Workers' Compensation Employee Guide

Workers' Compensation is a state-mandated benefit designed to be a "no-fault" system. The purpose of Workers' Compensation is to provide benefits and assistance to all workers who are either injured or develop a job-related illness as a result of their employment. Benefits may include:

• Medical costs
• Temporary disability
• Permanent disability
• Supplemental job displacement voucher
• Death benefits

The objective of UC San Diego's Workers' Compensation Program is to bring about your expedient recovery and return to productive work.

The California Labor Code's definition of the term "injury" includes "any injury or disease arising out of employment and occurring in the course of employment." The injury may result from either trauma or disease. Injuries can be categorized in three ways:

Specific – Injury to one or more parts of the body resulting from a specific incident.

Cumulative – Injury from repetitive traumatic activities over a period of time, such as exposure to chemicals or fumes that are injurious to an employee.

Aggravation – A preexisting condition or non-work-related condition aggravated by an occupational injury or disease. The employer provides medical treatment until the employee returns to the pre-injury status of the preexisting condition.

Who – UC San Diego employees and volunteers with paperwork on file.

Seek treatment at a UC San Diego Center for Occupational & Environmental Medicine (COEM) clinic, unless the incident requires emergency care or treatment is needed after COEM operating hours.

Use the COEM clinic convenient to your work location, main campus or Hillcrest:

• COEM Campus location: 8899 University Center Lane, Suite 160, San Diego, CA 92122 (map); please call (858) 657-1600 for an appointment weekdays, 8 a.m. – 4:30 p.m.
• COEM Hillcrest location: 330 Lewis Street, Suite 100, San Diego, CA 92103 (map); if possible, call (619) 471-9210 for appointment, weekdays, 8 a.m. – 4:30 p.m.

UC San Diego's Workers' Compensation Office should be billed directly for the treatment you receive. If you receive a billing statement, mail it to the Workers' Compensation Office at Mail Code 0925.

If you wish to be treated by your own doctor, you must have a written Designation of Physician form in your departmental personnel file prior to the occurrence of illness or injury.

Use one of the options below to report the incident.

Option 1

Use the online Workers’ Compensation reporting form:

• Employee's Occupational Incident Report
• Supervisor's Occupational Incident Report

Call the 1-800 reporting line: 877-6UC-RPRT (877-682-7778) to report the incident.

Supervisors must also complete the Supervisor's Occupational Incident Report.

Important: Completing an Occupational Incident Report form does not file a claim for Workers’ Compensation benefits.

After receiving your Occupational Incident Report form, the UC San Diego Workers’ Compensation Office will monitor your medical treatment to determine if level of care exceeds first aid treatment.

• First aid treatment may be appropriate treatment and is not considered a workers’ compensation benefit, although first aid costs will be paid by your employer.
• If medical treatment exceeds first aid treatment at the initial or subsequent medical visits, the UC San Diego Workers’ Compensation Office will send you a State of California Workers’ Compensation Claim Form (DWC-1).

• Complete and sign the Employee portion of the DWC-1.
• Describe your injury or illness. Include every affected part of your body.
• Make a copy of the form for your
• For expediency, fax a copy of the form to the UC San Diego Workers’ Compensation Office, (858) 246-0973.
• Mail the original form to Mail Code 0925. By returning the DWC-1 form, you are actually filing a claim for workers’ compensation benefits.

The Workers' Compensation Office obtains the information necessary to determine the category of your injury or illness:

• Incident: No medical treatment. The Incident Report is retained at the Workers' Compensation Office.
• First Aid: Minor medical treatment is received, no time is lost beyond the day of injury, and there are no modifications of job The Incident Report is forwarded to Sedgwick CMS for payment of the first aid bill.
• Claim: Your injury will be processed as a claim when any of these situations occur:
  • Medical treatment beyond first aid is received;
  • Or, time is lost beyond the day of injury per medical disability slip;
  • Or, the injury causes you to work modified.

If your injury or illness is categorized as a claim, your Incident Report is forwarded to Sedgwick CMS for approval.

Sedgwick CMS has a contract with the University of California to administer Workers' Compensation claims filed by university employees.

A Sedgwick CMS claim administrator will discuss your claim with you, investigate the injury, and determine acceptance of your claim. Reporting an injury or submission of a claim form does not imply automatic approval of your claim. Sedgwick CMS approves claims for UC San Diego.

Sedgwick CMS will notify you of the status of your claim within 14 days after they receive it for processing. Three possibilities exist: 

1. Accepted
2. Denied
3. A letter of delay is issued if more time is required to investigate the claim.

You may call the Sedgwick CMS number listed below to inquire about the status of your claim.

Any absence on the day of injury or illness is Administrative Leave with pay. Time lost after the day of injury or illness is covered by your selected leave accruals.

Regardless of whether your claim is ultimately accepted or denied, you will need to follow up with your department timekeeper and UC Path on how to document your hours.

If your claim is accepted, some of your sick leave may be reimbursed; if denied, your sick leave will be used to cover all of your absences. If you run out of accrued leave balances before a determination is made on your claim, then your absence would be considered time off without pay.

• Forward photocopies of disability slips from your doctor and photocopies of medical or pharmacy bills you may receive to the Workers' Compensation Office at Mail Code 0925.
• If you pay a bill, mail a photocopy of your receipt to the Workers' Compensation Office for reimbursement.
• Keep your supervisor informed of the status of your injury and claim.
• If you are working a reduced schedule due to a work-related injury or illness, ensure that your timekeeper and the Workers' Compensation Office are aware of your schedule and the hours that you are not working.

A decision on a claim may be delayed by Sedgwick CMS. If more time is needed to make a decision, Sedgwick CMS will mail a letter to your home stating the date a decision will be made. If your sick leave is exhausted while your case is pending, you may use your available comp time and vacation balances with departmental approval. When you exhaust all selected leave accruals, your department will place you on a no pay status until your case is accepted or you return to work. The Workers' Compensation Office will advise you by letter to apply for Non-Industrial Disability Benefits through the Benefits Office (858) 534-2816.

If your claim is accepted, Sedgwick CMS authorizes medical treatment and issues any temporary or permanent disability payments and medical payments you may be entitled to. If your doctor provides disability for your time off work or your department cannot accommodate the restrictions provided by your doctor, a temporary disability check will be mailed to your home address. The temporary disability check pays two-thirds of your weekly salary up to a maximum amount determined by the State of California. A letter confirming that the claim has been approved will be enclosed with the check from Sedgwick CMS.

Funding for these payments is provided by the University of California's self-insurance program. By law, there is a three-day waiting period before Sedgwick CMS begins to pay temporary disability. Your sick leave will be used to cover any lost time on the first three days you cannot work after the date of injury.

Even if you have a disability slip, Sedgwick CMS does not automatically pay for working a reduced schedule due to a work-related injury or illness. The State of California uses a formula to determine wage loss benefits for partial time lost. Based on this formula, you may or may not be paid by Sedgwick CMS. Lost time is charged to all employees working a reduced schedule whether they are on exempt or non-exempt status.

The amount of Workers' Compensation benefits and the process for paying claims are mandated by law. Once a claim is determined to be payable, the benefits are paid automatically by Sedgwick CMS. Eligibility for each of the five benefits is described below.

1. Medical Coverage

All medical, hospital, and prescription bills arising from an industrial injury will be paid.

2. Temporary Disability

If the treating physician determines that you are temporarily unable to work, you will be eligible for temporary disability. These payments are sent every two weeks to your home and pay two-thirds of your gross wage, up to the current statutory maximum amount. You are also eligible to receive temporary disability if you are off work because your doctor released you to return to work with restricted duty and your department cannot accommodate the restrictions.

Eligibility for temporary disability starts with the fourth day you are unable to work. The three-day waiting period is waived if you are hospitalized or disabled for more than 14 days, in which case your eligibility begins on the first day after* your injury.

*Per PPM 516-28 any time lost on the date of injury is to be recorded as administrative leave.

3. Permanent Disability

Your physician may determine your disability to be permanent and stationary, and you may have some level of permanent disability. If so, you might be eligible for compensation per the State of California permanent disability rating, even if you return to your job.

4. Supplemental job displacement voucher

If you are unable to return to work at UC San Diego as the result of a work-related injury or illness, you will be eligible to receive a supplemental job displacement voucher for education-related retraining or skill enhancement at state-accredited schools.

5. Death Benefit

Money is payable to your financial dependents if you die as a result of a work-related injury.

In addition to the state-mandated benefits, the University of California provides supplemental benefits described below:

Supplemental Leave: If you work 50% time or more, you will remain on 100% salary by using your sick leave to supplement the Workers' Compensation temporary disability payments paid by Sedgwick CMS.

Once your sick leave balances are depleted, you have the option of using your vacation leave and/or comp time to continue receiving a 100% paycheck. If you are losing time, you will receive a letter asking if you wish to use your vacation and/or comp time balances once your sick leave is exhausted. Your response to this letter will advise UC Path whether or not to use your vacation and/or comp time balances when sick leave is depleted.

Your timekeeper will use your sick leave and other selected leave balances to record your lost time. UC Path will then issue you a full paycheck minus any Workers' Compensation temporary disability payments already sent to your home by Sedgwick CMS. Since some of your lost time will have been paid by a Workers' Compensation temporary disability check, UC Path will work with your timekeeper to credit back some of your leave balances.

While on supplemental leave, you remain on pay status. Therefore, you are still accruing sick leave and vacation leave at the normal rate and may use leave as it accrues.

Once your sick leave is exhausted (and vacation and/or comp time), you may be eligible to receive 80% Extended Sick Leave Benefits. Your department will supplement your Workers' Compensation temporary disability payments up to 80% of your salary for a period of 26 weeks per injury.

Your UC San Diego check will be issued as an 80% paycheck minus any temporary disability payments already mailed to your home by Sedgwick CMS.

While on 80% Extended Sick Leave you accrue sick and vacation leave at the normal rate. However, you may not use it until you return to work.

All personal sick leave must be used before you are eligible to receive 80% Extended Sick Leave.

If a claim is denied, Sedgwick CMS will mail a letter to your home explaining why the claim has been denied. A copy of this letter will be mailed to the employee's supervisor and department timekeeper.