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Workers Compensation Insurance First Aid or Medical Treatment?

By January 25, 2015June 8th, 2020Insurance

 

Many employers are confused as to the difference between first-aid and medical treatment when it comes to workers compensation. It does not depend on whether the treatment is provided by a physician but rather the type of treatment an employee receives.

The California labor code, section 5401(a) defines first-aid as ‘any one– time treatment, and any follow-up visit for the purpose of the observation of minor scratches, cuts, burns, splinters or other minor industrial injury, which do not ordinarily require medical care. This one time treatment, and follow-up visit for the purpose of observation, considered first-aid even though provided by a physician or registered professional personnel”

UPDATE EFFECTIVE JANUARY 1 , 2017

Effective January 1,2017 all insured employers within the State of California must report ALL CLAIMS INCLUDING FIRST AID CLAIMS FOR WHICH MEDICAL TREATMENT COSTS ARE INCURRED. The reporting requirements for these claims is the same for any medical only claim.

Malpractice 2

Treatment is not considered first-aid in either of the following circumstances.

  • Medical care goes beyond a one time treatment and follow-up visit.
  • The injury causes an employee to lose time from work beyond his or her work shift.

We recommend;

  1. Promptly report any and all claims including those involving first aid.
  2. If you paid the claim yourself, you need to report the amount paid along with sending documentation, such as a medical bill.

We caution employers on self-determination of first-aid versus medical care. An employer must be very careful to make sure that the proper reporting forms are provided if the first-aid injury goes beyond a simple first-aid case. For example if the physician prescribes medication then the injury would no longer be considered a first-aid claim and must be reported to the carrier.

Physicians who offer first aid treatment must comply with section 6409(a) of the California labor code regarding first-aid injury treatment reporting. The physician is required to submit a doctor’s first report of injury or illness (DFR form 5021) to the carrier within five calendar days of the initial examination. A doctor’s first report of injury is not required if the physician is not involved in the first-aid treatment.

If at the request of an employer, a first-aid treating physician fails to submit a doctor’s first report of injury to the workers compensation carrier, the Department of Insurance and the Department of industrial relations may consider the arrangement improper. This arrangement can be viewed as contributing to possible criminal violations related to premium fraud and the fraudulent denial of workers compensation benefits to an injured worker.

We recommend contacting your insurance agent or the carrier to discuss whether a claim is first-aid versus medical care. For more information contact our office or your carrier.