District of Colombia Workers' Compensation Claim Handling Guidelines
- 1 DEFINITIONS
- 2 EXCLUSIVE REMEDY
- 3 JURISDICTION AND LIMITATIONS OF ACTIONS
- 4 COMPENSABILITY
5 EXCLUSIONS AND DEFENSES
- 5.1 Exclusions
- 5.2 Acts by third parties unrelated to work, but committed on the premises (e.g. “irate paramour” claims)
- 5.3 Defenses
- 6.1 Calculating the Average Weekly Wage
- 6.2 Permanent Total Disability
- 6.3 Temporary Total Disability
- 6.4 Permanent Partial Disability
- 6.5 Beginning payment of temporary benefits
- 6.6 “Waiting” or “retroactive” period for temporary benefits
- 6.7 Terminating temporary benefits
- 6.8 Disfigurement benefits
- 6.9 Vocational Rehabilitation
- 6.10 Death benefits
- 6.11 Subsequent Injury Fund Recovery
- 6.12 Re-opening a claim for worsening of condition
- 6.13 Attorney’s fees
- 6.14.1 Time limit for payment of medical bills
- 6.14.2 Compelling the production of medical information (reports and/or an authorization) at the administrative level
- 6.14.3 Claimant's choice of physician; Employer's right to second opinion and/or Independent Medical Examination
- 6.14.4 Standard for covered treatment (e.g. chiropractic care, physical therapy, etc.)
- 6.14.5 Prosthetic devices
- 6.14.6 Vehicle and/or home modifications
- 6.14.7 Medical fee guide or schedule
- 6.15 Penalties
- 7 SUBROGATION OR CREDIT
- 8 ATTORNEYS
- 9 CLAIMS PROFESSIONALS
- 10 LITIGATION AND APPEAL
- 11 SETTLEMENT
- 12 INSURANCE
Any individual, firm, association, or corporation, or receiver, or trustee of the same, or the legal representative of a deceased employer, using the service of another for pay within the District of Columbia.
An employee whose employer is an uninsured sub-contractor can assert a claim against the general contractor. Where there is a hierarchy of contractors, the first insured contractor in the hierarchy becomes liable for compensation benefits.
Employee includes every person, including a minor, in the service of another under any contract of hire or apprenticeship, written or implied, in the District of Columbia, with some limited exceptions. D.C.Code Ann.§32-1501(9).
Illegal aliens are entitled to workers' compensation benefits even though The Immigration Control Act indicates that they cannot be employees. However, most state acts include them within definition of “employee.”
The liability of the employer is exclusive and in place of all liability of the employer to the employee.
If the employer fails to secure payment of compensation as required by the Act, an employee may elect to claim compensation under the Act or to maintain an action at law for damages. If the employee elects to maintain an action at law, the employer may not plead the defenses of negligence of a fellow servant, assumption of risk or contributory negligence. Additionally, intentional acts and/or sexual harassment may constitute exceptions to the exclusivity of workers' compensation as a remedy and permit a separate civil action against the employer.
The injury or death of an employee that occurs in the District of Columbia if the employee performed work for the employer, at the time of the injury or death, while in the District of Columbia.
An injury that does not occur in the District of Columbia may still be covered under the Act if the employment is localized principally in the District.
Accidents, which occur while a worker was temporarily or intermittently in the District of Columbia, involving a worker and employer who are not residents of the District of Columbia and whose contract of hire was entered into in another state.
This exemption applies only if: a) the non-resident employer has workers’ compensation insurance in the other state which covers the worker in the District of Columbia, and b) the other state has reciprocal statutory provisions exempting a District of Columbia employer and employee from the state’s workers’ compensation law under the same circumstances.
A claim must be filed within one year from the date of injury or one year from the date the employee is aware or should have been aware of the causal relationship between the injury and the employment. D.C. Code Ann. §32-1514. However, the one year statute will not begin to run until the Employer's First Report of Injury is filed with the Office of Workers' Compensation. Furthermore, the employee must be advised by the employer of the filing of the First Report in order to commence the running of the statute. The employer is required to provide to the employee, by certified mail, return receipt requested, a statement of the employee's rights and obligations which identifies the employee’s notice and limitation requirements. D.C. Code Ann. §32-1532
The employee should notify the employer in writing within 30 days of the injury or within 30 days of awareness of the relationship between the injury and the employment. Late notice will not bar a claim unless the employer otherwise had no knowledge of the injury and was also prejudiced by the late notice. D.C. Code Ann. §32-1513
Injury means accidental injury or death arising out of and in the course of the employment, and such occupational disease or infection as arises naturally out of such employment or as naturally or unavoidably results from such accidental injury, and includes an injury caused by the willful act of third persons directed against an employee because of the employment. There is no requirement that a specific or unusual incident occur for there to be an injury under the Act. Tremmer v. A.G. Prada Co., H&AS No. 84-185 (1985). An employee in the District of Columbia enjoys a rebuttable presumption that the claim is compensable if something unexpectedly went wrong within his or her body, and that the working conditions could have caused the harm.
See Traumatic or “single occurrence” claims above. The same presumptions apply.
Depending on the facts of a particular case, injuries during recreational and other non-work activities can be compensable, if they are sponsored or otherwise encouraged by the employer.
It is well established that the deliberate assault upon an innocent employee by some third person or co-employee is an 'accidental injury. Grillo v. National Bank of Washington, 540 A.2d 743
In general, disability causally related to psychological injuries is compensable if the employee establishes that the psychological injury resulted from a specific identifiable source within the obligations or conditions of the employment, rather than the employee's perceived conditions of the employment. Psychological injury cases are compensable regardless of the Claimant’s pre-existing condition. The test for psychological injury is subjective rather than objective.
An employee who is receiving benefits under the workers' compensation law of any other state for the same injury or death, casual employees of an employer, and employees who are only temporarily or intermittently employed in the District of Columbia, are not covered by the Act. D.C. Code Ann. §32-1503
Acts by third parties unrelated to work, but committed on the premises (e.g. “irate paramour” claims)
Not generally compensable.
Liability for compensation does not apply where injury to the employee was occasioned solely by intoxication or the willful intention of the employee to injure himself or herself or another. D.C. Code Ann. §32-1503
There is no applicable statutory defense. Courts, however, have recognized willful misconduct and horseplay as potential defenses, depending on the severity of the conduct. An employee may be deemed to have gone beyond the scope of the employment if he or she:
(1) violated an express prohibition;
(2) acted without authorization; or
(3) was on a personal mission.
The injury, to be compensable, must arise out of a risk connected with the employment and flowing from it as a rational consequence. Wimmer v. Hoage, 90 F.2d 373, 1937 U.S. App. LEXIS 3820 (1937). If the cause for the injury is drug or alcohol, the injury is not compensable.
Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining compensation shall be guilty of a misdemeanor, and may be fined up to $1,000.00 or subject to imprisonment not to exceed one year. D.C. Code Ann. §32-1533.
Not per se, but any person who willfully makes any false or misleading statement or representation for the purpose of obtaining compensation shall be guilty of a misdemeanor, and may be fined up to $1,000.00 or subject to imprisonment not to exceed one year. D.C. Code Ann. §32-1533.
Effective April 16, 1999, the average weekly wage is based on the employee's wages during the 26 weeks preceding the injury; 13 weeks for injuries prior thereto. Wage stacking is permitted.
Lifetime permanent total disability benefits are calculated initially at the rate of 2/3 of the employee's average weekly wage. The maximum compensation rate for 2013 is $1,416.00 and the minimum weekly compensation benefit is $354.00. Additionally, a cost of living increase (supplemental allowance) must be factored in annually, not to exceed a five percent (5%) increase. There is no increase in Supplemental Allowance for 2013.
Such benefits are paid at two-thirds of the average weekly wage. The 2013 minimum compensation rate is $354.00, and the maximum compensation rate is $1,416.00. However, the Court of Appeals recently ruled that the minimum rate does not apply to TTD benefits, and benefits should be paid at the two-thirds rate without regard to the minimum compensation rate.Hiligh v. DOES
Each member listed in the schedule shown is assigned a corresponding number of weeks for which the employee will receive compensation if he or she has lost total use of the member. If the loss is only partial, then the percentage of permanent disability is determined by multiplying the anatomical rating by the number of weeks provided in the schedule.
|Arm 234 week||Leg 216 weeks|
|Hand 183 weeks||Foot 154 weeks|
|Eye 120 weeks||Thumb 57 weeks|
|Second Finger 23 weeks||Third Finger 19 weeks|
|Toe other than Great Toe 12 weeks||Fourth Finger 12 weeks|
|Loss of Hearing Both Ears 150 weeks|
|Loss of Hearing in One Ear 39 weeks|
Compensation for injuries that are not specifically covered by the schedule (head, back or neck, heart attacks, strokes, mental conditions, etc.) are compensated based on actual loss of wage earning capacity. The employee must show that the injury has resulted in an actual diminution in post-injury wages before entitlement to compensation is established. If a wage loss is established, the employee receives compensation at the rate of two-thirds of the wage loss. However, the employee cannot receive temporary partial and permanent partial for more than 500 weeks unless rated at 20% or more for whole body impairment, in which case an additional 167 weeks may be owed.
As soon as possible after the date of injury, but not later than the fourteenth day thereafter.
The employee must be out 14 days before recovering benefits for the first 3 days. §32-1505.
Benefits may be terminated by entering into a stipulation if the employee has returned to work, or by filing a Notice of Controversion ( Form No. 11 DCWC) setting forth the reason for the termination of the voluntary payment of benefits.
The hearing examiner shall award proper and equitable compensation for serious disfigurement of the face, head, neck, or other normally exposed bodily areas, up to $7,500.00. The calculation of disfigurement is discretionary and normally related to the extent that the injury interferes with the claimant’s work ability. Warren v. King, H&AS No. 85-116 (1986).
The statute requires that the employer provide vocational rehabilitation which must be designed, within reason, to return the employee to employment at a wage as close as possible to that earned at the time of injury. The Office of Workers' Compensation monitors vocational rehabilitation services and determines the adequacy and sufficiency of the rehabilitation. D.C. Code Ann. §32-1507 (6)
Funeral expenses up to $5,000.00 may be allowed. D.C. Code Ann. §32-1509
Death benefits are paid to the surviving spouse and children of the employee in the following manner: (1) a surviving spouse with no children receives 50 percent of the employee's average weekly wage during widowhood and receives a lump sum payment of two years compensation on the date of re-marriage; (2) 16 2/3 percent of the average weekly wage is added for each child supported by the surviving spouse; (3) a surviving spouse receives 50 percent of the average weekly wage for the first child and the amount is increased 16 2/3 percent of the average weekly wage for each additional child and is to be split evenly among the children. In any case, total compensation may not exceed two-thirds of the employee's average weekly wage, or the maximum benefit payable.
If the employee sustains a work-related injury that combines with a pre-existing disability or impairment and causes substantially greater injury or death, the employer's liability may be limited to 104 weeks of permanent disability compensation. However, Special Fund has been abolished for injuries after April 16, 1999.
The employee may allege worsening of condition or claim additional compensation for any reason within: (1) one year of the rejection of a claim; (2) one year from the last payment of permanent disability benefits under the schedule; or (3) three years of payment of benefits under “Other Cases.” The last payment of “compensation” does not include payment of medical expenses.
When a claim is controverted by the employer, and, through the services of an attorney, the employee is ultimately awarded benefits, the employer may be responsible for the employee's attorney's fee up to 20 percent of all benefits secured. These fees are paid in addition to the award.
There is no specific time limit for the payment of medical bills, but such bills are to be paid promptly when due.
Compelling the production of medical information (reports and/or an authorization) at the administrative level
Subpoenas for medical records, medical release authorizations and requests for production of documents may be used.
Claimant's choice of physician; Employer's right to second opinion and/or Independent Medical Examination
The Claimant has the right to choose a treating physician to provide medical care. The claimant may not change the treating physician without prior approval of the carrier. The claimant may obtain referrals from one specialty to another without prior approval.
All reasonable and necessary treatment which is causally related to the injury is covered, subject to the employer's right to seek utilization review of the proposed or previously rendered service. Chiropractic care and physical therapy are both covered.
The employer must furnish any prosthetic appliance for such period as the nature of the injury or the process of recovery may require.
Both covered, if related to the injury reasonable and necessary.
As of April 16, 1999, each provider of medical care or services must use a standard coding system for reports and bills. Medical care and services shall be billed at the rate established in the medical fee schedule adopted by the mayor. The fee scheduled is based on 113% of Medicare's prevailing rates. Utilization review is available for all medical providers' bills.
None under the Act, but such penalties exist under both District of Columbia and federal law, and vary according to the severity of the offense.
If the Department of Employment Services or a court determines that an employer/insurer has delayed the payment of any installment of compensation in bad faith, the employer/insurer must pay to the employee, for the duration of the delay, the employee's actual weekly wage for the period that the employee is eligible to receive benefits in addition to employee's regular compensation benefits.
An employer who discharges, or in any other manner discriminates against, an employee because he or she claims, or attempts to claim, compensation, or for testifying or preparing to testify in such a claim, is subject to a penalty up to $1,000.00. Any employee so discriminated against must be restored to his or her employment and compensated for any wage loss arising out of the discrimination. However, if the employee ceases to be qualified to perform the duties of the employment, he or she is not entitled to such restoration to employment and back pay. The employer alone, and not the insurer, is liable for any such penalties and payments.
Third parties can be sued by injured employees.
Co-employees are amenable to suit for work-related injuries.
The employer has a lien against an employee's third party recovery for workers’ compensation payments. This lien may be pursued by subrogation or direct action by the employer against that party.
Attorneys must be licensed to practice law in the District of Columbia.
There is no requirement for licensure of Claims Examiners in the District of Columbia.
The filing of a Notice of Controversion ( Form No. 11 DCWC) test all or part of a claim.
An Informal Conference concerning the claim is scheduled by a claims examiner of the District of Columbia Office of Workers' Compensation. The claims examiner issues a non-binding recommendation concerning the payment of compensation. Either party may reject the recommendation and request a Formal Hearing before an Office of Hearings and Adjudication examiner. The order issued after a formal hearing is binding.
Any party disagreeing with the decision of the Informal Conference and Formal Hearing may seek further review at the Compensation Review Board. The CRB reviews cases based on the record and memoranda filed by the parties. No additional or new evidence is allowed. The CRB will review the prior order to determine if it is “legally sufficient.”
An appeal from the CRB may be taken to the District of Columbia Court of Appeals, which must affirm the decision of the Department if it is rational, supported by substantial evidence, and in accordance with the law.
Stipulations and settlements must be in writing and submitted to the Office of Workers' Compensation for approval. Factors considered by the Office of Workers' Compensation include: (1) whether there is a valid dispute regarding issues of compensability of a claim; (2) the extent of total or partial disability and other liability under the Act; (3) the employee's age and educational level in relationship to vocational evaluation and entitlement; (4) whether the employee has reached maximum medical improvement; and (5) whether and why the employee has refused to undergo surgery to improve a medical condition. Full and final settlements with closed medicals are available as well. Also, stipulations and/or settlements must be approved by the state administrative body before they become binding.
Every employer in the District of Columbia is required to “secure the payment of compensation” under the District of Columbia Workers' Compensation Act, either through insurance or by qualifying as a self-insurer. The District of Columbia does not have an insurance fund, but insurance is available through private insurers and an assigned risk pool. Insurers must be authorized to transact workers' compensation insurance in the District of Columbia.
Employers may qualify as self-insurers by furnishing satisfactory proof to the District of Columbia government of the financial ability to pay compensation under the Act and by receiving authorization from the Mayor to pay such compensation directly. Applications for self-insurance are handled on a case by case basis and depend generally on the size and financial stability of the employer, the number of employees, and the previous claims history.
The Act does not specifically address group insurance or “pooling.”