Accident: An unplanned injurious or damaging event which interrupts the normal progress of an activity. An accident may be seen as resulting from a failure to identify a hazard or from some inadequacy in an existing system of hazard controls. See “Disease,” “Incident” and “Occurrence.”
Activity Check: Is a visual spot check investigation done by a representative of an insurer to observe an employee’s physical activity.
Adjuster: Person responsible for the evaluation and settlement of an insured claim.
Aggravation: A permanent worsening of condition, an acceleration, increase in severity, or qualitative worsening of a medical condition brought on by injury, accident, or occupational disease.
Audit: Survey of an insurer’s files to determine efficiency and effectiveness in the handling of a claim, and to determine a strategy for the closing as open/active claims.
Average Weekly Wage (AWW): The base amount of weekly wages and benefits that are used to calculate an injured employee’s Workers’ Compensation rate of pay. (Wages for the 52 weeks prior to the accident).
Benefits: Payments received from insurer by an injured employee for reimbursement of medical expenses and indemnity (in lieu of wages) payments.
Carpal Tunnel Syndrome: A condition caused by the compression of the median nerve in the carpal tunnel (passage within wrist) and characterized by discomfort and disturbances of sensation in the hand.
Chiropractic: A system of therapy which holds that disease results from a lack of normal nerve function and which employs manipulation and specific adjustment of body structures (such as the spinal column). A doctor in this therapy is a Chiropractor.
Claimant: A person making a demand for compensation of some type.
COLA: Cost of Living Adjustment that applies to an employee receiving benefits under Section 35A (Permanent and Total).
Coming and Going Rule: General rule that employees that are insured while in transit to or from a fixed place of work are not covered by Workers’ Compensation.
Compensable Injury: A personal injury preventing an employee from returning to the work site and falling under a State’s Workers’ Compensation legal definition of an acceptable Workers’ Compensation claim.
Compensation: Payments made to an insured party as dictated under a Workers’ Compensation policy and State and Federal laws.
Compensation Rate: The rate of payment of Workers’ Compensation benefits to an injured party based on previous earnings.
Conciliation: The first step in the litigation process to settle the claim by having the parties meet informally and resolve the issue.
Concurrent Employment: Being employed by two different employers at the same time. Sometimes a determinant when calculating Workers’ Compensation benefits for an injured party.
Conference: Sometimes referred to as Dispute Resolution, an informal conference held before a Judge and subject to the rules of evidence. The parties are represented by attorneys and the parties need to identify all the issues that are in the dispute.
Cumulative Trauma: Any physical or psychological disability that results from the combined effects of repeated injuries or illnesses. Although each injury or illness may be minor at the time it occurs, the cumulative effect over time can lead to claims for physical or psychological disabilities.
Dependent: Those individuals defined by statute as eligible for loss-of-support payments due to permanent disability or death of an employee. Includes spouse, children, and others directly dependent on the injured employee’s ability to work.
DIA: The Department of Industrial Accidents.
Disability: A legal term referring to a person’s inability to perform normal occupational duties. Disability can be defined as partial, temporary, or permanent under a state’s Workers’ Compensation laws.
Dual Capacity Doctrine: Rule of civil procedure which permits an employee entitled to Workers’ Compensation benefits to also sue the employer on the basis that the employer acted wrongfully in some other capacity (for example, as a supplier of goods or an occupant of premises), causing harm to the injured employee and is therefore obligated to compensate the employee for more than Workers’ Compensation benefits.
Ergonomics: Study of human characteristics for the appropriate design of living and working environments. Ergonomics attempts to “fit the job to the person” through, for example, proper lighting, furniture, or equipment.
Exacerbation: A worsening of an underlying disease or condition caused by a workrelated injury, accident, or occupational disease, usually a passing or one-time “flare-up.”
Fraud: An intentional falsehood created by one party which causes damages or loss to another party.
Gross Wages: The total wages that are earned on a weekly basis before the deduction of benefits and taxes.
Hearing: The same Administrative Judge that presides at the Conference will conduct the Hearing. It is a formal procedure and the rules of evidence do apply.
Impairment: Term used to define a person’s inability to perform certain physical activities or to perform an activity to a certain degree.
Impartial Exam: A medical exam performed by a Board Certified Doctor appointed by the Judge to serve as “prima facia” evidence for procedures at the DIA.
Incident: Untoward event which may or may not cause accidental loss, depending on the particular circumstances or the event. An accident is a type of incident which results in accidental loss, but not all incidents are accidents. See “Accidents.”
Incidence Rate: Injury/illness rate based upon 200,000 employee hours (approximately the hours worked by 100 employees during 50 weeks at 40 hours per week) used by the Bureau of Labor Statistics in gathering and reporting occupation injury and illness statistics to the Occupational Safety and Health Administration (OSHA).
IME: An independent medical examination performed by a third party in order to resolve conflicting medical opinions.
Loss of Function and Disfigurement: Commonly known as Section 36. Pays benefits for specified permanent injuries or loss of function. Disfigurement benefits are only paid for scarring on the face, neck, or hands.
Loss Control: Programs and procedures implemented to control the effects of an accident on the operations of an entity.
Loss Run: Periodic report that lists the accidental losses or claims incurred by an organization.
Lost Time Accident: Under Workers’ Compensation, any accident that results in a disability for an employee, to the point where the employee is eligible to file for compensation.
Lump Sum Settlement: Settlement of a claim through the one time payment of an amount of money.
Medical Only Claim: A claim for Workers’ Compensation benefits that is for medical expenses only.
Modified Work Program: A loss control program for providing, on a temporary basis, light-duty or modified work to an employee with a work-related disability.
Neurosurgeon: A surgeon specializing in the surgery of nervous structures.
No Lost Time Injury: Any occurrence of an injury which does not disable a person to the point where a claim for lost wages needs to be filed, according to a state’s Workers’ Compensation law.
Occupational Illness: An abnormal physical condition suffered by an employee, caused by exposure to an environmental factor associated with employment.
Occupational Medicine: The branch of medicine concerned with the prevention and treatment of occupational diseases.
Occurrence: An accident, including continuous or repeated exposure to conditions, which results in bodily injury or property damage neither expected nor intended from the standpoint of the insured.
Orthopedist: Medical practitioner in the field of the prevention and correction of skeletal deformities.
PWOP: “Pay Without Prejudice.” An insurer may pay benefits for a period of 180 calendar days from the commencement of disability without accepting liability for the claim.
Partial Disability: A person’s inability to perform certain physical or mental activities of a certain job position.
Permanent Disability: A disability that is expected to last for the lifetime of an injured person. Disability is permanent if medical improvement is at an endpoint and there is no further possibility of improvement.
Physical Therapy: The treatment of disease and injury by physical and mechanical means, also called physiotherapy.
PPD: Permanent Partial Disability.
Premium: Payment required for insurance.
PTD: Permanent Total Disability.
Rehabilitation: Process by which a disabled person is aided to recover maximum effective function in all personal activities.
- Medical Rehabilitation: Involves assistance to the employee in attaining proper medical treatment on a timely basis.
- Vocational Rehabilitation: Assistance in attaining additional education or retraining to obtain employment.
Repetitive Motion Injury: An injury resulting from a repeated action, such as Carpal Tunnel Syndrome.
Reportable: A work-related accident that under state statue is reportable to the state Workers’ Compensation Agency and/or the insurer.
Reserve: An amount established as the probable cost of future claim payments.
- Loss (or claim) Reserve: Reserve representing an insurer’s estimated amounts payable for insured losses which have already occurred (including losses which have occurred but not yet been reported to the insurer).
Risk Control: All methods of reducing the frequency and/or severity of losses including exposure avoidance, loss prevention, loss reduction, segregation of exposure units and non-insurance transfer of risk.
Risk Management: A management discipline whose goal is to protect the assets of profits of an organization by reducing the potential for loss before it occurs, and financing, through insurance and other means, potential exposures to catastrophic loss such as acts of God, human error, or court judgments.
Risk Manager: Person(s) responsible for carrying out an organization’s risk management program.
Safety: The ability to perform a job in a risk-free manner and in a risk-free environment.
Second-injury Fund: State-administered insurance fund which assumes liability for payments of Workers’ Compensation for aggravation of pre-existing injury claims.
Section 28: “Serious and Willful Misconduct on the Part of the Employer.” Defined as the intentional doing of something that is likely to result in serious injury and complete disregard for the probably consequences.
Self Insurer: An individual, partnership or corporation who retains all or part of its risk.
Structured Settlement: An alternative to lump-sum settlement of bodily injury liability claims or court verdicts. The claimant is paid specified sums at specified intervals as compensation for loss of income, medical and rehabilitation expenses, until a designated future date. Many structured settlements are financed through insured annuities.
Subrogation: Legal right of one who has paid an obligation owed by another to collect from the party originally owing the obligation. Thus, an insurer may endeavor to recover from a third party the amount it paid to its insured for a loss.
“Third-party-over” Action: Lawsuit brought by a third party against the employer of an injured employee after that third party has been held legally responsible for the employee’s work-related injury or disease. Based on the premise or the employer’s alleged contributory negligence or other wrongdoing.
TPD: Temporary Partial Disability.
TTD: Temporary Total Disability.
Utilization Review: The DIA has set forth regulations of pre-certification guidelines for health care services for all medical treatment received after October, 1993.
Waiting Period: In Workers’ Compensation, the number of days an injured employee must be away from work before being able to file for Workers’ Compensation benefits.
Workers’ Compensation Statute: A law, in each state, which requires employers to assume obligation for employee injuries, and some illnesses, as defined, which “arise out of and in the course of employment.” Such obligation applies regardless of fault.
Work Hardening: A type of intense physical therapy which involves reconstructing the duties and activities associated with a specific job in a controlled environment, and having the injured employee work within the job parameters.
