​First doctor, part of the carrier’s Medical Provider Network, said:”Back to work in no time after a small surgery.”
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The other doctor, chosen by the injured worker’s lawyer,  opined that the worker cannot even seat more than 30 minutes as inscribed below:

​Workers Compensation Insurance law is set up to protect the well beings of injured workers and also to mitigate the liability exposure of the employers in case a worker is injured in the course of work.   After a worker got injured at the course of work, the worker is protected from being terminated from his or her position even he or she cannot perform the duty anymore.  Also the employer cannot force the injured to undergo treatment that is selected by the employer. 
The above scenario apparently brings forward a loss/loss situation to the employer.  What can the employer do then?

To answer the above question, let’s go back to 2004 when Governor Arnold signed the SB 899 into law that strongly suggested the WC carriers or employers to set up a Medical Provider Network after Jan 1, 2005.  If an employer or insurer uses an approved Medical Provider Network, covered employees would receive their medical carrier in this network, unless a predestined physician is chosen prior to an injury.

Then forward to Sept. 18, 2012 when Governor Brown signed SB 863 into law that took effective on Jan 1, 2013, another milestone Workers Compensation Law of California. Let’s get into the new regulations regarding Medical Provider Network:
 
Treatment obtained from a non-network provider, without either authorization from the employer or insurance carrier or a workers’ compensation judge’s order permitting outside of network treatment, will not have to be paid for by the employer or carrier. If unauthorized treatment is unsuccessful, and results in a worsening of the injured worker’s condition, or a need for additional treatment, the employer/carrier will have no obligation to pay for that, either.
 
Now back to the loss/loss scenario that the employer is confronting. 
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The first doctor is belonging to the MPN (Medical Provider Network) chosen by the carrier/employer and the second doctor is referred by the lawyer that the injured worked sustained and he is a “non-network provider”. According to SB 863, the carrier would not validate the second diagnosis and either the employer or the carrier would be responsible for the treatment payment. Is the employer stuck in the Limbo?
 
Not quite, the WC carrier would be the party best suited to handle the case.  Just sit tight and let the carrier’s claim adjuster to deal with the conflicting diagnoses and the WC claim. The carrier understands the law, they have the expertise and that is what they deal with everyday.  This is probably the most important reason but always unaware by the insured why they should buy insurance: to transfer the litigation burden to the carrier who is obliged to defend the insured if the claim is falling under the covered causes of loss.  The litigation cost could easily be ballooned into hundreds of thousands of dollars even the claim may be proved to be baseless.
 
For those who are interested to know more about the newest WC law, click on the following link to review the overview of SB863 as prepared by the Department of Industrial Relations.

http://www.dir.ca.gov/dwc/Reports/SB863-Assessment-WC-Reforms-July-2015.pdf
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For the employers, please post the poster that outlined the most updated labor law where your employees can easily see.  Posting the poster is required by law and would help you to mitigate the claim against you when there is a work related injury. Check out the MPN information; accident happens and it would save valuable time if you know where to send the injured worker when accident does happen.  For the employees, information on the poster is vital for you to know your rights and where to get help if you feel that your rights are violated.

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​Accident does happen and you may see more of it happening than seeing a full moon.  Spend some times to find the agent that who appreciates your needs, knows well about the products, takes the effort to secure the right coverage for you.

Many business owners would be in shock when they see their group health insurance renewals these coming months.  Effective from 12/1/2015, all grandfathered and grand mothered groups (those group plans that enjoyed low premiums because they stayed with the original benefits before the introduction of ACA) are to be renewed with plans in compliance with ACA minimum benefits.  The new benefits would include pregnancy and pediatric dental coverage even the members are neither female nor minors.  What can they do to counter the sharp increase?  Not much as all health insurance carriers are required to offer the ACA plans after 12/1/2015 and there are no other alternatives unless they cancel their plans.  But if they have 100+ employees (two part time employees counted as one full time), then they are required by law to provide the health insurance to their employees.

Brokers are cancelling their vacations and getting ready for exhaustive long hours to work with their clients trying to smooth the wrinkles of the “premium shock”.  Carriers are sharpening their quoting tools and sales effort working to entice their competitors business transferring to their books of business.  September and October would be the frantic months as few business owners would like to wait till the last minutes to make the changes.

To quote you a real life example – one of our clients with less than 30 employees are experiencing an unforeseen 45% increase in premium for their Grandfathered Health Plan.  We checked with other carriers, similar plans are even offered at more than 10% higher rates.

Shocking right?

Golden Gate Bridge by N. Yuen taken on Aug 30 2015

We would also like to share beautiful vista with you besides the awful news of premium increase. 

3-Day Sick Leave Law
Effective July 1, 2015, all employees (including full time, part time and temporary) in California will enjoy 3-Day Paid Sick Leave. All Employers are required to post a notice in the office and give individual notices to employees starting 1/1/2015. We provide free 2015 posters and individual notice samples to our clients.

Highlights:

• 1 hour sick leave for every 30 hours worked
• Must have worked for 90 days before taking the leave
• Leave: worked at least 30 days or 24 hours in 2015
• Accrue up to 6 days or 48 hours
• Unused sick pay is not paid
• If rehired within 12 months, employees can have the unused sick pay reinstated

Useful links: http://www.dir.ca.gov/dlse/Paid_Sick_Leave.htm

DLSE- Division of Labor Standards Enforcement provides a detailed list of Questions and Answers for employers and employees to learn more about the new law.

CoveredCalifornia - ObamaCare

You still have time to sign up for ObamaCare (from now to April 30) if you are required to pay for the Individual Shared Responsibility Payment (the penalty for not buying health insurance in 2014). The penalty will double for 2015. Act now to avoid the penalty.

If you have filed your taxes, you will be familiar with the IRS forms 1095 (A, B, or C), form 8962, or form 8965. If not, then please be prepared with these forms when you file your 2014 tax return. The IRS is using these forms to track your health insurance tax credit and share responsibility. 

If you went without coverage for less than 3 consecutive months during the year you may qualify for the short coverage gap exemption and will not have to make a payment for those months. There are more exceptions that you may claim to avoid the payments. Call us to find out more.

Disclaimer:
The materials contained in this Newsletter are strictly for informational purposes only and are not intended as legal advice. Please consult your attorneys or legal advisers for proper interpretation and enforcement of the law.