A MATRIX Minute by MATRIX Group Benefits, LLC
Employer sponsored benefit plans typically include exclusions for injury or illness arising outside of employment. Typically, workers compensation claims are filed when an employee suffers an accidental injury while performing their job or develops an injury or illness over time due to some type of repetitive activity or frequent exposure.
As we have been dealing with the novel coronavirus causing COVID-19, many industries have been deemed essential and their employees have continued to work. Essential businesses include healthcare organizations, safety organization and first responders, food and grocery businesses, vehicle repair companies, and many types of manufacturing companies, to name a few. All of these businesses and their employees incurred greater risk of exposure to COVID-19, and many had, and may continue to have, employees test positive for the virus.
Under the Executive Orders and new laws passed by Congress, certain medical testing and telehealth services are required to be covered without cost to covered persons. These services are clearly meant to be a covered healthcare service that is covered by an employer’s benefit plan. But what happens if an employee working in an essential job in an essential business tests positive for the virus and requires medical care, including hospitalization? In these situations, employer plan sponsors should direct their contracted claim administrator to contact the employer to research how the employee may have become infected – such as verifying the employee had been working, inquiring if the employee had traveled recently, or had been exposed to someone who was sick or an individual who was positive for the virus in order to make a claim determination. If the employee is considered to have contracted the virus through an exposure related to working for the employer, a claim determination should be based on the plan’s exclusion of an injury or illness arising out of employment. The employer should then file a claim with the workers compensation program for the medical expenses related to the treatment for COVID-19.
If the employer plan sponsor has an occupational health department or program, or contracts with an occupational health program, the occupational health professionals can facilitate the research of how the employee likely contracted COVID-19 and provide a resource for the employer and the contracted claim administrator for the benefit plan. Employers and their claim administrators may also consider checking for any Bulletins issued by their State Insurance Department or an Executive Orders signed by their governors related to workers compensation claims related to COVID-19
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