Altering or modifying the assignments, duties, tasks or hours of the job.
Examples are part-time work, limited or modified duties, adding more rest
breaks, trading jobs, etc.
Work-site adjustments:
e Altering or modifying the work site, including the environment. Examples
are a change of position, altering repetitions of work, raising or lowering
workbenches, desks, shelves etc.
Tools, equipment or appliances:
¢ The use of tools, equipment or appliances to enable the worker to perform
the duties of the job while accommodating his or her medical limitations.
Examples are ergonomic chairs, adjustable tables, wrist supports, arm
rests, telephone headsets, modified hand tools, lifting devices, hoists,
conveyors, rubber stress mats for standing etc
Key personnel involved in a return to work program:
e Department manager
e Department supervisors/leads
e Clatms manager/administrator
© Vocational rehabilitation counselor
The steps in the program include:
e Identifying one or more temporary transition duty positions that could be offered
to employees recovering from an industrial injury. The position will identify
useful tasks that could be combined into a temporary position and clarify physical
demands of the task(s).
e Developing written physical demand job analyses for as many positions as
possible. These analyses will be easily accessible by the company claims
coordinator.
e Furnishing the medical provider, with a copy to the injured worker, the job
analysis for the job of injury and transitional work.
» Providing a cover letter requesting medical approval of transitional work.
* Requesting an estimate of when full duty may be resumed.
Once the medical provider has given authorization, the injured worker will be offered the
position in writing. The offer will indicate the nature of the work and the shift hours,
wages to be paid, who, when, and where to report to work. The injured worker will be
required to sign the offer to verify acceptance or rejection of the job offer. A rejection of
the offer may result in a loss of time loss benefits.
Before beginning work, both the worker and supervisor will review the employee’s
limitation and the job duties of the transitional work, to assure the recovering employee
does not aggravate their condition.
If in the medical provider’s opinion, the injury will prevent the worker from returning to
the job of injury, the Risk Management Department will request analysis of additional
return to work options for the worker. The claims manager may assign a Vocational
Rehabilitation Counselor or Vocational Services Specialist to the claim.
During the transitional work period the Risk Management Department will maintain
communication with the worker, supervisor and medical provider to assure that recovery
is progressing as expected.
When offering the return-to-work position the Risk Management Department will
identify the terms of the position (such as the length of time the position will be available,
or if it is a permanent position.).
The injured worker and his/her supervisor will assure that medical limitations contained
in the employment agreement are adhered to. Under the medical provider’s guidance,
on-the-job physical conditioning efforts may be increased in order to return the employee
to full duty.
The Risk Management Department may enlist the assistance of a Vocational
rehabilitation counselor to help the injured worker achieve maximum medical and
vocational outcomes in a timely and cost effective manner. The counselor may be hired
for a complete assessment or just one or two task assignments to obtain the necessary
information.
Policies and Procedures — Section #5
Time Loss Payments
The intent of the Time Loss Policy is to provide compensation to restore a portion of a
worker’s wage loss while temporarily unable to work in any capacity due to an industrial injury
or occupational disease.
Documents used to determine if Time Loss Benefits are due include:
« Employee Application for Compensation and Report of Injury or Occupational Disease
e Disability Claim Attending Physician Statement
@ Supervisor’s Accident Report of Injury
The claim arrival date will be the date all the required documents are received by the Risk
Management Department. A determination on claim acceptance or denial will be made once
the claim arrival date has been established.
When Time Loss compensation is payable, the first payment thereof shall be made within
fourteen (14) calendar days after acceptance of the claim and shall continue at regular
semimonthly or biweekly intervals.
The Risk Management Depariment determines timeliness of first time loss payment by
counting fourteen (14) calendar days from claims acceptance. Day one would be the day
following claim acceptance.
e The day the time loss compensation is paid to the worker is included in the calculation.
The first payment is late if paid after the fourteenth (14) calendar day, unless the
fourteenth (14) calendar day falls on a holiday or Sunday, in which case the following
day would constitute the fourteenth (14) calendar day.
« Sometimes a condition will not be disabling until surgery is performed. In these
instances, time loss compensation becomes payable effective the date of surgery unless
otherwise medically justified, and payment of time loss must be made within fourteen
(14) calendar days of the last day worked.
Payments due to an injured worker under the age of eighteen (18) years “...shall be paid to
his/her parent, guardian, or other person having legal custody”. The parent or legal guardian
can, upon written authorization, allow payment to be made directly to the minor worker.
Time loss benefits are never provided for the date of injury, and are not paid for the first three
calendar days following the day of injury unless the injured worker’s disability continues for a
period of fourteen (14) consecutive calendar days from the date of injury.
The determining factor is the injured worker’s disability on the fourteenth (14) calendar day.
Payment would be made for the waiting period if the worker remains disabled on the
fourteenth (14) calendar day, less the time actually worked. If a worker attempts to return-towork and is able to work less than four hours, there should be no time loss deduction for that
day.
Examples:
Ted was injured on June 2". He was unable to work June 3” through June J 4. He returned
to work on June 15".
How many days of time loss is Ted eligible for?
Ted is eligible for 9 days of time loss. He is not eligible for the date of injury, June 2", nor is
he eligible for the three days following as he returned to work on the 13" day.
~~
Mary is injured on September 15"; she is certified to be off work through October 2", and
returns to work on the 3°
How many days of time loss is Mary eligible for?
Mary is not eligible for September 15" as this is her date of injury. However, since Mary was
off work for 17 consecutive days, the waiting period is waived and she is paid for all 17 days.
Time Loss compensation calculations are based on the wages the injured worker receives in
his/her regular work schedule. These wages must include all employment.
Compensation includes:
e Gross cash wages from employer of injury
e Wages from second job
The following schedule is used to determine the number of days a worker works in a month:
Days worked Per Week Multiply Daily Wages Times
30
26
22
18
13
9
5
PNW EAD ~]
Wages are determined by multiplying the daily wage by the number of days the worker is
“normally employed" e.g. If "normally employed" 5 days per week, muitiply the daily wage by
22, ifemployed 3 days per week, multiply the daily wage by 13.
An injured worker will receive a percentage of wages based upon marital status and the
number of dependents at the time of injury. The worker is entitled to:
Single with no dependents 60% Married 65%
Each qualified dependent under age 18 2% Each qualified dependent under 18 2%
Maximum of 5 dependents 70% Maximum of 5 dependents 75%
Any child conceived prior to the date of injury but born after the date of injury entitles the
injured worker to an additional 2% of gross monthly wage effective the date of the birth of the
child.
If the dependent is 18 years old and is attending an accredited school, the dependents portion
continues up to the age of 23. (School attendance must be documented). A dependent child,
who is an invalid, continues to receive benefits beyond the age of 18 as long as he or she is a
dependent.
If the worker necessarily incurs traveling expenses in attending an examination pursuant to the
request of the Risk Management Department, such traveling expenses shall be repaid to him or
her out of the accident fund upon proper voucher and audit.
The Risk Management Department may under certain circumstances suspend the compensation
of an injured worker for unacceptable behavior. The use of this type of penalty should not be
casually considered or implemented and is to be used as a last resort after proper warning has
been given to the worker of the consequence of the following actions:
* Refusal to submit to or obstruction of medical examination requested by the Risk
Management Department “at a place reasonably convenient for the worker.”
® Persistence of the worker in “unsanitary or injurious practices, which tend to. impede or
retard his or her recovery.”
« Refusal to submit to medical or surgical treatment “as is reasonably essential to his or
her recovery.”
e Refusal or obstruction of vocational evaluation or rehabilitation or failure to cooperate
in “reasonable effort” at such rehabilitation.
Here are the items included in a suspension letter:
® What do you want them to do - This should be specific. Just telling them that they must
cooperate is not specific. What exactly do they need to do to cooperate? Attend an
exain or agree to attend an exam? Have the surgery or agree to have the surgery? You
must be specific as to what you consider to be cooperating.
e Why you want them to do it - This should be supported by medical or vocational
information. You can’t make them agree to have a surgery if the doctor bas offered it
as only one of several treatment options. The doctor must say that surgery is the only
treatment option.
e When you want them to do it- You must give a specific time frame for them to respond,
as well as how you want them to respond. You should always get it in writing.
*® What will happen if they don’t - You must let them know what benefits are in jeopardy.
If an injured worker is paid more time loss compensation or permanent partial disability than
he/she is entitled, an overpayment exists. To compute the amount of the overpayment, a
determination of the correct benefits due is subtracted from the amount of benefits paid the
worker. The difference is the overpayment. Overpayments can be deducted from future time
loss or permanent partial disability benefits,
If an overpayment is made, the worker will be notified of the existence of the overpayment and
informed of the Risk Management request for recovery of the overpayment.
When a large overpayment exists and disability benefits continue to be awarded, there is an
option of deducting partial amounts of the overpayment for the ongoing benefits. In
considering the amount to deduct from ongoing benefits several factors should be considered.
Of primary concern is that the amount deducted from each payment should not be so large as to
place a hardship upon the injured worker. Secondly, steps should be taken to ensure that the
overpayment is recovered. An overpayment, which exists at the time of closure, can be
deducted from a permanent partial disability award if such an award is paid. Each case will
present its own circumstances.
Recovery of overpayments can be recovered from a second claim in which compensation is
being paid.
If the Risk Management Department receives a “child support” lien, an initial determination is
made as to the type of benefits for which the lien is intended (Time Loss Payments, PPD).
Once the intent of the lien is properly recognized, the injured worker must be informed of the
action to be taken.
6-15-1
6-15-2
6-15-3
6-15-4
. jurisdiction of any other'court of law or equity.
Chapter 6-15 WORKERS COMPENSATION CLAIMS ACT
GENERAL PROVISIONS
Purpose ,
This act shall be known and cited as the “workers compensation claims act” (hereinafter “the
act”), The purpose of the act is to establish the rights and benefits of employees of the
Confederated Tribes of the Colville Reservation (hereinafter “tribe”) for on-the-job bodily injuries
due to accidents or occupational disease as set forth herein. - : -
No Waiver of Sovereign Immunity .
Nothing in the act shall be deemed or construed as waiver of sovereign immunity by the tribe
and/or any of its affiliated entities. The State of Washington’s statutory workers’ compensation
system shall not apply to employees of the tribe or any of its affiliated entities, The tribe does not
consent to the jurisdiction of any state’s workers’ compensation appeals board or to the
Insurance .
Every employer must provide for workers compensation benefits.
Definitions , ;
Pronouns of the masculine gender used in the act shall apply to both sexes. Unless stated
. otherwise in a specific section of the act, time limits shall be calculated using calendar days.
Unless the context otherwise requires; the definitions which follow govern the construction
and meaning of the terms used in the act:
(a) “Administrator” shall mean the workers’ compensation program of the tribe, or its
successor in duties.
(b) “Attending physician” shall mean the physician, or other approved medical care
provider responsible for planning, provision, and oversight of medical treatment to a covered
worker who sustains a covered injury. :
(c) “Average weekly wage” shall be determined as follows:
(1) Fora covered worker hired to a regular, full- or part-time position
expected to last at least 13 weeks, the average weekly wage shall be calculated based on
the preceding thirteen (13) weeks of the covered worker’s actual wage earning from a
covered employer. In the case of a worker who has not worked for a covered employer
within the immediate preceding thirteen (13) weeks, the average weekly wage shall be
calculated based on the salary level the worker was hired at or is currently receiving.
(2) For covered worker hired on a temporary, emergency or special projects basis who
has continuously worked for a minimum of thirteen (13) weeks, the average weekly wage ©
shall be calculated as provided in paragraph (1) above.
(3) For covered workers hired on a temporary, emergency, or special projects basis who
have not continually worked for the preceding 13 weeks, the average weekly wage
shall be calculated by taking the expected total gross wages and divide by the
expected number of work weeks. .
(4) For covered workers serving as volunteers, the average weekly wage shall be the
salary of similarly paid positions for the covered employer performing similar work. .
1 (March 2011 Version of Chapter 6-15)
(5) For purposes of this definition, the work week shall be as defined by the personnel
manual or policy applicable to the covered employee at the time of injury.
(d) “Benefits” shall mean the indemnity and medical payments provided by this act. “indemnity”
shall mean total disability and partial disability income benefits and impairment payments; and
“medical” shall mean medical expense, mileage, and other expenses associated with medical
treatment.
(e) “Child” includes dependent natural children, dependent stepchildren, adopted children, but
does not include married children unless they are shown to be dependent.
(f) “Claimant” means the injured covered worker, or in the event of death of the covered worker,
dependents of the deceased.
(zg) “Consulting physician” shall mean the physician, other health care provider or other care
expert that is retained by the administrator to assist the administrator in. carrying out his duties and .
responsibilities under this act,. Such activities may include, but are not limited to, determiriation of
the validity of a claim; review of an attending physician’s diagnosis and treatment plans;
determination of MMI; determination of impairment rating. At the discretion and expense of the
administrator, an injured worker may be required to be seen by the consulting physician to assist
in making any required recommendations to the administrator.
(h) “Course and scope of employment” shall mean the employer’s employment of the covered
worker at the time the injury occurred. An injury must arise out of and be in the course and scope
of employment, and the worker must be acting in the furtherance of the employer’s interest at the
time of the incident and/or accident, in order for a claim to be compensable.
(i) “Covered employer” and “employer” shall mean the tribe and its agencies, and any tribal
corporations and enterprises.
@) “Covered worker” and “worker” means every person who has entered into the employment of
or performs work for an employer, works under contract of service, express or implied, or
apprenticeship, for an employer, every executive offer elected or appointed and empowered under
and in accordance with the charter and bylaws of a corporation, including a person holding an
official position, or standing in a representative capacity of the employer, including officials
(elders) elected or appointed by the tribe, compensated monetarily or otherwise, except as
hereinafter specified. The terms covered worker and worker shall not include an independent
contractor working under contract for an employer, whether that contract be express or implied.
Covered workers shall include all persons employed by the employer regardless of where they
work, whether it be on or off the Colville Reservation. Covered workers shall include volunteers
or other persons providing work for an employer who do so without receiving compensation.
Covered workers.shall not include persons serving in the tribal police department reserve program
or volunteer firefighters working for the tribal fire department or other volunteer positions covered
by a tribal accident insurance policy.
(k) “Death” i is any fatality of the covered worker proximately and directly caused by work injury
or occupational disease,
() “Dependents” are the following persons, and they shall be deemed to be the only recognizable
dependents under the provisions of this act:
(1) The widow ot widower, if legally married and living with the deceased at the time of
deceased’s death and legally entitled to be supported by the deceased as a dependent
defined by the most recent filed 1040 federal tax return. For purposes of this act, a
covered worker may, in a written self-declaration to be provided by the employer,
designate a person as their domestic partner, which person shall be treated as a dependent
2 (March 2011 Version of Chapter 6-15)
widow(er) ifthe person was living with the deceased covered worker at the time of
” his/her death and listed on the most recently filed 1040 federal tax return.
(2) A child, natural or adopted, under 18 years of age, or incapable of self-support and
unmarried; or a child under 25 years of age enrolled as a full-time student in an
accredited education institute at the time of the covered worker’s death.
(m) “Disability” means the inability of the covered worker to obtain and/or retain wages
equivalent to the pre-injury wage rate as a result of a direct loss of functional capacity
compromising that individual’s ability to perform the necessary duties of the job, This functional
loss must be directly and materially attributable to a compensable work-related i injury and/or
occupational disease and must be supported by the worker’s attending physician and, if requested
by the administrator, the consulting physician. “Partial disability” is distinguished as any
incapacity less than 100% inability as defined above.
(n) “Impairment” means any anatomic or functional abnormality or loss existing after reaching
maximum medical improvement (MMI) as defined herein that results from a compensable injury -
and/or occupational disease and is reasonably presumed to be permanent based on reasonable
medical probability.
(oy “Injury” shall mean any physical impairment, including, without limitation, death and/or
occupational disease as further herein defined. “Arising out of and in the course of employment”
excludes an injury sustained while a covered worker is at home or preparing for work. “Injury”
excludes any injury resulting primarily from the natural aging process, or normal daily activities,
or an injury sustained during voluntary recreational or social activities. The injury must arise out
of and in the course of employment, requiring medical services or resulting in disability or death;"
and is further defined as a specific, traumatic incident at a definite time and place, while in the
course of employment, that produces an immediate onset of pain and is established by medical
evidence supported by objective findings.
(p) “Intoxication” means blood alcohol content in excess of .02 percent or conviction of the
offense of driving while intoxicated (or words to that effect) by any jurisdiction or, loss of the
normal use of one’s mental and/or physical faculties resulting from the voluntary introduction into
the body of (1) an alcoholic beverage; (2) a controlled substance; (3) a mind-altering drug and/or
hallucinogenic; (4) an abusable glue or aerosol pain; or (5) any other similar substance.
(Q “Maximum medical improvement” (MMI) means the earlier of:
(1) The point at which further material recovery from or last improvement to an injury
can no longer reasonably be anticipated, based on the reasonable medical probability; or
(2) The expiration of 36 months from the date incapacity income benefits begin to accrue,
(rt) “Occupational disease” shall be only those diseases which arise out of an in the course and
scope of the worker’s employment. Such diseases shall have a direct causal: connection with the
employment and must have followed as a natural incident thereto from injurious exposure
occasioned by the nature of the employment. Such disease must be incidental to the character of
the businéss, occupation, or process in which the worker was employed and not independent of the
employment. Such disease need not have been foreseen or expected but after its contraction it
must appear to have had its origin in a risk connected with the employment and to have resulted
from that source as an incident and rational consequence. A disease which follows from a hazard
to which a worker has or would have been equally exposed outside of said occupation is not
compensable as an occupational disease.
(8) “Settlement” shall mean the date the release of all claims is executed and the monetary terms
of the agreement met.
3 (March 2011 Version of Chapter 6-15)
6-15-5
() “Tribal Court” shall mean the Colville Tribal Court.
(u) “Tribal workers benefit system” shall mean this act, any and all rules and regulations
promulgated hereunder.
(v) “Tribe” and “tribal” mean to refer to the Confederated Tribes of the Colville Reservation, a
‘federally recognized Indian tribe, and its agencies, and any tribal corporation and enterprises.
Acknowledgement of Act .
(a) All covered workers and persons asserting claim shall be conclusively presumed to have
_ elected to take workers benefits in accordance with the tenets, conditions, and provisions of this
act by virtue of employment with the tribe or other employers as defined herein. The tribal
workers benefits system is the exclusive remedy for any covered accidents and injuries. All
covered workers and/or persons asserting a claim for workers benefits acknowledge that the tribe
is a federally recognized American Indian tribe andsis exercising its » inherent sovereign authority i in -
providing workers benefits under this: code. .
(b) The employer shall be responsible for and shall post in a conspicuous location a notice as
follows:
NOTICE TO TRIBAL GOVERNMENT AND ENTERPRISE EMPLOYEES
AS EMPLOYEES OF THE CONFEDERATED TRIBES OF THE COLVILLE RESERVATION OR
ITS ENTERPRISES, YOU ARE INSURED FOR ON-THE-JOB INJURIES UNDER THE TRIBAL
WORKERS COMPENSATION CLAIMS ACT
If you are injured or sustain an occupational disease while at work, you may be entitled to benefits as
provided by the Tribal Workers Compensation Claims Act, Chapter 6-15 of the Colville Tribal Code.
NOTIFY YOUR EMPLOYER IMMEDIATELY OF ANY INJURIES, NO MATTER HOW SLIGHT.
If you fail to do so, you may lose your benefits under the tribal workers benefits system. In no event
shall benefits be paid to a worker who failed to notify his or her employer within fourteen (14) working
days after sustaining such work-related injury, excepting cases where an extraordinary reason
prevented the worker from reporting the injury or occupational disease to the employer in a timely
manner.
It is your responsibility to file a claim for benefits under the act with the administrator of the system.
You are required to file a claim for any injuries or occupational disease no more than thirty (30) days
after you have knowledge thereof. It is your responsibility to obtain any necessary forms from the
tribal workers benefits system claims administrator at:
Your exélusive remedy for any work connected injury or disease is through the tribal workers
benefits system. The state’s workers compensation system has no authority to accept a claim
from you related to employment by the Confederated Tribes of the Colville Reservation, a
sovereign Indian Nation employer, which is exclusively under the jurisdiction of the tribal
workers benefits system.
6-15-6
Notification to Employer of Injury by Worker
(a) Any person claiming benefits under this act must notify his supervisor and the administrator of
any and all injuries immediately, and in no event latér than fourteen (14) working days from the
date of occurrence. Failure to report such on-the-job injury shall result in the worker’s forfeiture
of benefits under this act, unless the claimant can demonstrate an extraordinary reason that
prevented the reporting of the injury or occupational disease in a timely manner.
4 (March 2011 Version of Chapter 6-15)
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6-15-8
6-15-9
6-15-10
6-15-40
6-15-41
6-14-42
(b) The supervisor must submit a supervisor's report to the administrator within seven (7) days of
receipt from the covered worker. .
Time Limit for Repor ting of Incidents and Filing of Claims
(a) Claims for injury shall be made by the covered worker to the administrator within thirty (30)
. days of the date of occurrence. For purposes of this act, a covered. worker filing a claim for
benefits under this act with the human resources office shall constitute filing a claim with the
administrator.
(b) Claims for occupational disease shall be made by the covered worker to the administrator
within thirty (30) days from the date of first notice to the claimant by a physician or from the date
of manifestation of symptoms, whichever is earliest, but in no event longer than six (6) months
from the date the worker terminates his employment with the tribe.
(c) Failure to give notice of injury to the employer as required by section 6-15-6 of the act or to
file a claim with the administrator, within the time limit set forth in this section shall constitute a
forfeiture by the covered worker, or his representatives in case of death, of all benefits available
and payable under this act.
Burden of Proof
The burden of proof shall rest upon the covered person, or his dependents in the case of death, to
prove:
(1) That the injury alleged was a result of an incident, accident or occupational disease;
(2) That it arose out of the covered person’s employment;
(3) That it arose while in the course and scope of employment and arose proximately out of
covered employment; and
(4) That it arose while in the furtherance of the employer's interests.
Right to Waive Defenses
The administrator shall have the right and power to waive any and all defenses affecting the
compensability of a covered injury under this act.
Guardian for Minor or Incompetent . ‘
Any person who is mentally incompetent and/or under the age of 18 and is entitled to receive
compensation under this act, shall be appointed a guardian or other representative by the tribe ifa
guardian has not been appointed in a prior action.
[6-15-20 to 6-15-39 RESERVED]
ADMINISTRATIVE DUTIES AND POWERS
Custodian Duties .
The administrator or its designee shall be the payor of the workers benefits, and shall be the
custodian of all claim files and related documents.
Payment and Distribution of Benefits
The administrator shall administer this act in accordance with the terms and conditions described
herein and remit payment for all matters.of benefit claims as provided for in this act. Further, the
administrator shall have the authority to determine the distribution of benefit cliecks.
Administrator Powers and Duties -
5 - (March 2011 Version of Chapter 6-15)
6-15-43
6-15-50
6-15-51
6-15-52,
(a) The administrator shall be empowered to request medical reports, police reports, autopsy
reports, and special investigations, engage the services of adjusters and consultants, and perform
other activities as required to process any claim for benefits or to further this act. .
(b) The administrator may retain a consulting physician for purposes of assisting the administrator
to carry out the duties and powers of this act.
(c) The administrator shall maintain complete and accurate administrative records and claim files
on all activities relating to the claims made under this act. All closed files shall be preserved for
not less than seven (7) years.
Acceptance/Denial of Claim
Upon receiving a claim for benefits from an injured worker, the administrator shall promptly
investigate the claim and begin payment of compensation within 21 days ofa valid claim or the
administrator shall send the claimant written notice, within 21 days, that further investigation is
needed and the reasons for further investigation. The administrator shall complete its
investigation within 45 days of receipt of the claim and shall commence the payment of benefits or
notify the claimant in writing that the claim is denied.
COVERAGE AND COMPENSABILITY
Entitlement of Benefits
(a) Any claimant for benefits under this act shall be responsible for filing his claim with the
administrator,
(b) Coverage exists under the act for a covered worker’s injury without regard to fault or
negligence if the injury arises out of and in the coursé and scope of employment and if the worker
was acting in furtherance of the employer's interest at the time of the injury and/or incident,
including, without limitation, any covered worker whose work at the time of injury was subject to
the Longshore and Harbor Workers Compensation Act (33 U.S.C, §§ 901-950), the Jones Act (46
U.S.C. § 30104 or any other federal workers compensation acts. If an injury is an occupational
disease as defined herein, the employer in whose employ the worker was last injuriously exposed
to the hazards of the disease is considered to be the employer of the worker for purposes of = -
. obtaining benefits under this act.
Disclosure of Preexisting Disabilities/Conditions
(a) All workers shall disclose any preexisting physical or mental conditions, disorders, and
disabilities that could potentially affect or impair the worker’s ability to perform in a reasonable
’ and safe manner the activities involved in the position in which he or she works, Disclosure shall
be made in the employment application or interview before commencing employment or before
commencing new job duties after job reclassification, reassignment, promotion, demotion, or other
change in job duties. The content of such disclosure shall be made promptly by the covered
worker after submitting a claim for benefits under this act.
(b) When a worker has a preexisting disability. or condition which is aggravated, the tribal workers
benefit system shall only be responsible for the portion of the injury attributable to the
aggravation.
Mental Trauma Injuries :
(a) Mental traumas, disorders, and/or conditions, even if manifested in physical symptoms and/or
related to stress, are not compensable injuries under this act, except ‘that mental trauma is only
recoverable if resulting from accidental physical injury traceable to a definite time, place, and
cause rather than from repetitive mental trauma.
6 (March 2011 Version of Chapter 6-15)
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6-15-54
6-15-55
6-15-56
6-15-57,
6-15-58
(b) Regardless of subsection 6-15-52(a), a mental trauma or emotional injury that arises
principally from a personnel action, including, without limitation, a transfer, promotion, demotion,
or termination is not a compensable injury under this act,
Going to and Returning from Work
An accident and/or incident occurring to a worker while on the way to or from work, including
lunch break, is not within the course and scope of employment except when such traveling is
directly connected with the worker’s work and in furtherance of the employer’s interest. This
exception will not apply if the worker deviates from a reasonably direct route of travel and/or is
not acting in the interests of the employer.
Benefits Precluded by Neglect and/or Refusal of Worker to Submit to Treatment
(a) No benefits shall be payable for the death and/or disability of a worker if the worker’s death
and/or disability is caused by, or the worker’s disability aggravated, caused or continued by, an
unreasonable refusal and/or neglect to submit to and/or follow any competent or reasonable
surgical or medical treatment, medical aid, or advice. A worker who has refused and/or neglected
to submit to medical and/or therapeutic treatment, or to take medications prescribed, will be
deemed to have reached maximum medical improvement as defined herein. Any such existence
of a disability that could have been reasonably treated to success with reasonable medical
probability will be discontinued in determining the appropriate incapacity rating as described
herein. - -
(b) Any covered worker entitled to benefits under this act shall be presumed to have reached
maximum medical improvement if such claimant has refused and/or neglected to seek appropriate
medical treatment within three (3) months from the date of occurrence or from the last date of
prior treatment.
Injury or Death by Consumption and/or Ap plication of Drugs and/or Chemicals
No. benefits of any nature shall be payable for injury and/or death caused or contributed to by any
drug, including narcotics and hallucinogens, whether organic or chemical in nature, or any gas,
vapors, and/or fumes taken and/or inhaled voluntarily, or by voluntarily poisoning, except those
drugs prescribed by a physician or other practitioner licensed to prescribe such medication.
Intoxication
No benefits of any nature shall be payable for any covered worker injured or killed while
intoxicated as defined in section 6-15-4(p), regardless of whether or not the intoxicated condition
was the proximate cause of the injury or death. It is only necessary to prove that the covered
’ worker was intoxicated at the time of the incident or accident to deny benefits under this act. All
workers accepting employment with an employer and under this act, agree to submit to postincident/post-accident.drug and alcohol screening as authorized in the applicable tribal personne!
policies,-and agree to waive any privilege associated with the results of said tests.
False Statement or Representation to Obtain Compensation; Penalty and Forfeiture
If, in order to obtain any benefits under the-provisions of this act, any person willfully makes a
false statement or representation, they shall forfeit all rights to compensation, benefits, or payment
upon proof that the offense was committed. Any claim resulting from an employment-related
aggravation of a preexisting condition which was not disclosed as required under this act will be
declined by the administrator pursuant to section 6-15-51. -
‘Injuries Resulting from Self-Inflicted Injuries, Willful Misconduct, “Horseplay”, or Safety
Violation
No benefits of any nature shall be payable for any covered worlker’s injury or death caused by a
covered worker’s willful intention to injure himself or another. An injury sustained during
“horseplay” is not incurred in the course and scope of employment, and thus such an injury under .
this act is not compensable. In addition, the willful disregard of a-safety order from the employer
to the worker to wear or use a safety device and/or to perform work in a certain manner may cause
7 (March 2011 Version of Chapter 6-15)
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6-15-60
6-15-61
6-15-62
6-15-70
6-15-71
6-15-72 _
such person to forfeit all rights to compensation, benefits, or payment upon proof that.the offense
was committed and that such disregard or performance was the direct and proximate cause of the
injury, death, and/or occupational disease, A covered worker’s willful disabling of safety devices
on equipment constitutes a willful intention to injure himself thereby precluding eligibility for her
benefits under this act.
Injuries Resulting from Natural Causes
No benefits of any nature shall be payable for any covered worker injured or killed when the
injury or death results from natural causes, i.e., heart attack, stroke or other natural function
failure, which does not arise out of the course and scope of employment while the worker was
acting in furtherance of the employer’s interest.
Recreational, Social. or Athletic Activities
(a) No benefits shall be payable for any covered worker injured or killed if the injury or accident
occurred as a result of the worker’s voluntary participation in an off-duty, recreational, social, or |
athletic activity not constituting part of the worker’s work-related duties, except where these
activities are expressly required by the employment. «
(b) No benefits under this act shall be payable to any covered worker if the injury, disease, or
death arises from participation in voluntary physical fitness activities during the regular work day,
regardless of whether the employee is or is not compensated for the time in which the physical
fitness activities take place. :
Injuries Caused by Third Parties :
No benefits of any nature shall be payable for any covered worker injured or killed as the result of
an act of a third party, including co-workers, who intended to injure the worker because of reasons
personal to that worker and not directed at the worker for reasons related/relevant to his
employment.
Secondhand. Smoke
No benefits under this act shall be payable to or on behalf of any covered worker injured or killed
as aresult of exposure to or injury by secondhand smoke.
BENLTITS — GENERAL PROVISIONS
Right to Compensation and Medical Treatment Benefits
. Every covered worker coming within the provisions of the act who is injured, and in the event ofa
worker’s death, the dependents of every such covered worker, arising out of and in the course and
scope of employment and while acting in furtherance of the employer’s interest at the time of the
incident and/or accident, unless the injury is otherwise limited or excluded by.the terms and
conditions of this act, shall be entitled to receive, and shall be paid, for loss sustained on account
of the injury, death and/or occupational disease, such benefits as provided under the act.
Workers Benefit as Exclusive Remedy
The rights and remedies provided by the provisions of the act for a worker on account of injury or
occupational disease for which benefits under the act are recoverable, shall be the exclusive and
only rights and remedies of such worker, the worker’s personal or legal representative,
dependents, or next of kin, at common Jaw or otherwise, on account of such injury and/or
occupational disease against the employer, the employer’s representatives, insurer, guarantor or
surety, for any matter relating to the occurrence of or payment for an injury or death covered under
this act. To that end, all civil causes of action against the covered employer and its employees,
arising from said injuries or death, and the jurisdiction. of all courts over such causes of action are
hereby abolished and barred, except as specifically provided by this act.
Effect of Compensation Paid in Other Jurisdictions or Third Party Recovery
An injured worker who pursues and recovers compensation under laws of another jurisdiction or
8 (March 2011 Version of Chapter 6-15)
6-15-73
6-15-74
6-15-75.
from a third party shall notify the administrator. The injured worker forfeits compensation under
this act in proportion to their recoveries from the other jurisdiction or third party.
Liability of Third Parties - Subrogation
(a) The employer and/or their representative, insurer, guarantor, or surety shall be subrogated to
the common law rights of the worker to pursue any claims for compensation against any third
party that is liable for the death of, or injuries to, said worker arising out of and in the course and
scope of employment and while the worker was acting in the furtherance of the employer’s
initerest to the extent of the benefits bestowed upon the said worker, .
(b) In case of recovery, the administrator shall enter judgment for distribution of the proceeds
thereof as follows:
(1) Asum sufficient to repay the employer and/or the administrator for the amount of the
compensation actually paid to the worker under this act up to that time;
(2): A sum sufficient to pay the employer the present worth, computed at the current legal
interest rate for court judgments and decrees, of the future payments of compensation for
which the employer is liable, but the sum is not the final adjudication of the future payments
which the worker is entitled to receive and if the sum received by the employer is in excess of
the amount required to pay the compensation, the excess shall be paid to the worker.
(3) The balance, if any, shall be paid over to the worker.
(c) For subrogation purposes hereunder, any payment made to a covered worker, his guardian,
parent, next of kin, or legal representative, by or on behalf of any third party, his or its principal or
agent liable for, connected with, or involved in causing an injury to such worker shall be
considered as having been so paid as damages resulting from and because said injury was under
circumstances creating a legal liability against said third party, whether such payment be made
under a covenant not to sue, compromise settlement, denial of liability, or otherwise.
Assignability of Benefits — Attachment of Liens
Benefits received under this act are not assignable, except that a legal beneficiary may, assign the
right to death benefits. Income from death benefits are subject only to the following liens or
claims, to the extent of any income or death benefits that are unpaid on the date the administrator
receives written notice of the lien, judgment, or claim in the following order of priority:
(1) Court-ordered child support issued or recognized by the Courts of the Confederated
Tribes of the Colville Reservation;
(2) A subrogation interest established under this act; and
(3) Debts owed to the tribe. : ot :
Aggravation of Preexisting Disease or Condition
Ifa covered worker is suffering from a preexisting disease.and/or injury at the time an
occupational incident, accident and/or disease occurs or arises in the course and scope of
employment and the worker was acting in furtherance of the employer’s interest at the time of the
injury and/or incident, and the pre-existing disease and/or injury is aggravated thereby, the
aggravation of the disease or injury is, subject to provisions herein, compensable under this act.
The amount of the award for that disability as set forth in this act may be reduced or denied i in its
entirety by the administrator in consideration of the following:
(1) A prior settlement from any source for the same impairment;
9 (March 2011 Version of Chapter 6-15)
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6-15-80
6-15-81
6-15-82
(2) The difference between the degree of impairment of the worker before the covered
accident and/or occupational disease and the degree of impairment after the covered accident
or occupational disease; or
(3) The benefits to be paid for impairments and/or disabilities would be in excess of 100% of
the whole person. For purposes of this subsection, benefits include those benefits or
payments made under this act, benefits from the worker’s compensation laws of any other
jurisdiction or payments from third parties.
Termination of Benefits Upon Death
Where a worker is etititled to compensation under this act for an injury sustained, and death ensues
from any cause not resulting from the injury for which he was entitled to the compensation,
payments of the unpaid balance for such i injury shall cease and all liability for such compensation
thereafter shall terminate.
BENEFITS
Vocational Rehabilitation
(a) Vocational rehabilitation benefits or training are not mandatory under this act, but may at the
discretion of the administrator, be ordered pursuant to his authority established herein, or as
required under rules promulgated by the administrator.
(b) The administrator is authorized to consider and, if appropriate develop a “return to work” or
similar program designed to allow injured employees to return to active employment as quickly as
possible,
Waiting Period
An initial waiting period of three (3) consecutive calendar days is to accrue before the covered
worker shali be entitled to benefits under this act. If the covered worker misses more than _
fourteen (14) consecutive calendar days, the first three (3) calendar days can be considered for
benefits if the covered worker received no other compensation during this time including but not
limited to, sick time, and vacation time. .
Total Disability and Partial Disability Income Benefits
(a) When the worker is disabled from work duty as determined by the consulting physician, or in
the administrator’s discretion, the attending physician, by reason of a compensable injury or
occupational disease, benefits shall be payable as follows:
(1) Ifthe covered worker is 100% disabled, benefits are payable at 60% of the worker’s pre-
" injury average weeldy wage. However, this amount will be increased by 5% if the covered
worker is married, and by 2% for each minor dependent living with the covered worker, up to
a maximum of 75% of the worker’s preinjury average weekly wage.
(2) If the covered worker is less than 100% disabled, benefits are payable at 60% of the
_ difference between the worker's preinjury average weckly wage and the wage the covered
worker is earning or capable of earning in his partially disabled condition.
(b) Except as provided herein, such benefits will continue to be paid in accordance with the terms
of this act until which time the earliest of the following occur:
(1) The expiration of 12 months from the date of occurrence, or in the case of an
occupational disease, 36 months from the earliest of the first manifestation of the
symptoms or notification from a physician that the illness is inherent or related to the
worker’s occupation;
10 (March.2011 Version of Chapter 6-15)
6-15-83
(2) The consulting physician, or in the discretion of the administrator, the attending
physician, declares that the worker has reached maximum medical improvement;
(3) The claimant is incarcerated;
(4) A full, unrestricted release is provided by the consulting physician, or in the discretion of
the administrator, the attending physician,
(5) A modified or light duty release is provided by the consulting physician, or in the
discretion of the administrator, the attending physician, and a bona fide job offer of
suitable work consistent with the worker’s disability is rejected;
(6) Anew or intervening incident is the proximate cause of disability;
(7) Benefits are refused by the worker;
(8) Presumption of MMI or abandonment of medical treatment as defined by section 10-4-54
of this act;
(9) The worker’s earning capacity is reduced for reasons other than the disability from the
work-related injury;
(10) The covered worker dies from any cause not resulting from the injury for which he was
entitled to compensation under this section, and the covered worker? s estate is not entitled
to any further benefits as defined by this act.
Impairment Benefits
(a) At the expiration of 12 months from the date of the incident, accident and/or occupational
disease, the worker is presumed to have reached MMI regardless of disability and/or current
medical status. The consulting physician, or in the discretion of the administrator, the attending
physician, is to provide an impairment rating in accordance with the most current edition of the
American Medical Association (AMA) based on reasonable medical probability, In addition, at
this time the consulting physician,.or in the discretion of the administrator, the attending physician
is required to provide a treatment plan for reasonable and necessary future medical needs. The
attending physician’s impairment rating and treatment may be subject to review and revision by
the consulting physician at the discretion of the administrator.
(b) For purposes of converting the impairment rating into a monetary figure the administrator will
issue, and periodically update as necessary, an award schedule for permanent partial disability,
(c) A rating may not be issued prior to the declaration of MMI, The administrator may reserve
issuance of payment under the following conditions:
(1) Contribution of prior impairment ratings;
(2) Clarification by the administrator of this act as to the validity of the date for MMI,
(3) Similar rating or MMI issues to be resolved by the consulting physiciati or, if necessary,
the arbitration panel established under this act,
@) The rating recognized by the arbitration panel i is binding. The rating will not be retroactively
paid for weeks accrued in resolving the rating issue subsequent to the date of MMI. Such benefits
will become effective the date of the ruling and commence at that time.
(ey ‘Notwithstanding provisions herein, the administrator shall retain the right and discretion to_
order lump sum settlements by way of compromise and release.”
li (March 2011 Version of Chapter 6-15)
6-15-84
6-15-85
- 6-15-86
6-15-90
6-15-91
Benefit Issuance Period
Except as provided herein:
_ (a) All benefits under this act are to be issued biweekly.
(b) There shall be no acceleration of benefits under this act.
(c) Any settlement issued on behalf of a covered worker shall be executed by signed memorandum
only.”
Not to Exceed Preinjury Average Weekly Wage
In no event may the worker’s impairment benefits exceed 100% of the worker’s preinjury average
weekly wage except as may be increased by a tribally approved cost of living adjustment.
Benefit Offsets: . .
The adminigtrator is entitled to reduce benefits payable to covered workers under this act in an
amount equal to employee payments paid for by the employer for any pecuniary wages paid in the
form of social security, long-term and short-term disability, employer elected salary contribution,
vacation or sick leave, or any other entitlement of a similar nature paid in whole or in part by the
employer, Further, if any overpayment is made under this chapter to the covered worker of any
disability income benefits as set forth in section 6-15-82 of this act, such shall be deducted from
any benefits payable under functional impairment benefits as set forth in section 6-15-83 of this
act; or in the case where no functional impairment benefits are payable, then such overpayment of
benefits may be deducted through payroll deductions.
DEATH BENEFITS
Distribution of Death Benefits
(a) When death ensues to the covered worker by reason of a compensable injury or occupational
disease, benefits shall be payable to the dependents who were dependent as defined in section 10-
4-4 on the earnings of the worker for support at the time of his injury, compensation upon the
basis of 65% of the worker’s average weekly wage, commencing from the date of death as .
follows:
(L)If there are no children entitled to benefits, then all to the surviving spouse for the ~
projected probable life span of the decedent based on established mortality tables. To be an
eligible “surviving spouse” under this act, the surviving spouse must have been married and
living with the decedent at the time of the compensable injury, ‘proof of eligibility may be
required. If there are surviving eligible dependents, the surviving spouse shall be entitled to
one-half of death benefits. If there is a surviving spouse, one-half of death benefits paid to
each surviving eligible dependent irr equal shares.
(2) If there is no surviving spouse, equal share of all to dependents as defined in section 6-15-
4,
(3) Notwithstanding any other provisions of the act, the maximum amount payable as a death
benefit under section 90 is $100,000.
(b) Where a worker is entitled to compensation under this act for an injury sustained, and death
ensues from any cause not resulting from the injury for which he was entitled to the compensation,
payments of the unpaid balance for such injury shall cease and all liability thereafter shall
terminate. : :
Redistribution of Death Benefits
2 "(March 2011 Version of Chapter 6-15)
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This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.