Workers' Compensation Employee's Guide

Transcription

1 Wrkers' Cmpensatin Emplyee's Guide Intrductin What is Wrkers' Cmpensatin? What is a Wrk-Related Injury? Wh Is Cvered by the UCSD Wrkers' Cmpensatin Prgram and When? Where D Yu Receive Initial Medical Treatment? Hw D Yu Reprt an Injury? Hw Is Yur Claim Prcessed? Wh Is Sedgwick CMS? Recrding Time Lst Due t a Wrk-Related Injury r Illness What Are Yur Respnsibilities? Prcedures Fr Pending Claims Prcedures Fr Accepted Claims If Yu Are Wrking a Reduced Schedule State-mandated Benefits Hw UC Supplemental Leave Is Used 80% Extended Sick Leave Prcedures Fr Denied Claims Additinal Phne Numbers t Call Fr Assistance Intrductin These guidelines were prepared by the EH&S/Risk Management Office t help emplyees understand the Wrkers' Cmpensatin Prgram at UC San Dieg. These guidelines will familiarize yu with the prcedures that are activated when an emplyee experiences a wrk-related injury r illness. If yu have questins r need assistance, please call r Pamela Hauser: , phauser@ucsd.edu Alysn Hng: , a3hng@ucsd.edu Edie Mitchell: , e1mitchell@ucsd.edu What is Wrkers' Cmpensatin? Wrkers' Cmpensatin is a state-mandated benefit designed t be a "n-fault" system. The purpse f Wrkers' Cmpensatin is t prvide benefits and assistance t all wrkers wh are either injured r develp a jb-related illness as a result f their emplyment. Benefits may include: Medical csts Temprary disability Permanent disability Supplemental jb displacement vucher Death benefits The bjective f the Wrkers' Cmpensatin Prgram is t bring abut yur expedient recvery and return t prductive wrk. What is a Wrk-Related Injury? The Califrnia Labr Cde's definitin f the term "injury" includes "any injury r disease arising ut f emplyment and ccurring in the curse f emplyment." The injury may result frm either trauma r disease. Injuries can be categrized in three ways: Specific - Injury t ne r mre parts f the bdy resulting frm a specific incident. 1

2 Cumulative - Injury frm repetitive traumatic activities ver a perid f time, such as expsure t chemicals r fumes that are injurius t an emplyee. Aggravatin - A preexisting cnditin r nn-wrk-related cnditin aggravated by an ccupatinal injury r disease. The emplyer prvides medical treatment until the emplyee returns t the pre-injury status f the preexisting cnditin. Wh is Cvered by the UCSD Wrkers' Cmpensatin Prgram and When? Wh UC San Dieg emplyees and vlunteers with paperwrk n file. When - Wrkers' Cmpensatin cverage begins the first minute yu are n the jb and cntinues any time yu are fficially n the jb. The nly requirement is that yu are fficially wrking as an emplyee prviding a service t the University at the time f yur injury. Where D Yu Receive Initial Medical Treatment? Seek treatment at a UC San Dieg Center fr Occupatinal & Envirnmental Medicine (COEM) clinic, unless the incident requires emergency care r treatment is needed after COEM hurs f peratin. Use the COEM clinic cnvenient t yur wrk lcatin, main campus r Hillcrest: * COEM Campus lcatin 8899 University Center Lane, Suite 160 San Dieg, CA (PDF map) (858) (Call fr an appintment, please) Mnday Friday, 8 a.m. 4:30 p.m. * COEM Hillcrest lcatin 330 Lewis Street, Suite 100 San Dieg, CA (PDF map) (619) (Call fr appintment, if pssible) Mnday Friday, 8 a.m. 4:30 p.m. UC San Dieg's Wrkers' Cmpensatin Office shuld be billed directly fr the treatment yu have received. If yu receive a billing statement, mail it t the Wrkers' Cmpensatin Office at Mail Cde If yu wish t be treated by yur wn dctr, yu must have n file in yur departmental persnnel file a written Designatin f Physician frm prir t the ccurrence f illness r injury. Hw D Yu Reprt an Injury? Use ne f the ptins belw t reprt the incident: Optin 1: Use the nline Wrkers Cmpensatin reprting frm: Optin 2: Emplyee's Occupatinal Incident Reprt: Supervisr's Occupatinal Incident Reprt: 2

3 Call the Reprting Line: 877-6UC-RPRT ( ) t reprt the incident, and Supervisrs: cmplete the Supervisr Reprt page f the nline Wrkers' Cmpensatin Occupatinal Incident Reprt frm: Imprtant: Cmpleting an Occupatinal Incident Reprt frm des nt file a claim fr wrkers cmpensatin benefits. After receiving yur Occupatinal Incident Reprt frm, the UC San Dieg Wrkers Cmpensatin Office will mnitr yur medical treatment t determine if level f care exceeds first aid treatment. First aid treatment may be apprpriate treatment and is nt cnsidered a wrkers cmpensatin benefit, althugh first aid csts will be paid by yur emplyer. If medical treatment exceeds first aid treatment at the initial r subsequent medical visits, the UC San Dieg Wrkers Cmpensatin Office will send yu a State f Califrnia Wrkers Cmpensatin Claim Frm (DWC-1). If yu wish t initiate a claim: Cmplete and sign the Emplyee prtin f the DWC-1 frm. Describe yur injury r illness cmpletely. Include every affected part f yur bdy. Make a cpy f the frm fr yur recrds. Fr expediency, fax a cpy f the frm t the UCSD Wrkers Cmpensatin Office: (858) Mail the riginal frm t Mail Cde By returning the DWC-1 frm, yu are actually filing a claim fr wrkers cmpensatin benefits. Hw Is Yur Claim Prcessed? The Wrkers' Cmpensatin Office btains the infrmatin necessary t determine the categry f yur injury r illness: 1. Incident - N medical treatment received. The Reprt f Injury is retained at the Wrkers' Cmpensatin Office. 2. First Aid - Minr medical treatment is received, n time is lst beynd the day f injury, and there are n mdificatins f jb duties. The Reprt f Injury is frwarded t Sedgwick CMS fr payment f the first aid bill. 3. Claim - Yur injury will be prcessed as a claim when any f the fllwing ccur: Medical treatment beynd first aid is received; Or time is lst beynd the day f injury per medical disability slip; Or the injury causes yu t wrk mdified duties. If yur injury r illness is categrized as a claim, yur Reprt f Injury is frwarded t Sedgwick CMS fr apprval. Wh Is Sedgwick CMS? Sedgwick CMS has a cntract with the University f Califrnia t administer Wrkers' Cmpensatin claims filed by University emplyees. 3

4 A Sedgwick CMS claim administratr will discuss yur claim with yu, investigate the injury, and determine acceptance f yur claim. Reprting an injury r submissin f a claim frm des nt imply autmatic apprval f yur claim. Claims are apprved by Sedgwick CMS fr UC San Dieg. Sedgwick CMS will ntify yu f the status f yur claim within 14 days after they receive it fr prcessing. Three pssibilities exist: 1. Accepted 2. Denied 3. A letter f delay is issued if mre time is required t investigate the claim Yu may call Sedgwick CMS at (619) t inquire abut the status f yur claim. Recrding Lst Time Due t a Wrk-related Injury r Illness Any absence n the day f injury r illness is Administrative Leave with pay. Time lst after the day f injury r illness is cvered by yur selected leave accruals. Regardless f whether yur claim is ultimately accepted r denied, yu need t mark yur timecard r absence slip with a "WC" t indicate that time lst is due t a wrk-related injury r illness. If yu recrd wrk hurs by telephne, use the cde "WCK" t recrd yur lst time. If yur claim is accepted, sme f yur sick leave may be reimbursed; if denied, yur sick leave will be used t cver all f yur absences. Shuld yu run ut f accrued leave balances befre a determinatin is made n yur claim, then yur absence wuld be cnsidered time ff withut pay. Yur department will place yu n Family and Medical Leave (FMLA) if yu are eligible fr cverage and unable t wrk as the result f yur wrk-related injury r illness. Please cntact yur supervisr if yu have nt received ntificatin f this plicy. What Are Yur Respnsibilities? Frward phtcpies f disability slips frm yur dctr, and phtcpies f medical r pharmacy bills yu may receive t the Wrkers' Cmpensatin Office at Mail Cde If yu pay a bill, mail a phtcpy f yur receipt t the Wrkers' Cmpensatin Office fr reimbursement. Keep yur supervisr infrmed f the status f yur injury and claim. If yu are wrking a reduced schedule due t a wrk-related injury r illness, please make sure yur timekeeper and the Wrkers' Cmpensatin Office are aware f yur schedule and the hurs that yu are nt wrking. Prcedures fr Pending Claims A decisin n a claim may be delayed by Sedgwick CMS. If mre time is needed t make a decisin, Sedgwick CMS will mail a letter t yur hme stating the date a decisin will be made. If yur sick leave is exhausted while yur case is pending, yu may use yur available cmp time and vacatin balances with departmental apprval. When yu exhaust all selected leave accruals, yur department will place yu n a n pay status until yur case is accepted r yu return t wrk. The Wrkers' Cmpensatin Office will advise yu by letter t apply fr Nn-Industrial Disability Benefits thrugh the Benefits Office (858/ ). Once a decisin is made n a claim, Sedgwick CMS will infrm yu by mail. Prcedures fr Accepted Claims 4

5 If yur claim is accepted, Sedgwick CMS authrizes medical treatment and issues any temprary r permanent disability payments and medical payments yu may be entitled t. If yur dctr prvides disability fr yur time ff wrk r yur department cannt accmmdate the restrictins prvided by yur dctr, a temprary disability check will be mailed t yur hme address. The temprary disability check pays tw-thirds f yur weekly salary up t a maximum amunt determined by the State f Califrnia. A letter cnfirming that the claim has been apprved will be enclsed with the check frm Sedgwick CMS. Funding fr these payments is prvided by the University f Califrnia's self-insurance prgram. By law, there is a three-day waiting perid befre Sedgwick CMS begins t pay temprary disability. Yur sick leave will be used t cver any lst time n the first three days yu cannt wrk after the date f injury. Since yur weekly salary is mre than the amunt paid by Sedgwick CMS, the rest f yur salary is paid thrugh the UCSD payrll system using yur accrued sick leave. The Payrll Office will issue a full paycheck minus the amunt already paid t yu by Sedgwick CMS. If Yu Are Wrking a Reduced Schedule Even if yu have a disability slip, Sedgwick CMS des nt autmatically pay fr wrking a reduced schedule due t a wrk-related injury r illness. The State f Califrnia uses a frmula t determine wage lss benefits fr partial time lst. Based n this frmula, yu may r may nt be paid by Sedgwick CMS. Lst time is charged t all emplyees wrking a reduced schedule whether they are n exempt r nn-exempt status. State-mandated Benefits There are five state-mandated benefits: 1. Medical cverage 2. Temprary disability 3. Permanent disability 4. Supplemental jb displacement vucher 5. Death benefit The amunt f Wrkers' Cmpensatin benefits and the prcess fr paying claims are mandated by law. Once a claim is determined t be payable, the benefits are paid autmatically by Sedgwick CMS. Eligibility fr each f these five benefits is described belw: 1. Medical Cverage All medical, hspital and prescriptin bills arising frm an industrial injury will be paid. 2. Temprary Disability If the treating physician determines that yu are temprarily unable t wrk, yu will be eligible fr temprary disability. These payments are sent every tw weeks t yur hme and pay tw-thirds f yur grss wage, up t the current statutry maximum amunt. Yu are als eligible t receive temprary disability if yu are ff wrk because yur dctr released yu t return t wrk with restricted duty and yur department cannt accmmdate the restrictins. Eligibility fr temprary disability starts with the furth day yu are unable t wrk. The three-day waiting perid is waived if yu are hspitalized r disabled fr mre than 14 days, in which case yur eligibility begins n the first day after* yur injury. (*Per PPM any time lst n the date f injury is t be recrded as administrative leave.) 3. Permanent Disability Yur physician may determine yur disability t be permanent and statinary, and yu may have sme level f permanent disability. If s, yu might be eligible fr cmpensatin per the State f Califrnia permanent disability rating, even if yu return t yur jb. 4. Supplemental jb displacement vucher 5

6 If yu are unable t return t wrk at UCSD as the result f a wrk-related injury r illness, yu will be eligible t receive a supplemental jb displacement vucher fr educatin-related retraining r skill enhancement at state-accredited schls. 5. Death Benefit Mney is payable t yur financial dependents if yu die as a result f a wrk-related injury. UC Supplemental Benefits In additin t the state-mandated benefits, the University f Califrnia prvides supplemental benefits described belw: Supplemental Leave - If yu wrk 50% time r mre, yu will remain n 100% salary by using yur sick leave t supplement the Wrkers' Cmpensatin temprary disability payments paid by Sedgwick CMS. Once yur sick leave balances are depleted, yu have the ptin f using yur vacatin leave and/r cmp time t cntinue receiving a 100% paycheck. If yu are lsing time, yu will receive a letter asking if yu wish t use yur vacatin and/r cmp time balances nce yur sick leave is exhausted. Yur respnse t this letter will advise yur department timekeeper and the Payrll Office whether r nt t use yur vacatin and/r cmp time balances when sick leave is used up. Hw Supplemental Leave is Used Yur timekeeper will use yur sick leave and ther selected leave balances t recrd yur lst time. The UC San Dieg Payrll Office will then issue yu a full paycheck minus any Wrkers' Cmpensatin temprary disability payments already sent t yur hme by Sedgwick CMS. Since sme f yur lst time will have been paid by a Wrkers' Cmpensatin temprary disability check, the UC San Dieg Payrll Office will infrm yur timekeeper t credit back sme f yur leave balances. Occasinally there culd be a few days delay in issuing yur UC San Dieg paycheck. If yu participate in the Sure Pay direct depsit prgram, it is advisable t cntact yur bank n payday t verify the depsit f yur UC San Dieg paycheck. While n supplemental leave, yu remain n pay status. Therefre, yu are still accruing sick leave and vacatin leave at the nrmal rate and may use leave as it accrues. 80% Extended Sick Leave Once yur sick leave is exhausted (and vacatin and/r cmp time), yu may be eligible t receive 80% Extended Sick Leave Benefits. Yur department will supplement yur Wrkers' Cmpensatin temprary disability payments up t 80% f yur salary fr a perid f 26 weeks per injury. Yur UC San Dieg check will be issued as an 80% paycheck minus any temprary disability payments already mailed t yur hme by Sedgwick CMS. While n 80% Extended Sick Leave yu accrue sick and vacatin leave at the nrmal rate. Hwever, yu may nt use it until yu return t wrk. All persnal sick leave must be used befre yu are eligible t receive 80% Extended Sick Leave. If yu cntinue t receive Wrkers' Cmpensatin temprary disability payments, yu will als be eligible t receive extended sick leave up t a maximum f 26 weeks. If yu d nt return t wrk at the end f 26 weeks, yu will be advised by the Wrkers' Cmpensatin Office t apply fr Nn-industrial Disability Benefits thrugh the Benefits Office ( ). 6

7 Prcedures fr Denied Claims If a claim is denied, Sedgwick CMS will mail a letter t yur hme explaining why the claim has been denied. A cpy f this letter will be mailed t the emplyee's supervisr and department timekeeper. Any time lst n the day f the injury will n lnger be cnsidered Administrative Leave. Yur accrued leave balances wuld be used t cver time lst n that day. Additinal Phne Numbers t Call fr Assistance Sedgwick CMS (619) Sedgwick CMS is under cntract with the University t manage and determine the validity f all claims and ensure that injured emplyees receive any benefits due t them. Envirnment, Health & Safety On campus, (858) At the Medical Center, (619) EH&S is respnsible fr the Wrkers' Cmpensatin Prgram elements which relate t prviding infrmatin and advice regarding safe wrk practices and ergnmics. Infrmatin & Assistance Office Lcal (619) State (800) A state ffice that prvides infrmatin and assistance t emplyees filing wrkers cmpensatin claims. If yu have questins r need assistance, cntact the UC San Dieg Wrkers' Cmpensatin Office: Department ehswc@ucsd.edu Risk Management Main Phne Line: Pamela Hauser: , phauser@ucsd.edu Alysn Hng: , a3hng@ucsd.edu Edie Mitchell: , e1mitchell@ucsd.edu Fax: (858) Mail Cde 0925 MAILING ADDRESS: 9500 Gilman Drive, 0925 La Jlla, CA Last mdified 09/18/15 7