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Workers' Compensation Handbook - Chapter 1
Summary: Chapter 1 Overview
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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:
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.
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.
Chapter 3 provides the locations for obtaining both initial and follow-up medical care, along with information about physician choices.
Chapter 4 describes to supervisors how to process a claim, and provides information about possible outcomes of claims.
Chapter 5 describes benefits available for injured or ill employees who lose more than three days from work.
Chapter 6 describes considerations to be made for an employee returning to work after a work-related illness or injury.
Chapter 7 describes the process of providing care and benefits for covered volunteers who become ill or injured while volunteering on campus.
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.
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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.
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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 interchangably) 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.
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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.
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.
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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)
- 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.)
- 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.)
- Any other person, such as a campus visitor, who is not included in the list of Covered Workers.
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.
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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.)
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.
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Types of Injuries and Illnesses
Injuries can be categorized in the following four ways:
- 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.
- 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.
- 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.
- 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.
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Types of Claims
Workers’ Compensation claims are divided into the following four types:
- Incidents: no medical treatment is required. The completed Supervisor’s Incident Investigation and Report of Occupational Injury form is retained in UCSC Risk Services.
- 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 for contact info for SCOMC.
- 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 Medical Center. See Treatment in Santa Cruz County for contact info for SCOMC.
- 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.
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Benefits & Limits
The California Labor Code requires that employers carry Workers’ Compensation Insurance and sets limits and benefits as outlined below:
- 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.
- 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).
- 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.
- Vocational Rehabilitation (VR) (for injuries incurred prior to 1-1- 04): 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 459-4602 or email roberts@ucsc.edu.
- Supplemental Job Displacement Benefit: (for injuries incurred on or after 1-1-04) 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.
- Survivor Benefits: Money is payable to the qualified dependents of an employee who dies as a result of an industrial injury.
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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.
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Contact Info
Sedgwick Claims Management Services (CMS), Inc. 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 UCSC Risk Services.
Sedgwick CMS
P.O. Box 2063
Oakland, CA 94604
Tel. (510) 302-3000
Fax (510) 302-3277
UCSC Risk Services
1156 High Street - Barn H
Santa Cruz, CA 95064
(831) 459-2850
(831) 459-3268 (Fax)
Last revised: January 15, 2008 (am)
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