UHS: Faculty and Staff Services A-Z

The Claims Process (return to top)
The following stages of the claims process take place when an employee is injured or becomes ill:

Injury occurs and medical treatment is obtained.
Within 24 hours of knowledge of injury, the Department Represenative must complete the Employer's Report of Incident form and fax it to Disability Management Services (DMS) at (510) 642-6505.
Disability Management Services notifies the University's third-party Administrator, Sedgwick CMS, of this incident.
Sedgwick CMS contacts the injured employee, the employee’s supervisor, and the employee’s treating physician. An initial decision is usually made within the first 14 days. If there are questions regarding compensability, Sedgwick CMS will send a “Delay in Decision” letter to the injured worker and proceed with a claims investigation. Disability Management Services will notify the Department Benefits Counselor (DBC). If the claim is denied, the same process takes place. The final decision must be made within 90 days.
If approved, temporary disability (TD) benefits are paid until the employee returns to work or the medical condition becomes permanent and stationary (P&S).
If an employee is unable to perform his/her usual and customary job on a temporary or permanent basis, the employee's restrictions will be reviewed for possible accommodation through transitional or alternative work. This arrangement is handled by a campus Vocational Rehabilitation Counselor.
Injured employees who are permanently disabled, are eligible to receive permanent (PD) benefits. The percentage of PD is determined using State guidelines and an assessment of the injured employee’s permanent impairment and limitations. The funds are paid directly to the employee and are not considered income. Departments are not notified when an employee receives PD. Future medical treatment may also be awarded, depending on medical recommendations.

Claims Investigation (return to top)
Some claims require further investigation by the University's third-party administrator Sedgwick CMS to verify that they are work-related. These cases may include stress claims and overexertion/overextension cases due to repetitive activities. In order for these claims to be deemed compensable, the injury must be arising out of employment and occurring in the course of employment (AOE/COE). Sedgwick CMS may visit the worksite and meet with the employee’s supervisor and co-workers to obtain more information concerning the injury, in addition to reviewing medical records and requesting medical evaluations.

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.

Questions and Answers (return to top)
Q.What is a Delay in Decision?
A. A Delay in Decision is a notice sent by Sedgwick CMS to an injured worker when there is a question related to the compensability of the injury.

Q. Can I, as a department supervisor, be personally sued?
A. As a general rule, no, unless you act outside your scope of employment with “serious and willful misconduct” or discrimination. In such cases, you may be held personally liable. In addition to seeking an increase in benefits, an employee may pursue civil remedies.

If an employer knowingly violates a safety order and the violation is the cause of the injury, it will constitute serious and willful misconduct. Also, if the employer fails to provide a safe place to work as required by law, the intent required for serious and willful misconduct may be inferred. See Chapter 7: Preventing Injuries on how you can take an active part in preventing injuries.

The term “willful” means that the conduct was intended. “Misconduct” is defined as “inappropriate behavior.” An employee seeking an increase in benefits must prove that the employer’s conduct involved an intent to injure or showed a reckless disregard for employee safety.

If an employer discharges, threatens to discharge, or discriminates against an employee because he or she has filed or made known an intention to file an application for adjudication, or because the employee has received a rating, award, or settlement, the employer is guilty of a misdemeanor. The employee can file an action known as a "132a."

If you are found to have caused an injury by serious and willful misconduct or to have discriminated against an employee, the department will be responsible for the payment of any award or increase in benefits that results.

Chapter 3: Workers' Compensation Claims

Chapter 3:
Workers' Compensation Claims