303 North Church Street
Murfreesboro, TN 37130
Phone: (615) 898-7715
Fax: (615) 867-4602
OJI – Frequently Asked Questions
(For questions regarding injuries prior to January 1, 2009, please call the Insurance Dept.)
- What is considered a work-related injury, illness or death claim?
- An injury, illness and/or death that occur during the performance of an individual’s specific job duties, which are within the scope and course of their employment.
- Are there any exclusions to the OJI Program?
- All injuries and or illnesses that occur during the qualified individual’s hours of work may not qualify for OJI. All non-occupational injuries or illnesses not qualifying for OJI should be presented to the medical insurance carrier, if applicable, for payment according to the then in-force rules and regulations of that program. The Safety Coordinator or OJI representative will make determination of questionable injuries or illnesses.
Injury or illness resulting from the adverse effects of prescription or over-the-counter medications (as determined by County designated physician) not related to an on-the-job injury or illness.
Injury or illness resulting from alcohol or from unlawful use of drugs (as determined by County designated physician).
Misconduct, including horseplay.
Intentional or self-inflicted injury even as a result of a medical or mental condition.
Failure or refusal to use safety devices and/or personal protective equipment as outlined in the County Safety Manual as amended from time to time, failure to perform duties as required by law, or failure to follow general safety precautions in performing ones duties.
On the job injuries or illness aggravated by any activity while off-duty.
Injuries suffered while traveling to and/or from work, except when such travel is in the performance of the employee’s duties driving a personal or County-owned vehicle. “To and from work” is defined as beginning when you enter your work space and leave your work space; injuries or illnesses sustained while getting in or out of your vehicle or in a county parking lot coming to or leaving work are not covered.
Health conditions which are attributed to degenerative conditions.
Participation in physical fitness or recreational activities UNLESS the activity is part of an organized program approved by the Department Head AND the employee’s participation is made mandatory by the Department Head. Voluntary participation in such activities is covered neither during work hours nor during off-duty hours.
Use of articles, objects, or appliances for climbing or lifting that are not intended and/or adequate for those specific purposes.
Benefits will not be provided for personnel who choose to work when directed not to do so.
Rutherford County will require injured employees to submit to a drug and alcohol test. A positive drug or alcohol test will result in a presumption that intoxication or drug use was the proximate cause of the injury or accident, such that compensation under this Policy is not payable.
- If I am injured on the job, what should I do?
- All injuries and/or illnesses, on the job, whether requiring medical attention or not, must be reported to the supervisor immediately or within the current working shift after such occurrence. An exception to the injury and/or illness reporting requirement shall be made if the circumstances of the injury and/or illness are such that the employee does not have reason to know of the injury and/or illness at the time it occurs and if there is independent evidence regarding the injury and/or illness that supports making such an exception. However, in no event will such exception be made if the injury and/or illness is not reported within three (3) calendar days from the date of injury.
Supervisors must call in notification of an OJI to the Insurance Department within one (1) working day from the date of occurrence. Non-compliance with this rule may cause the cost of any injury to be deducted from the budget of the affected department.
Completed reports of injuries and/or illnesses and other documentation must be filed with the Insurance Department by the supervisor on all injuries, accidents and/or illnesses whether medical treatment is necessary or not, within two (2) working days from the date of the event. (Employees will be responsible for completing and submitting documentation as required by the supervisor). The Safety Coordinator or designee (OJI Representative) will complete and sign off on all reports of injuries, accidents and/or illnesses.
Qualified individuals must report to their supervisor all potentially unsafe conditions, and any hazardous or safety violations which could contribute to or result in injuries and/or illnesses to employees or others.
Qualified individuals will practice safety awareness and exercise good judgment and common sense in the performance of their jobs and while on County premises and/or job locations. Everyone also has a moral as well as a legal responsibility to ensure that their physical/emotional conditions are such that they have the mental clarity and physical ability to perform assignments, responsibilities and duties as related to their jobs.
- How is my supervisor kept informed of my progress?
- It is the employee's responsibility to keep their supervisor informed of their work status. Following a doctor's appointment an employee needs to meet with their supervisor and provide them with a copy of their physicians report and any updates that would affect their work status.
- May I go to my personal physician for treatment of my work-related injury?
- No. Qualified individuals shall receive treatment only at authorized County designated facilities. Any non-authorized treatment will be at the employee’s own expense except for unavoidable emergency situations. Once the patient is stabilized the County has the right to direct or relocate the qualified individual to a designated health care provider or facility. Notification will still need to be made to the Insurance Department. Non-authorized treatment will void any future OJI benefits for this specific claim.
Qualified individuals shall follow all orders given by a County designated physician, including but not limited to: using prescribed and non-prescribed medications properly; participating in physical exercise or therapy programs; adhering to prescribed dietary programs; the keeping of appointments; and limiting themselves to any restrictions ordered by the physician both at work and at home. Failure to keep scheduled appointments or comply with physician’s orders could result in termination of benefits.
- What must I do if I need emergency treatment?
- In the event that an OJI occurs that is deemed life-threatening such as: Heart attack, stroke, poisoning, convulsion, serious breathing difficulty, unconsciousness, major lacerations, smoke inhalation, head injuries or other acute conditions which would lead to disability or death if not treated, employees are to seek treatment at the nearest emergency medical facility or that facility selected by the medical emergency transport responders.
For OJIs that are not emergencies such as referenced above, and where medical treatment is necessary, employees are to seek assistance at one of the authorized treatment centers (see Panel of Physicians). These are the ONLY authorized treatment centers for OJI injuries and/or illnesses. When specialized treatment is required, the injured employee will be presented a panel of specialist physicians from which to choose for further medical care. No other treatment centers will be compensated for any OJI related treatment without prior approval from the Insurance Department.
- What happens if I need surgery?
- Prior to scheduling any major surgical procedures for an OJI, except in the case of an emergency, the treating physician will notify the OJI Representative. Once the Representative has been contacted, they will work with the physician and/or his/her medical staff to ensure that all the necessary arrangements are made.
- What if the physician says that I need a MRI or CT Scan?
- The OJI Representative will arrange for these tests.
- If the physician prescribes medicines for me, what do I do?
- Employees should NOT use the county insurance card to pay for prescription. Prescription drugs are covered under the OJI program. The employee must fill the prescription at one of the following authorized pharmacies.
The list of authorized pharmacies is as follows:
(All Rutherford Locations)
(All Rutherford Locations)
(All Rutherford Locations)
(All Rutherford Locations)
LaVergne Drug Publix
(All Rutherford Locations)
(All Rutherford Locations)
(All Rutherford Locations)
- What if I need physical therapy?
- The authorized treating physician will make the referral for physical therapy. The OJI Representative will arrange the visits.
- Am I required to pay a portion of the cost of the medical care I receive for my work-related injury?
- No. All physician’s bills and reasonable medical bills are covered if treatment was with an authorized physician. All medical charges are paid according to the usual and customary rate for the geographical area for the type of service rendered. THE INJURED EMPLOYEE IS NOT RESPONSIBLE FOR CHARGES ABOVE THE USUAL AND CUSTOMARY RATE. However, if the employee is billed for those costs, contact the OJI Representative to assist in getting the charges corrected.
However, the injured employee will be responsible for bill(s) when:
- The injury is found by the Safety Coordinator not to be compensable;
- The physician, who was not authorized by the employer at the time the services were rendered, knew that he/she was not an authorized physician; or
- The employee knew the physician was not authorized and it was not an emergency.
- Will I be contacted about my work-related injury?
- Yes. Upon verbal or written notice of the injury, the OJI Representative has to make verbal or written contact with the injured employee within two (2) working days to confirm facts of the claim, history of prior claims, work history, wages and job duties. This may include a recorded statement.
The OJI Representative has fifteen (15) calendar days within verbal or written notice of the injury to determine if it is compensable. The injured employee will be notified, verbal and written, on the decision of their claim.
In the event that an OJI claim is denied, the denial determination may be reviewed and appealed through a two (2) tier process:
If the employee disagrees with, disputes, or does not understand any determination regarding benefits, compensation or medical services decisions under this OJI policy, the employee may seek a review of the determination in question. A review must be requested in writing by the employee on a form available from the Insurance Department. The review must be requested within ten (10) calendar days following the employee’s notification of the determination which is questioned or disputed.
Upon receipt of an employee’s written request for a review, the Safety Coordinator will schedule a meeting within ten (10) calendar days.
The review consists of a meeting between the employee and the Safety Coordinator (or OJI Representative). At this meeting, these persons will discuss the facts and review all available information related to the claim and the claim determination; will delineate the question(s) or dispute(s); and will engage in a discussion in an attempt to answer the questions and/or resolve the disputes by agreement. The Safety Coordinator (or OJI Representative) will explain the employee’s rights under this OJI policy in a manner which will permit the employee to make informed decisions, and will attempt to reach a mutual agreement resolving any dispute.
Participation in the review is a requirement before any further appeal will be considered. If the employee fails or refuses to timely initiate or participate in the review, then the initial claim determination shall be final and binding.
If the matter is not resolved during step one, the individual may file an appeal, in writing, with the OJI Appeals Committee within ten (10) calendar days of receipt of the Safety Coordinator’s decision. The OJI Appeals Committee will consist of the Insurance Director (chairperson, voting only in the absence of one of the other members), the Human Resources Director or Human Resources Coordinator of the County division that employs the individual, an Insurance Committee Representative (at large) and an Insurance Committee Representative or designee of the County division that employs the individual (i.e. County General, Highway, Sheriff or Schools). The Committee will meet with the individual seeking OJI benefits. The individual has the right to have present family members, friends, counsel, or a designated representative, the opportunity to present evidence, call witnesses, and examine witnesses. (In order to provide a timely appeal and decision by the Committee a complete list of all individuals attending the hearing on the individual’s behalf must be submitted to the Insurance Director 5 days prior to the hearing). The Committee will receive the information and make its decision on the submission of such materials, statements, and evidence. The Committee will notify the employee of its decision within thirty (30) calendar days of receipt of the individual’s written notice of appeal. The decision of the Committee will be final.
- What if the authorized physician orders light or restricted duty?
- When the County designated physician allows the employee to return to work on an unspecified “light” or “restricted” duty assignment, the Insurance Department/Safety Coordinator will contact the physician to determine how light or restricted duty is defined in terms of what can and cannot be done, and anticipated length of time the employee may be expected to remain in said status. Approved modified duty assignments are temporary in nature, and will not be permanent job modifications.
Discretionary judgment decisions as to whether there is a temporary “light” or “restricted” duty assignment available will be made by the Department Head on a case by case basis. The County will not discriminate on the basis of disability or any other protected status, and will comply with applicable federal and state law with regard to issues of alternative duty, restricted duty, or reasonable accommodations.
- What if the authorized physician recommends part-time work?
- Temporary Partial Disability is a benefit payable to an employee when the employee returns to work in a temporary job paying less as a result of an on the job injury. Eligible employees will be compensated by OJI at a rate equal to 66 2/3% of the difference between the gross weekly income earned and the average weekly wage prior to the injury.
- What if the authorized physician determines I am unable to work or if there is no light, restricted or part-time work?
- Qualified Rutherford County employees shall receive 2/3rds of salary average over the past 52 weeks provided there is medical documentation from a county-designated physician stating that it is medically necessary for the qualified individual to remain off work due to an OJI, or to undergo therapy in relation to an OJI. For continued time off work for an OJI, there must be provided medical documentation from a county-designated physician stating that it is medically necessary for the qualified individual to remain off work due to an OJI every 30 calendar days thereafter until released. You will not receive OJI pay for days you are not scheduled to work. Upon receiving medical notification to remain off work, the qualified individual will continue to accrue sick, annual, compensatory or holiday leave time, unless precluded by a collective bargaining agreement, for a period of six (6) calendar months . FMLA and all other leave policies, as per County Policy Handbook, will run concurrently with the OJI Program. The maximum amount of compensation will not exceed six (6) calendar months. After six (6) calendar months of compensation have been exhausted, the qualified individual shall seek income replacement from the County sponsored Long Term Disability insurance. The qualified individual may use his/her remaining accumulated sick, annual, compensatory or holiday time leave until maximum improvement is reached, however, notwithstanding any other provision herein, the total maximum period of any benefits payable for any type of an OJI (not including Long Term Disability benefits) shall not extend beyond one (1) calendar year from the date of injury or illness.
- How and when will I be compensated for missed work?
- The date of injury and the first seven (7) calendar days following the injury are the waiting period. Compensation begins on the eighth (8th) calendar day of disability “from work”. Consult the supervisor about the use of sick time for the seven-day waiting period. Benefits are due for each day over the seven (7) calendar day waiting period until the lost time reaches fourteen (14) calendar days. If the lost time goes beyond fourteen (14) calendar days, the employee “may” qualify for temporary total disability benefits (TTD) for the full period of disability. Temporary total disability benefits will be calculated beginning with the day following the injury and will be scheduled so the employee will receive their compensation 14 calendar days from the day of injury and biweekly there after. (This date will most likely not coincide with the individual’s county pay period). However, an employee will not be compensated for the first seven calendar days if sick or annual time was used. TTD benefits are based on 66 2/3% of the gross average weekly wage for the last 52 weeks worked prior to the injury. This is called the weekly compensation rate and is subject to the minimum and maximum rates in effect on the day of the work-related injury.
- What happens if my disability becomes permanent?
- Currently Rutherford County provides a Long Term Disability (LTD) policy for all qualified employees working fifteen (15) hours or more per week. For definitions, criteria, and/or eligibility please see the applicable insurance agreement, which is maintained by the Insurance Department.
If the qualified individual cannot return to his/her job, and is totally and permanently disabled, and there is no job available within the County for which the individual qualifies, then the employee will be separated from employment with Rutherford County.
- Can I be compensated for occupational related diseases?
- Yes. If the disease meets certain tests the employee can be compensated. The condition must be medically documented by a County-designated physician to be related to a specified work task or essential function as per the employee’s job description. It cannot be a disease that is an ordinary disease of life to which others are exposed.
- What happens if I re-injure a pre-existing condition or injury?
- Claims of work related aggravation of a pre-existing condition must be medically documented by a County designated physician to be causally related to a specified work task or essential function as per the employee’s job description. The mere manifestation of symptoms or medical conditions which are present during the completion of a qualified employee’s specific work task do not indicate an aggravation of an existing or pre-existing injury, unless medical documentation substantiates a new injury resulting from the performance of work as described in the employee’s job description. To receive OJI benefits, records must be obtained by the injured employee from the previous treating physician, regarding the existing medical conditions.
- Can I be compensated for a repetitive motion injury?
- Yes. Repetitive motion injuries are compensable if they arise out of and in the course and scope of employment. However, Health conditions which are attributed to degenerative conditions are excluded from the OJI Program.
- Once I am treated for my injury and reach maximum medical improvement and begin having problems in the future due to my injury, may I receive additional treatment for this injury?
- Possibly. When a covered claim has met the conditions for cessation of benefits, any request to re-open the claim by the injured employee is at the discretion of the Insurance Department.
- Am I paid for work time lost to attend doctor visits or PT?
- No. Rutherford County does not pay for work time lost, except for the initial doctor's visit on the day of injury. The employee may use sick, personal or vacation time to attend doctor visits or PT.
- Can my OJI benefits be terminated?
- Yes. Benefits for OJI will cease when one or more of the following conditions are met:
- Termination of employment with Rutherford County either by resignation, retirement, discharge, or death, except for coverage provided by an insurance policy specifically designated to continue after such event.
- Failure to follow medical advice of County designated physician or OJI instructions.
- Acceptance of employment with another employer.
- Upon completion of medical treatment.
- Upon return to work, or directive to return to work without restrictions by treating physician.
- When the point of maximum medical recovery has been reached as determined by County designated physician.
- Seeking treatment with medical provider(s) not authorized by the Insurance Department, except for unavoidable emergency situations.
- Medical treatment not sought within seven (7) calendar days after the date if injury, unless it is shown by clear and convincing evidence that the condition is a covered condition under the provision of this program.
- Inactivity of 30 consecutive calendar days of last County designated physician visit, unless under continuing treatment.
- After the passing of one (1) calendar year from date of initial claimed injury (does not apply to Long Term Disability benefits).
- What, if any, death benefits are available under the OJI Program?
- In the event a regular full-time county employee suffers an OJI, which results in that employee's death, then the employee's surviving spouse or beneficiary shall be entitled to a lump sum death benefit of $75,000. In accidental deaths, the $75,000 combined with the $60,000 accidental death benefit provided by the County's life insurance will provide a total benefit of $135,000. In certain cases, a death that is determined to be work related may not be considered accidental. In those cases the death benefit will be a $75,000 lump sum from the County combined with the County's $30,000 life benefit for a total of $105,000.
In the event a regular part-time County employee suffers an OJI, which results in that employee's death, then the employee's surviving spouse or beneficiary will be entitled to a lump sum death benefit of $75,000.