Workers’ Compensation Insurance
When an Injury or Illness Occurs on the Job:
- In case of a life-threatening emergency, call 9-1-1 for both on and off campus emergencies.
- If medical (but not emergency) treatment is needed, accompany the injured employee to one of the following locations depending on the time and the nature of the injury, or to the personal physician, if the employee has previously submitted a Physician Designation form (Appendix C) to the Corporation Human Resources office.
Medical (But Not Emergency) Treatment is Needed:
Family & Industrial Medical Center
47 Santa Rosa Street, SLO
542-9596 8:00 am-8:00 pm (M-F)
9:00 am-6:00 pm (Sat)
9:00 am-4:00 pm (Sun) Med Stop
283 Madonna Road, Suite B, SLO
549-8880 8:00 a.m. – 7:00 p.m. (M-F)
8:00 a.m. – 4:00 p.m. (S,S)
For Emergency Work Related Injuries (or When Above is Closed):
Sierra Vista Regional Medical Center
24 hours per day
1010 Murray Avenue, SLO
For First Aid Only Injuries (Simple Wound Cleaning or Dressing)
- Provide doctor with Authorization for Workers’ Compensation Medical Care form (see Appendix D). The Corporation is Self -Insured. The third party administrator is Sedwick CMS.
- Provide injured employee with Workers’ Compensation Claim Form (DWC1) within 24 hours (see Appendix F).
- Alert Human Resources Office of injury at 756-1151. Complete Supervisor’s Injury/Illness Report (see Appendix E) and submit to Human Resources Office within 24 hours of the incident or at the beginning of the following workday (M-F, 8 am – 5 pm). Attach completed DWC1 FORM if medical treatment was given.
- Inform the Human Resources Office (756-1151) of the employee’s injury or illness progress and return to work status.
- Request a doctor’s release before permitting employee to return to work. Forward original doctor’s release-to-work form to Human Resources Office.
Introduction to Worker’s Compensation
The purpose of this section on Workers’ Compensation Insurance is to provide an overview of the workers’ compensation program and a description of the procedures to handle a work-related injury or illness. The Human Resources Office (756-1151) is available to provide assistance and answer questions concerning a work related injury or illness, the status of a claim, medical treatment, benefit payments, or other related questions.
What is Workers’ Compensation
Workers’ compensation insurance provides protection for Cal Poly Corporation employees in case they are injured or become ill as a direct consequence of their jobs. Program benefits include payment of all medical care required to treat a work related injury or illness and disability benefit payments, which will partially replace lost income. Workers’ compensation insurance is basically a “no fault” system with benefits paid no matter who is at fault. The main goal of a workers’ compensation program is to bring about a prompt and complete recovery. (NOTE: As a general rule an injury is not compensable if it arises out of voluntary participation in any off duty recreational, social, or athletic activity which does not constitute part of the employee’s work-related duties.)
Who Does It Cover?
All Corporation employees, including intermittent employees and student assistants, are covered by workers’ compensation insurance.
How Much Does It Cost?
The cost of workers’ compensation insurance is paid entirely by the Cal Poly Corporation. Workers’ compensation insurance is separate from personal health insurance and there is no deductible for medical treatment covered by workers’ compensation. In addition, benefit payments are tax free and not subject to deductions for social security.
The Cal Poly Corporation is self-insured. Sedgwick Claims Management Service (CMS) is the third party administrator and risk management consulting firm which provides assistance with managing workers’ compensation insurance. The address of Sedgwick CMS is P.O. Box 14629, Lexington, KY 40512; (916) 851-8059. Final determination of eligibility for workers’ compensation benefits is made by Sedgwick CMS. They base their decision to accept or deny the claim findings based on the facts regarding the injury/illness that has been reported by the supervisor and medical information provided by the treating physician.
What is the Process When an Injury or Illness Occurs?
The law requires each employer to provide a safe place of employment. However, injuries may occur and employees are encouraged to report all injuries no matter how minor as soon as possible. Once a supervisor is notified that an injury has occurred, he/she is responsible for ensuring that the injured employee receives medical care quickly and that all required paperwork is completed and submitted to the Human Resources Office within 24 hours of the injury or illness or at the beginning of the following workday. This process is briefly outlined below:
- Medical Treatment – The Public Safety Department (Emergency extension 9-1-1) should be called immediately in all cases involving serious or life-threatening injuries (off-campus, dial 911). If medical (but not emergency) treatment is needed, the individual should be escorted to the Corporation’s primary treating facility: Family & Industrial Medical Center. For emergency treatment, or when the primary treating facility is closed, escort the employee to Sierra Vista Hospital. Decisions to seek medical treatment should rest ultimately with the injured. As a guide, the employee should seek medical treatment for a work related injury if they would seek treatment for the same injury if it had occurred at home. The injured employee may be escorted to the personal physician if a Physician Designation form has previously been submitted to the Human Resources Office (see Appendix C).If an employee requires medical treatment, the employee is to be given a completed AUTHORIZATION FOR WORKERS’ COMPENSATION MEDICAL CARE – CALIFORNIA form (see Appendix D). The Authorization for Medical Care Form is to be taken to the medical treating facility with the employee. This lets the treating facility know where to bill for treatment.
- Claim form within 24 hours of knowledge of an injury or illness, a supervisor is required by law to give to the injured employee an “Employee Claim for Workers’ Compensation Benefits” form DWC 1 (see Appendix B). This form advises employees of potential eligibility for workers’ compensation benefits and provides them with an opportunity to describe how the injury or illness occurred. The employee completes the “Employee” section (top) of the form and the supervisor completes the “Employer” section (bottom) of the claim form. The “Employee’s Temporary Receipt” (green) of the claim form should be given to the employee immediately and the “Employee’s Copy” (pink) is given to the employee after the employer’s section has been completed; the “Original-Employer’s Copy” (white) and the “Insurer Claims/Administrators Copy” (yellow) should be forwarded to the Human Resources Office for processing.There may be circumstances that prevent a supervisor from providing the claim form to the employee within 24 hours. In these situations, the supervisor should complete the “Employer” section of the claim form, attach a signed and dated notification memo, and mail the claim form/memo to the employee’s home address. The supervisor should make copies of the claim form and notification memo, these copies will provide proof of compliance with notification requirements. It is unlikely that the claim form will reach the employee within the required 24 hour time limit; however, the important point is that the Corporation can demonstrate to compliance agencies that it made a good faith effort to provide the form to the injured worker. Forms can also be hand carried to an employee’s home, if appropriate. (Exception: When an employee suffers a very minor or “Band-Aid” injury and does not seek medical treatment, the supervisor is not required to provide the employee with a claim form.)
- Supervisor’s Injury/Illness Report: In all cases, a Supervisor’s Injury/Illness Report must be completed by the supervisor and submitted to the Human Resources Office for processing (see Appendix E).The Employee Claim Form and the Injury/Illness Report are important documents that must be submitted to the Human Resources Office within 24 hours of the incident. A delay in reporting can cause a delay in the employee’s benefits and may result in penalties of up to $5000 per violation being assessed against the department guilty of non compliance with mandated deadlines.
- Absences from Work: An employee is paid for the entire work shift on the day of injury. If the Workers’ Compensation Insurance Administrator accepts an employee’s claim as work related and a physician authorizes a period of convalescence for an injury, the employee must wait 3 days before any disability benefit payments will be paid. Because this 3 day waiting period is a calendar date period, it may include the weekend. If weekend time is not involved it will be necessary for the employee to use accrued leave credits (sick leave, vacation, CTO) to cover this 3 day waiting period. However, this waiting period is waived if the employee is hospitalized or disabled for more than 14 calendar days. The following hypothetical situations may clarify these guidelines:Employee is injured on Wednesday and is authorized by the doctor to be off work for the remainder of the week: no charge for Wednesday (day of injury), 16 hours of sick leave/other leave credits for Thursday and Friday (3 day waiting period includes Thursday, Friday and Saturday). Employee returns to work on Monday.
Employee is injured on Thursday and is authorized to be off Work for one week: no charge for Thursday (day of injury); 8 hours sick leave/other leave credits for Friday (3 day waiting period is Friday, Saturday, Sunday); no charge for following Monday, Tuesday or Wednesday (on workers’ compensation status). Employee returns to work on Thursday.
Employee is injured on March 3 and authorized to be off work until March 22; the waiting period is waived and employee is on workers’ compensation status for entire period of disability (more than 14 calendar days).
All absences must be authorized by a physician and an injured employee must provide the supervisor with a written doctor’s note, which confirms the period of disability. The original doctor’s note should be forwarded to the Human Resources Office.
When Can the Employee Return to Work?
It is important for the supervisor to maintain contact with the injured employee during the period of disability. Likewise, it is the employee’s responsibility to keep the supervisor informed concerning the employee’s medical condition and when he/she will be able to return to work.
An injured employee may return to work earlier than expected through some form of temporary light work. However, an employee may return to light work only upon receiving a written release from a physician. The physician must indicate any physical limitations or restrictions, which the employee may have and the duration of the modified work assignment. In all instances where the doctor is unable to give the employee a full release, the Corporation reserves the right to accept or reject modified work assignments. This decision is based on an assessment of the employee’s job duties and the feasibility of accommodating the work restrictions imposed by the doctor.
Whenever possible, modified work or light duty should be encouraged and allowed. Disability time is thus minimized and the injured employee can slowly ease into a regular work routine.
When an employee is able to return to work without restrictions, he/she must obtain a written release from the physician. It is Corporation policy that a physician’s release to return to work must be secured by all employees whose injuries required a period of convalescence beyond the day of injury. Supervisors should receive this release from the employee no later than the day on which the employee is scheduled to return to work. (See above.) The original release should be sent to the Human Resources Office.
If a physician releases an employee to return to work but the employee feels that he/she is not ready, the employee should be advised to call the Human Resources Office immediately.
The insurance company cannot continue to pay the employee temporary disability benefits or allow the use of sick leave if it is not authorized by the physician.
Change of Doctor
If at any time an employee is dissatisfied with the treatment program of a physician or facility, he/she can contact the Human Resources Office. An attempt will be made to solve the problem with the current physician; if this is not possible, another physician may be recommended. If more than 30 days have elapsed since the date of injury, the employee may be treated by a doctor of his/her choice; however, employees may change their treating doctors only once. Employees should notify the Human Resources Office immediately of any change in treating physician.
Continued Medical Care
A physician may release an employee to return to work full time but still prescribe continuing treatment such as physical therapy for a brief period. Employees should be advised that once they are released to full time employment, they must use leave credits for absences due to doctor’s appointments. Employees are therefore encouraged to schedule all necessary appointments around employment hours whenever possible.
Additional Lost Time
After recuperating from a work related injury, an employee may return to work for a short period of time and then suffer a reoccurrence of the injury. The supervisor should instruct the employee to return to his/her physician for re evaluation. If another period of convalescence is required, the employee must secure written authorization from the physician for this further period of disability. Likewise, the employee is required to obtain a written release before returning to the job again. It is essential that the supervisor notify the Human Resources Office immediately when an employee loses additional work time.
What Benefit Options Are Available to the Employee?
Assuming that all the appropriate documentation and medical reports have been submitted promptly to Sedgwick CMS, the employee should receive from Sedgwick CMS, within 14 days, a letter of notification concerning his/her workers’ compensation benefits. The Human Resources Office will also receive a copy of this letter along with a statement from Sedgwick CMS, which verifies the employee’s temporary disability and authorizes a period of absence.
The rate of temporary disability (TD) compensation is determined by law. The TD rate is the actual earnings of the employee, if the earnings are less than $126.00 a week. For employees whose earnings fall between $126.00 and $189.00, the TD rate is $126.00 a week; for employees whose earnings exceed $189.00 per week, the TD rate is 2/3 of their wages with a maximum weekly benefit payment of $ 490.00. (Effective January 2003, the maximum benefit rate will increase to $602.00). These payments will be made by the insurance company to the employee every 2 weeks.
Temporary Disability With Supplementation
Employees may supplement TD payments issued by Sedgwick CMS with accrued sick leave or vacation credits to the amount of their normal salary.
State Disability Insurance for Non Work-Related Injuries
In the majority of cases, Sedgwick CMS will make a determination within 14 days regarding an employee’s eligibility for workers’ compensation benefits; however a determination can take up to 90 days. In these situations, employees are generally advised to apply for State Disability Insurance (SDI) pending a decision on their workers’ compensation claim. SDI provides a monthly benefit payment to employees who become temporarily disabled and are unable to work because of a non-work related injury or illness. Before benefit payments begin, an employee must first exhaust all sick leave credits and serve a 7 day waiting period (unless hospitalized). The benefit payment amount may vary according to employment status. The maximum disability benefit period is 26 weeks per disability. Eligibility for SDI benefits is based on PERS membership, time base and length of appointment. If it is later determined that an employee was eligible for workers’ compensation benefits, he/she will receive the difference between SDI and workers’ compensation payments and all used leave credits will be reinstated to the employee.
A permanent disability describes any lasting effects of an on the job injury or illness. If an employee has a permanent physical disability from an injury, the employee is provided with additional payment. The amount of payment depends upon the severity or effect of the injury, and the age and occupation of the employee at the time of the injury.
An employee who is unable to perform his/her job because of an illness or injury which is expected to be permanent or last indefinitely may be entitled to retire and receive a monthly disability allowance payable for life or until recovery. To apply for this benefit, a minimum of five years of PERS credit service is required. The actual cause of disability need not be job related.
One of the most important components of the workers’ compensation program is helping an employee return to his/her old job, or if necessary, preparing the employee for a new one. The Corporation may provide a vocational rehabilitation plan to an employee who needs a permanent work change due to an injury. During rehabilitation, the injured employee is entitled to TD payments. The Sedgwick CMS office will assign a rehabilitation counselor to work with the employee and the Corporation. Once the vocational rehabilitation program is successfully completed, one of the following actions will be taken: (1) the employee will be restored to his/her position; (2) the employee will be transferred to another position; or (3) the employee will be placed in another line of work with another employer, if possible.
Avenues of Appeal
If an employee is dissatisfied with:
- A decision made by Sedgwick CMS regarding liability for an injury or illness;
- A decision regarding a change of physician;
- Eligible benefits;
- Other matters, he/she may:
- Contact the Corporation Human Resources Office
- Contact the claims adjuster at Sedgwick CMS
- Contact the nearest Information and Assistance Officer (209-445-5355)
- Consult an attorney or representative of choice.
It is important that employees fully understand that they must act promptly so as not to risk losing benefits. As a rule, proceedings must begin within one year from the date of injury.
When Can the Injured Employee’s Position Be Filled?
An employee’s position may be replaced due to business necessity. An injured employee off work due to industrial injury or illness for more than 7 days, will be placed on Medical Leave of Absence and subject to MLOA policy (see Personnel Manual, appendix M). Time off due to an injury or illness will be counted toward the 12 weeks allowed in a 12-month period (beginning with initial Family Medical Leave eligibility) covered by the Federal and State Family and Medical Leave Acts.