Workers’ Compensation FAQs
When should I report my injury/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, an injury must be reported within 24-hours of the injury or onset of the illness. An employee, who suspects they sustained an injury at work, has one year from the date of knowledge of the injury, in which to pursue the claim.
What happens after I file a claim?
The University’s WC staff member will contact the employee to investigate the circumstances surrounding the employer injury/illnesses. The WC staff member will also review the benefits provided by WC and respond to any questions the employee may have. If the employee needs medical treatment, the employee is required to visit Brea Urgent Care, Sand Canyon Urgent Care or Saddleback Urgent Care for a medical examination. If the treating doctor takes the employee off work because of the injury/illness, the WC staff member will review with the employee how to account for the employee time off work. If the employee receives temporary restrictions, the WC staff member will review the temporary work restrictions with your manager to determine if the department can accommodate those restrictions. Please remember that the University investigates all claims. If the employee suffers a work-related injury/illness, an adjuster from Sedgwick CMS, our third-party administrator, will also contact the employee.
At times, the WC staff member will conduct an investigation. At other times, an investigator may be hired to take the employee’s statement. The results of the investigation is not only to determine whether an injury/illness is work-related, but also helps to determine whether a need exists to adjust any applicable safety procedures.
If my injury is not severe, should I still complete an Injury/Illness Report?
At Cal State Fullerton, 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 (WC) benefits, and providing benefits in a timely manner. Early reporting also helps eliminate the question of causation due the employee’s late reporting, if they do require treatment at a later date. Visit the forms page and navigate to the Total Wellness > Workers' Compensation section to find the Employee/Volunteer Injury/Illness Report form.
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/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 the information about the circumstances surrounding the injury/illness is gathered and complete.
Who is Sedgwick CMS?
Sedgwick CMS is the third party administrator that administers all of the WC 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 WC claim.
What happens if my claim is accepted?
If the employee claim is accepted, Sedgwick CMS will work with the employee to assure that the employee receives timely and appropriate medical care to ensure a speedy recovery.
What happens if my claim is delayed?
If the employee’s claim is delayed, Sedgwick CMS has determined that it needs to obtain additional information to aid in the evaluation of the employee claim. If there is a question of medical causation, Sedgwick CMS will notify the employee of their need to obtain additional information. The employee may be asked to participate in an investigation and/or attend medical evaluations. The employee’s cooperation is needed in this discovery process. Failure to fully participate may result in further delay or possible denial of the employee’s claim.
Even if the employee’s claim is delayed, within one working day of receipt of a signed Employee Claim Form, Sedgwick CMS will authorize medical treatment for the employee’s injury until the employee’s 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 utilization review.
Sedgwick CMS has 90 days from the time the employee claim is filed to notify the employee of their decision concerning acceptance or denial of the employee claim. If all information is not available at the decision date, the claim will be denied and reassessed when all information is received. If the employee is off work, the employee can use any accrued sick or vacation leave credits. The employee can also apply for non-industrial disability, to account for any lost wages. If the employee’s claim is accepted, depending on the disability plan that the employee selects, the employee’s sick and vacation leave credits will be restored.
What happens if my claim is denied?
If the employee’s claim is denied, Sedgwick CMS has determined, based on available information, that the employee’s injury/illness is not work related. The employee has the right to challenge this decision. The employee has one year from the date of the denial notice to pursue the claim. The employee must act by filing an Application for Adjudication with the WC Appeals Board within this time period.
What if I can't go to work because of my injury/illness?
If the employee’s claim has been accepted and the employee’s doctor takes the employee off work, the employee may be eligible to receive Industrial Disability Leave or Temporary Disability benefits. If the employee’s claim has been delayed or denied, the employee may be able to receive non-Industrial Disability Leave benefits.
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 after suffering a work-related injury/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/illness, the WC staff member will conduct a Benefits meeting with the employee to explain these benefits.
Can I choose my own doctor?
Employees may pre-designating a physician of their choice in the event of a work-related injury/illness. The pre-designation form must be signed by the physician and the employee and Total Wellness department prior to a work-related injury/illness. The employee can find this form in the Forms section of this website or go to Physician Pre-designation form.
How do I pre-designate my doctor as my treating physician if I am injured or become ill at work?
Employees 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. The law defines "personal physician" as (1) employee's regular licensed physician or surgeon; (2) is the primary care physician and has previously directed the employee's treatment and retains the employee's medical records and medical history; (3) who agrees to be pre-designated. The employee may fill out a Physician Pre-designation Form.
Visit the
forms
page and navigate to the Total Wellness > Workers' Compensation section to find the Physician Pre-designation
form
.
Employees bear the responsibility of keeping their physician Pre-designation current.
If the employee has a pre-designated physician but is unable, at the determination of the employee’s supervisor, to drive due to the extent of the employee’s work-related injury/illness or to arrange timely transportation to that location, please contact the HRIE – Total Wellness Workers’ Compensation office to arrange transportation.
Where can I receive First Aid?
If an injury/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 will
not
provide "First Aid" treatment to faculty, staff or student employees who become injured/ill at work. If First Aid is not administered in the department, then proceed to one of the medical facilities listed under the next question below.
What if I need non-emergency medical treatment?
If an injury/illness requires medical treatment beyond First Aid, and the employee is unable to drive or unable to arrange timely transportation to the employee’s pre-designated physician, or the employee has not pre-designated a physician please contact the HRIE – Total Wellness Workers’ Compensation office to arrange transportation to one of the below listed locations:
For employees at CSU, Fullerton:
Brea Urgent Care
395 W. Central Avenue
Brea, CA 92821
(714) 494-2828
Clinic Hours:
- Mon – Fri: 8am – 8pm
- Sat & Sun: 8am – 6pm
*Open 7 days a week
*After Hours: Call (714) 494-2828
*Allow 20 minutes for doctor to arrive
For employees at the Irvine Center:
Sand Canyon Urgent Care Medical Center
15775 Laguna Canyon Road Ste. 100
Irvine, CA 92618
Phone: (949) 417-0272
Clinic Hours:
- 8 a.m. to 8 p.m., Monday through Friday
- 9 a.m. to 5 p.m., Saturday
- 11 a.m. to 5 p.m., Sunday
(when Sand Canyon Urgent Care Medical Center is closed)
Saddleback Family & Urgent Care
22855 Lake Forest Drive Ste. A
Lake Forest, CA 92630
Phone: (949) 452-7544
Clinic Hours:
- 8 a.m. to 7 p.m., Monday through Friday
- 8 a.m. to 3 p.m., Saturday & Sunday
*Closed on Major Holidays
Saddleback Family & Urgent Care
23962 Alicia Parkway Ste. I-1
Mission Viejo, CA 92691
Phone: (949) 452-7699
Clinic Hours:
- 8 a.m. to 7 p.m., Monday through Saturday
- 8 a.m. to 5 p.m., Sunday & Major Holidays
What is Permanent Disability?
Employees who have a permanent impairment because of a work-related injury/illness may be entitled to receive payment for permanent disability benefits. These benefits account for the nature of the employee’s injury, occupation, age and diminished future earning capacity.
The amount of the permanent disability benefits is based upon the employee’s treating physician or a qualified medical evaluator's description of the employee’s permanent restrictions. The restrictions are based on guidelines published by the American Medical Association (AMA) and outlined in a written final medical report.
If the employee does not agree with the medical report written by the treating physician, the employee may contact the Department of Workers' Compensation (DWC) to request a panel (list) of three (3) Qualified Medical Examiners (QME's). All of the above information and instructions on how to request a QME panel will be provided to the employee at the time that the final medical report is received. The employee will receive a copy of this report.
What does permanent and stationary mean?
When the employee’s medical condition has reached maximum medical improvement, meaning the employee’s condition is well stabilized and unlikely to change, the treating physician will declare the employee’s injury to be “permanent and stationary” or they have reached their maximum medical improvement.
Do I need an attorney?
Most employees who hire an attorney do so because of a lack of understanding of the WC system or a misunderstanding about WC benefits. If the employee has concerns regarding medical care or benefits, or general questions, the employee can discuss those concerns with someone in the Total Wellness department. The University will take measures to ensure that employees receive appropriate medical care and treatment, and timely benefits.
If the employee wants to speak to someone about WC benefits who is not employed at Cal State Fullerton, please contact an Information and Assistance officer. A link to this State office is located under the heading “Resources.” This office exists to help injured/ill employees resolve problems with their WC claims.
The employee is free to hire an attorney. However, please be aware that unlike tort liability claims, the amount of benefits the employee receives by “winning” the dispute in court is set by statute and not by a jury or judge. In addition, usually 15% of the employee’s total award will be used to pay attorney’s fees.
Can I lose my job because of a workers' comp claim?
No, the law prohibits discriminating against the employee or discharging the employee from their job, because the employee sustains a work-related injury/illness and file a WC claim.
How do I account for my time off work due to my work injury?
Beyond the date of injury/illness, absences to attend medical and/or physical therapy appointments during work hours should be charged to your available leave credits, consistent with CSU policy on reporting absences for non-exempt and exempt employees. If you do not have any available leave credits; sick, vacation or comp time, you should attempt to schedule such appointments during non-work hours. If you must leave work and have no accrued time, you should be docked for your time away from work.
