Workers' Compensation

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FAQ

The following are frequently asked questions about Workers' Compensation:

What is workers' compensation?

It is insurance that your employer is required by law to carry to help you in case you are injured on the job or become ill due to your job.

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What is workers' compensation injury?

Any injury or illness that occurs due to employment is considered a workers' compensation injury. Under workers' compensation law, you will receive help if you are injured no matter who was at fault.

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If I'm injured do I have to file a claim form?

No but it is advisable. A claim form is necessary when medical treatment is needed. However, an Employee Injury Report should always be completed despite medical treatment needs. As soon as you can after your injury, tell your supervisor that you have been hurt. Your supervisor will immediately direct you to the Human Resources Management department to complete an Employee Injury Report and a Claim Form if necessary. On these forms, you will describe your injury and how, when, and where it occurred. Your claim will be reported to Sedgwick CMS and a representative will contact you to explain the benefits you will be receiving.

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If my injury is not severe, should I still complete an Injury/Illness Report?

At Cal State Dominguez Hills, employees are strongly encouraged to report to their manager or supervisor work-related accidents, and/or near miss incidents. Early reporting assists the University in identifying and addressing safety hazards, determining an employee’s eligibility for Workers’ Compensation benefits, and providing benefits in a timely manner. Additionally if treatment is not immediately sought but found to be needed at a later date, it is best to have a report on file in the Human Resources Management department.

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Where can I receive first aid?

If an injury or illness requires only “First Aid” treatment, such as removing a splinter or the treatment of minor cuts and abrasions, utilize the First Aid kit located in your department.

The University's Student Health Center can also provide "First Aid" treatment to faculty, staff or student employees who become injured or ill as a result of a work-related injury or illness. However please keep in mind, if treatment is received at the Student Health Center, the employee must report the injury immediately to the Human Resources Management department.

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What if I need non-emergency medical treatment?

The University's Student Health Center can provide one-time "First Aid" treatment to faculty, staff or student employees who become injured or ill as a result of a work-related injury or illness. They do not provide follow up treatment. However the University has designated Western Medical Group to treat all employees for work-related injuries or illnesses which require one or more visits.

Western Medical Group
21081 Western Ave., #150
Torrance, CA 90501
(310) 782-3333
Clinic Hours: 24hrs, 7 days a week

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What if I cannot drive myself to obtain medical treatment?

If an injury or illness requires medical treatment beyond first aid and you are unable to drive or cannot arrange for timely transportation, the Human Resources Management department will only arrange transportation to Western Medical Group in Torrance. This service is only provided on the first day of treatment. All subsequent transportation needs must be arranged by the employee.

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When should I report my injury or illness?

Any suspected work-related accident, injury, illnesses and/or near miss incident should be reported to an employee’s supervisor as soon as possible after it happens. In most circumstances, a report should be made within 24 hours of the injury or onset of the illness.

In most circumstances, an injured or ill employee has five years from the date of injury or one year from the date the last benefit was provided to pursue a claim. However early timely reporting is encouraged.

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Is workers' compensation the same as State Disability?

No. Workers' compensation is only for injuries or illnesses that occur due to employment. State Disability is for injuries or illnesses that are not work-related and is handled by the Employment Development Department.

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What happens after I file a claim?

The University’s Workers’ Compensation (WC) Program Manager will contact you to investigate the circumstances surrounding your injury or illnesses. The WC manager will also review the benefits provided by Workers’ Compensation and respond to any questions you may have. If you need medical treatment, but have not yet seen a doctor and/or have not pre-designated a physician, the WC manager will send you for a medical examination. If your treating doctor takes you off work because of your injury or illness, the WC manager will review how to account for your time off work. If you are able to work modified or light duty, the WC manager will review your work restrictions with your manager to determine if a temporary modified or transitional work assignment is available.

Please remember the University investigates all claims. If you suffer a work-related injury or illness, you will also be contacted by an account representative from Sedgwick CMS.

At times, the WC Program Manager will conduct the investigation. At other times, an investigator may be hired to take your statement. The results of the investigation not only help determine whether an injury or illness is work-related, but also to determine whether a need exists to adjust any applicable safety procedures.

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Who is Sedgwick CMS?

Sedgwick CMS is the third party administrator that administers all of the Workers’ Compensation claims in the California State University system. Sedgwick CMS is responsible for determining whether to accept, delay or deny a claim, coordinating the provision of medical treatment, and payment of the medical and disability benefits related to the workers' compensation claim.

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Why are you investigating my claim; don't you trust me?

To ensure that only appropriate claims are accepted, the University investigates all claims of work-related injury or illness. Some of these investigations are conducted in-house and some are conducted by off-campus personnel. Early reporting of work-related injuries and illnesses makes it more likely that complete information about the circumstances surrounding the injury or illness can be gathered.

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What happens if my claim is accepted?

If your claim is accepted, Sedgwick CMS will work with you to assure that you receive timely and appropriate medical care to ensure a speedy recovery.

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What happens if my claim is delayed?

If your claim is delayed, Sedgwick CMS has determined that it needs to obtain additional information to aid in the evaluation of your claim. If there is a question of medical causation, Sedgwick CMS will notify you of their need to obtain medical verification that the injury or illness occurred and that it is work-related. If your claim is delayed, you will be asked to choose a physician from a panel of three doctors provided to you by the Administrative Director of the Division of Workers' Compensation Medical Unit. Only a physician from this panel is allowed to evaluate you to determine your eligibility for workers' compensation benefits. It will be your responsibility to (1) complete the QME panel request form, (2) mail the form to the Administrative Director, (3) select a doctor and schedule the appointment (4) notify Sedgwick CMS of the doctor you have chosen and the date and time of the appointment. If you do not select a doctor with 10 days, Sedgwick will make the selection for you.

Your cooperation is needed in the injury process. Failure to return the forms or speak with Sedgwick CMS can result in further delay or possible denial of your claim.

Even if your claim is delayed, within one working day of receipt of a signed Employee Claim Form, Sedgwick CMS will authorize medical treatment for your injury or illness until your claim is accepted or denied, up to a limit of $10,000. Only medical treatment consistent with established guidelines will be authorized. All treatment is subject to the utilization review process.

Sedgwick CMS has 90 days from the time your claim is filed to notify you of their decision concerning acceptance or denial of your claim. If you are off work, you can use any accrued sick or vacation leave credits. You can also apply for non-industrial disability, to account for any lost wages. If your claim is accepted, depending on the disability plan that you select, your sick and vacation leave credits will be restored.

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What happens if my claim is denied?

If your claim is denied, Sedgwick CMS has determined, based on available information, that your injury or illness is not work related. You have a right to challenge this decision.

You have one year from the date of the denial notice to pursue your claim. You must act by filing an Application for Adjudication before the Workers' Compensation Appeals Board within this time period.

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What if I can't go to work because of my injury or illness?

If your claim has been accepted and your doctor takes you off work, you may be eligible to receive industrial disability leave or temporary disability benefits. If your claim has been delayed or denied, you may be eligible to receive non-industrial disability leave benefits.

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What is industrial disability leave? What is temporary disability?

“Industrial Disability Leave” and “Temporary Disability” are two different types of benefits employees are eligible to receive if they are unable to return to work are after suffering a work-related injury or illness. These benefits are intended to help the employee recover from any lost wages. Industrial Disability Leave benefits are paid by the University and Temporary Disability benefits are paid by Sedgwick CMS.

At the onset of loss time due to an injury or illness, the University's Workers' Compensation Program Manager will conduct a benefit meeting with the employee to explain these benefits.

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What is permanent disability?

Employees who have a permanent impairment as a result of a work-related injury or illness may be entitled to receive payment disability benefits. These benefits are to account for the nature of your injury, your age and occupation, and other factors.

The amount of permanent disability will be outlined in a final written medical report by the treating doctor after the employee’s condition has stabilized and determined unlikely to change. In the final report, the doctor will indicate the employee has reached their maximum medical improvement (MMI) or permanent and stationary (P&S) status.

If you do not agree with the medical report written by your treating doctor you may contact the Administrative Director of the Department of Workers' Compensation (DWC) to request a panel (list) of 3 Qualified Medical Examiners (QME's). All of the above information and instructions on how to request a QME panel will be provided to you at the time that your doctor's permanent and stationary report is received. You will be provided with a copy of the permanent and stationary medical report.

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What does permanent and stationary mean?

When your medical condition has reached maximum medical improvement, meaning your condition is well stabilized and unlikely to change substantially in the next year with or without medical treatment. At this time, the treating physician will indicate you have reached your maximum medical improvement (MMI) or permanent and stationary (P&S) status.

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How does this affect my own health insurance?

Workers' compensation is separate from personal health care insurance. Workers' compensation insurance covers work-related injuries and illnesses. There is no deductible all approved medical bills will be paid. It is important to let the treating doctor know if your injury is work-related.

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Can I choose my own doctor?

Employees who have non-occupational group health care coverage have the option of pre-designating their personal physician as their treating physician in the event of a work-related injury/illness. This designation must occur prior to a work-related injury/illness. You can find this form in the Forms section of this website or go to Physician Pre-designation form [PDF].

Employees bear the responsibility of keeping their physician pre-designation current.

If you have pre-designated a physician but are unable to drive or cannot arrange for timely transportation, the Human Resources department will only arrange transportation to Western Medical Group in Torrance. This service is only provided on the first day of treatment. All subsequent transportation needs must be arranged by the employee.

Western Medical Group
21081 Western Ave., #150
Torrance, CA 90501
(310) 782-3333
Clinic Hours: 24hrs, 7 days a week

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Do I need an attorney?

Most employees who hire an attorney do so because of a lack of understanding of the Workers’ Compensation system or a misunderstanding about benefits. If you have a concern regarding your medical care or benefits, or general questions about Workers’ Compensation, please discuss those concerns with the University’s Workers’ Compensation Program Manager. The University will take measures to ensure that employees receive appropriate medical care and treatment, and timely benefits.

If you want to speak to someone about your benefits who is not employed at the University, please contact an Information and Assistance officer. A link to this State office is located under the heading “Resources” or by clicking this link. State's Worker's Compensation Information and Assistance. This office exists to help injured and ill employees resolve problems with their claims.

You are free to hire an attorney. However, please be aware that unlike tort liability claims, the amount of benefits you may receive by “winning” your dispute in court is set by statute and not by a jury or judge. There is no pain and suffering or punitive damages paid. In addition, usually 15% of your total award will be used to pay your attorney’s fees.

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Can I lose my job because of a workers' comp claim?

No, the law prohibits discriminating against you or discharging you from your job because you have been injured and need to file a Workers' Compensation claim.

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When should I ask for help?

If you have questions about your claim, seek help immediately, from either your supervisor or the Campus Workers’ Compensation Program Manager at (310) 243-1056.

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