WORKERS COMPENSATION HANDBOOK. University of California, Santa Cruz

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1 WORKERS COMPENSATION HANDBOOK University of California, Santa Cruz

2 Copyright The Regents of the University of California. All rights reserved. Produced by the Office of Risk Services, University of California, Santa Cruz. 03/05/2010 Workers Compensation Handbook

3 Workers Compensation Handbook Table of Contents Chapter 1: Overview Introduction Goals Workers Compensation Defined Covered Workers Workers Not Covered Coverage of Illnesses & Injuries Types of Injuries and Illnesses Types of Claims Benefits & Limits Program Funding Contact Info Chapter 2: Information for Injured & Ill Workers Introduction Obtaining Benefits Medical Care Replacing Lost Wages Permanent Disability Survivor Benefits Taxes on Payments Disability Management Services Dispute Resolution Other Benefits California Law Chapter 3: Medical Treatment Emergency Treatment Procedures Treatment in Santa Cruz County Benefits of Medical Treatment at SC Occupational Med Center 3-3 Treatment Outside Santa Cruz County Additional Off-Campus Treatment Locations Follow-up Medical Cares /05/2010 TOC-1 Workers Compensation Handbook

4 Predesignation of Physician Changing Treating Physician Chapter 4: Claim Processing Introduction Reporting Job-related Injuries and Illnesses Forms Claim Process Possible Claim Outcomes Chapter 5: Disabled Workers Benefits Introduction Temporary Disability Benefits Options for Supplementing TD Option One Option Two Option Three Family Medical Leave (FMLA) Eligibility Extended Sick Leave Benefits UC Retirement Benefits Summary UCSC s Pay Process Coordination of Benefits Chapter 6: Returning to Work Introduction Contact During Injury or Illness Stay at Work/Return to Work Process Permanent Disability Disability Management Services The Process Additional UC Services Special Selection Services Chapter 7: Injured Volunteers Introduction Requirements of Departments Utilizing Volunteer Services Contact During Injury or Illness Return to Work Process Workers Compensation Handbook TOC-2 03/05/2010

5 Chapter 8: Responsibilities Introduction Employee Responsibilities Supervisor Responsibilities Santa Cruz Occupational Medical Center (SCOMC) Dominican Hospital Emergency Department Cowell Student Health Center Personal Physician/Health Care Provider Risk Services Environmental Health and Safety Office Sedgwick Claims Management Services Staff/Academic Human Resources Payroll Office Fire and Police Departments Disability Management Services Benefits Office Employee Assistance Program (EAP) Equal Employment Opportunity Office Labor Relations Office Ombudsman Glossary G-1 Index I-1 03/05/2010 TOC-3 Workers Compensation Handbook

6 This page available for your notes. Workers Compensation Handbook TOC-4 03/05/2010

7 CHAPTER 1 Overview

8 Chapter 1 Overview Introduction California's workers compensation law, passed by the state Legislature more than 90 years ago, guarantees prompt, automatic benefits to workers injured on the job. This handbook describes the Workers Compensation process, providing information needed to handle Workers Compensation cases. The material has been divided into the following chapters: 1. Chapter 1 contains an overview of what workers compensation is, who is covered and who is not covered, as well as a listing of types of injuries and types of claims. Additionally, the source of UCSC s workers compensation program funding is described and contact information for the administration of workers compensation claims is provided. 2. Chapter 2 is written to injured and ill workers - to describe the process of obtaining care. Available workers compensation services are described in detail, as well as the processes to use to obtain these services. 3. Chapter 3 provides the locations for obtaining both initial and follow-up medical care, along with information about physician choices. 4. Chapter 4 describes to supervisors how to process a claim, and provides information about possible outcomes of claims. 5. Chapter 5 describes benefits available for injured or ill employees who lose more than three days from work. 6. Chapter 6 describes considerations to be made for an employee returning to work after a work-related illness or injury. 7. Chapter 7 describes the process of providing care and benefits for covered volunteers who become ill or injured while volunteering on campus. 8. Chapter 8 describes the roles and responsibilities of various members of the campus community with regard to workers compensation. Additionally the Glossary includes acronyms and an Index can help readers find specific topics of interest. Workers Compensation Handbook /05/2010

9 Goals Goals Gaining knowledge about the workers compensation process will encourage the following outcomes: assurance that an employee who is injured or becomes ill as a result of a work-related injury or illness receives all of his or her benefits, and has the best possible chance of a prompt return to his or her job; a more complete understanding of the role and responsibilities of supervisors as they relate to the Workers Compensation process; more complete University compliance with all applicable State Workers Compensation laws. 03/05/ Workers Compensation Handbook

10 Chapter 1 Overview Workers Compensation Defined If an employee suffers an occupational injury or illness, workers' compensation pays their medical bills and if necessary provides compensation to help replace lost income until they can return to work. An occupational injury (or industrial injury - the terms are used interchangeably) is any injury, illness, or disease that results from work or working conditions, and that occurs during the employee's service to the employer. Even first-aid type injuries are covered by workers compensation. An example of an occupational injury is an arm broken from falling off a ladder while on the job. An example of an occupational illness is a skin inflammation that results from exposure to chemicals or solvents on the job. Workers compensation is a no-fault system with benefits paid no matter who is at fault. Benefits guaranteed under workers' compensation include the following: Medical care to cure or relieve the effects of the occupational injury; Compensation payments to help replace lost wages; Permanent disability payments to compensate for diminished earning capacity; Supplemental Job Displacement Benefits for help in returning to work; Death benefits paid to surviving dependents. Generally, a claim for workers compensation benefits must be filed within one year of either the date of injury, or for a cumulative injury, within one year from the date the employee suffered a disability or injury and knew, or should have known, the disability or injury was work-related. Workers Compensation Handbook /05/2010

11 Workers Compensation Defined Covered Workers UCSC s Workers Compensation Program provides coverage to the following four groups of people on campus: Employees: Anyone working in California who is paid on the University payroll is covered by the Workers Compensation Program. This includes faculty, staff and student employees; full-time, part-time, and temporary employees; and student research assistants (SRAs) and teaching assistants (TAs) if they are paid with University funds. Qualified out-of-state employees: Employees temporarily working outside of California, and receiving their paycheck from the University of California are covered. For out-of-state employees whose permanent residence and long-term employment are outside of California, the University Unit/Department must complete a Request for Out of State Workers Compensation Coverage form and forward the form to UCSC Risk Services no later than 30 calendar days prior to the employee s start date. The employee s unit will be billed by the Office of the President, Risk Services (OPRS) for the insurance premium. Contracted coverage: any person for whom the University has assumed a contractual obligation to provide workers compensation coverage. All such contracts must have the approval of UCSC Risk Services for coverage to be effective. Qualified university volunteers: a person providing service for the primary benefit of the University may be covered by the Workers Compensation Program if the following conditions are met: Election form: the volunteer has completed a UCSC Volunteer Election of Workers Compensation Coverage form prior to the injury. It is the responsibility of the supervisor to ensure that the election form is signed by the volunteer before they provide any volunteer service for the University. University Supervision: the volunteer must be supervised by a University of California employee whose job duties include volunteer supervision. Volunteer Records: the University Unit/Department for which the volunteer is providing service must have maintained a written record of the dates and times when volunteer services were provided and the duties assigned to the volunteer. These records must be provided to Risk Services upon request. 03/05/ Workers Compensation Handbook

12 Chapter 1 Overview To be eligible for workers compensation, the volunteer s service may not be used by the volunteer to receive any of the following benefits: Any type of academic credit toward a degree, academic program, or course work; Credit for community service to pay for, or to work off, any criminal or civil fine or penalty; Any type of certification or hours registered toward certification. Workers Not Covered Important: In a medical emergency call 911 to summon a paramedic ambulance for on-scene treatment and transportation to the nearest hospital, regardless of whether that person is covered by UCSC s Workers Compensation Program. Workers on the UCSC campus not covered by the campus Workers Compensation Program include the following groups: Contract employees; for example: Non-University contract temporary workers (temps) Note: If a temporary or contract employee is injured while performing their work duties under the supervision of a UCSC employee please contact Risk Services immediately. Although workers compensation benefits may not be overed by the UCSC Workers Compensation program, the campus must record or report the incident to OSHA. Non-University construction workers Non-University catering service employees Non-University food service employees Students, with the following two exceptions: Students actively engaged in University volunteer service at the time of injury (see Qualified University Volunteers on page 1-4.) Students actively being paid as University employees and performing that job at the time of injury Out-of-state employees: any person who is not a California resident and who is hired by the University to work at a site outside of the state of California, unless Special Workers Compensation is secured. (See the Qualified out-of-state employees description on page 1-4.) Workers Compensation Handbook /05/2010

13 Workers Compensation Defined Any other person, such as a campus visitor, who is not included in the list of Covered Workers on page 1-4. If a person who is not covered by the campus workers compensation is injured on the job, they need to contact their supervisor to obtain directions for medical care. 03/05/ Workers Compensation Handbook

14 Chapter 1 Overview Coverage of Illnesses & Injuries To be covered by workers compensation, an employee must have incurred some injury or illness that is job related, as opposed to a mere exposure. For example, incidental contact with asbestos is not an injury for the purposes of a workers compensation claim. The injury or illness must arise out of employment (AOE) and occur during the course of employment (COE) to be covered under Workers' Compensation. For example, if a warehouse employee injures himself while stacking boxes, s/he would meet the test for both AOE and COE. The injury would have arisen out of his employment (stacking boxes) and would have occurred during the course of his employment (while working as a warehouse clerk.) Note: If a work injury causes a second injury, that second injury will also be covered under workers' compensation. A claim will likely be accepted if the service being performed by the employee or eligible volunteer at the time the injury occurred meets all of the following criteria: For the benefit of UCSC Within work hours On UCSC's premises or out of town or off-campus conducting University business During reasonable time and space margins (Employees are covered during a reasonable period of time immediately before and after their shift. For example, if an employee who works from 8 am to 5 pm comes in at 7:45 am to make coffee for the office and burns their arm, s/he would likely be covered.) Workers Compensation Handbook /05/2010

15 Workers Compensation Defined A claim will most likely be denied if injuries occurred in one or more of the following situations: Normal commute Recreational activity that is not required by employer Horseplay Intoxication Self-inflicted injury Initial physical aggressor - The injuries of the person who starts a fight are not covered. Non-industrial medical conditions - such as the flu, seizures or injuries caused by non-work activities. Types of Injuries and Illnesses Injuries can be categorized in the following four ways: 1. Specific incident: a single injury to one or more parts of the body resulting from a specific incident. Examples are injuries resulting from a slip and fall, from breaking a glass beaker, or from lifting several heavy boxes. 2. Cumulative injury: an injury resulting from repetitive traumatic activities over a period of time. Examples are loss of hearing from repetitive loud work-related noises or overuse syndrome from repetitive use of a computer keyboard. 3. Occupational disease: a disease that is directly related to a person's work and develops over time, such as asbestosis, which results from an employee's long term exposure to asbestos. 4. Aggravation of a pre-existing condition: if employment aggravates a pre-existing condition, the employer could be liable for the portion of treatment due to the aggravation. The employer provides medical treatment until the employee returns to their pre-aggravation status. 03/05/ Workers Compensation Handbook

16 Chapter 1 Overview Types of Claims Workers Compensation claims are divided into the following four types:. 1. Incidents: no medical treatment is required. The UCSC Report of Injury to Employee form is retained in UCSC Risk Services. 2. First Aid: a situation where the employee only requires one-time first-aid treatment for the injury. The injury must be minor in nature, such as scratches, cuts, burns, splinters, or other minor work-related injuries. No time is lost beyond the day of the injury. If the attention of a medical professional is needed, these cases should be seen at the Santa Cruz Occupational Medical Center. See Treatment in Santa Cruz County on page 3-2 for contact info for SCOMC. 3. Medical Only: these claims involve only medical payments for examinations and/or treatment rendered. The injured employee has not lost more than three calendar days from work and is not receiving any other Workers Compensation benefits as a result of the injury or illness. If the employee eventually misses more than three calendar days from work due to the work-related injury or illness, the claim converts to an indemnity claim. These workers also need to go to Santa Cruz Occupational Health Center. See Treatment in Santa Cruz County on page 3-2 for contact info for SCOMC. 4. Indemnity Claim (Lost Time): these claims involve Temporary Disability payments because an employee has lost more than three calendar days from work as a result of the occupational injury or illness. Time lost is confirmed by a medical disability slip. Medical reports from various physicians may need to be interpreted so that all applicable benefits are coordinated. Workers Compensation Handbook /05/2010

17 Workers Compensation Defined Benefits & Limits The California Labor Code requires that employers carry Workers Compensation Insurance and sets limits and benefits as outlined below: 1. Medical Treatment: An ill or injured employee is entitled to reasonable treatment to cure or relieve the effects of the work-related injury or illness. 2. Temporary Disability (TD): Money may be paid to an employee who is temporarily unable to work because of an industrial injury/illness. Temporary disability is paid until the employee s medical condition is resolved or is determined to be Permanent and Stationary (P&S). 3. Permanent Disability (PD): Once the injured worker is permanent and stationary, any remaining disability which reduces the employee s ability may entitle the employee to a Permanent Disability rating, which results in a monetary payment as compensation. 4. Vocational Rehabilitation (VR) (for injuries incurred prior to ): When the employee is unable to return to regular job duties as a result of his/her job injury, the employee will be contacted by the Vocational Rehabilitation Counselor. The VRC will assist the employee in possible work modification, or a formal training program and placement assistance into a new, more appropriate line of work. The VR contact number is or 5. Supplemental Job Displacement Benefit: (for injuries incurred on or after ) When an employee has sustained a work injury resulting in permanent disability and the employee is unable to return to work as a result of their disability, the employee may be entitled to a non-transferable voucher for education-related training or retraining. 6. Survivor Benefits: Money is payable to the qualified dependents of an employee who dies as a result of an industrial injury. 03/05/ Workers Compensation Handbook

18 Chapter 1 Overview Program Funding The University pays its own Workers' Compensation benefits. There is no insurance carrier. Costs associated with claims and the management of the program are paid through Sedgwick CMS out of a trust fund into which each campus contributes premiums. Premium payments made into the trust fund are based on the payroll, loss experience, and future loss projections associated with each campus. Within the UCSC campus, cost centers are assessed a certain amount per $100 of salary for each employee in the department. Funding for this program is a departmental expense. Department managers and supervisors play a key role in controlling departmental costs by providing a safe work environment for employees and responding promptly when injuries occur. Workers Compensation Handbook /05/2010

19 Contact Info Contact Info Sedgwick Claims Management Services (Sedgwick CMS) is the UCSC Workers' Compensation Claims Administrator. They will provide any medical or compensation benefits an injured worker is entitled to receive. If you have any questions, contact Sedgwick CMS or the UCSC Risk Services. Sedgwick CMS P.O. Box 2063 Oakland, CA Tel. (510) Fax (510) UCSC Risk Services 1156 High Street - Barn H Santa Cruz, CA (831) (831) (Fax) 03/05/ Workers Compensation Handbook

20 Chapter 1 Overview This page available for your notes. Workers Compensation Handbook /05/2010

21 CHAPTER 2 Information for Injured & Ill Workers

22 Chapter 2 Information for Injured & Ill Workers Introduction You in this chapter refers to an employee who has a work-related injury or illness. The following topics are covered in this chapter: How to obtain benefits Available medical care Temporary disability to replace lost wages Permanent disability benefits Death benefits payable to surviving dependents Taxes on payments Disability Management Services Dispute resolution options Other benefits, such as SDI and UPD California law regarding fraudulent Workers' Compensation claims Workers Compensation Handbook /05/2010

23 Obtaining Benefits Obtaining Benefits You must report your injury or illness to your supervisor or employer immediately. You will be given a form titled Employee's Claim for Workers' Compensation Benefits (DWC-1) if your injury or illness requires medical treatment beyond first aid or it results in lost wages beyond the date of injury or illness. ( First aid means any one-time treatment of minor scratches, cuts, burns, splinters or other minor work injury.) The claim form will be provided by the UCSC Office of Risk Services (for the address and phone number see Contact Info on page 1-12). The claim form will ask what, where, when and how the injury or illness happened. The key to ensuring your rights is prompt reporting of the injury. Your department or UCSC Risk Services, along with Sedgwick CMS, will see that you get medical help if needed, and make sure the necessary reports are filed. Remember, prompt reporting is the key. Benefits are automatic, but nothing can happen until your employer knows about the injury, no matter how slight. 03/05/ Workers Compensation Handbook

24 Chapter 2 Information for Injured & Ill Workers Medical Care Good medical care is important - and quality medical treatment can support your quick recovery. Benefits include not only payment of doctor's bills, but also prescriptions, hospital costs, fees for lab tests, x-rays and even travel expenses. There is no deductible, so an injured or ill worker should never see a bill. If you become injured at work and believe you need treatment, GET MED- ICAL CARE IMMEDIATELY. See Chapter 3 "Medical Treatment" for details about locations that provide care. If you have a special medical problem, you may be referred to a local medical specialist, who has expert knowledge of your specific injury. In addition, UCSC designated physicians will be familiar with workers' compensation requirements and will report promptly so your benefits are not delayed. You are entitled to be treated by your own personal physician if you've notified the University of the doctor's name and address in writing before the injury. (Your personal physician is one who has treated you in the past and maintains your medical records.) You may contact UCSC Risk Services for details on pre-injury physician designation. See Predesignation of Physician on page 3-6. If you haven't predesignated a physician prior to the injury, you may switch to your own doctor after the employer's medical control expires (following the first 30 days of treatment). If you want to change doctors for any reason, ask UCSC Risk Services or contact Sedgwick CMS, who will provide you with a choice of other doctors. (See Contact Info on page 1-12.) You should report any desire for change of physician immediately so that your bills can be properly considered for payment. Workers Compensation Handbook /05/2010

25 Replacing Lost Wages Replacing Lost Wages Temporary disability benefits are paid to you if your physician certifies that your illness or injury causes you to lose time from your regular job and suffer a loss of wages because no temporary alternative assignment was available. These benefits are not paid the first three days you're unable to work unless you're hospitalized as an in-patient or are unable to work for more than 14 days. In these two instances, even the three-day waiting period will be paid. Temporary disability payments are generally two-thirds of your actual wages subject to a minimum and maximum set by the state Legislature. For injuries occurring on of after January 1, 2008, the maximum payment is $ per week. Your first temporary disability check should be mailed within 14 days of disability. These payments will be sent every two weeks until the doctor releases you to return to work. The University may have supplemental benefits available to you contingent upon receipt of temporary disability benefits. Contact UCSC Risk Services for additional information. Also, see Options for Supplementing TD on page 5-2 for calculations of supplemental benefits. In an effort to facilitate your recovery and return you to full duties, your doctor may return you to a part-time work schedule. In that case, partial temporary disability or wage loss benefits may be payable to you - subject to the same minimum and maximum limits. Your doctor may also return you to work with temporary restrictions on your work activities. Take any written instructions from your doctor to your supervisor so that you can assure the modified work meets the doctor's specifications. Sedgwick CMS and UCSC Risk Services will work closely with the doctor and supervisor to accommodate any restrictions. 03/05/ Workers Compensation Handbook

26 Chapter 2 Information for Injured & Ill Workers Permanent Disability Survivor Benefits Taxes on Payments After you recover to the fullest extent possible, the doctor who treated you will determine if there are any permanent or lasting effects of your injury. You and the University may agree to rely on your treating doctor's report to establish if there are any permanent disability benefits due. If you have questions about the report, you may contact Campus Risk Services for assistance. If you don't agree with your doctor s report and are not represented by an attorney, you may choose an evaluating doctor from a panel list of three independent doctors provided by the state. If you are represented by an attorney, and you don't agree with your doctor's report, the attorney will arrange the medical evaluation. Your permanent disability benefits will be based on the results of the doctor's evaluation and such factors as your age and pre-injury occupation. The limits vary according to the date of injury and level of disability and are set by the State legislature. If you have any permanent disability, the benefits calculation will be fully explained in a letter from Sedgwick CMS. Death benefit payments to survivors are set by state law according to the number of dependents. Payments are made at the same rate as temporary disability benefits. Burial expenses are also included, not to exceed $5,000. Workers' compensation payments are tax free. There are not deductions for state or federal taxes, Social Security, union or retirement contributions, etc. Workers Compensation Handbook /05/2010

27 Disability Management Services Disability Management Services If the injury keeps you from returning to your regular work permanently, the University will advise you if your regular job can be modified or another position can be provided to accommodate your permanent limitations. Many employers are subject to the Americans with Disabilities Act or the Fair Employment and Housing Act. An employer subject to these laws must provide reasonable accommodations to qualified disabled individuals who would then be able to perform all the essential job functions. If you are not able to return to your regular job because of a disability, you may have rights under these laws. For more information call the Disability Management Coordinator at or You may also call the Equal Employment Opportunity Commission at If you can't return to your work with the University because of your disability, you may qualify for vocational rehabilitation benefits or a supplemental job displacement benefit. The Disability Management Coordinator will work with you to assist you in obtaining any needed services. Contact Sedgwick CMS to discuss benefits to which you may be entitled if you are unable to return to your regular work as a result of your injury. 03/05/ Workers Compensation Handbook

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