Frequently Asked Questions (FAQ's)
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 benefits, and providing benefits in a timely manner. Go to the Employee/Volunteer Injury Illness Report .
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.
What happens after I file a claim?
The University’s Workers’ Compensation Program Manager will contact you to investigate the circumstances surrounding your injury or illnesses. She 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, she will send you for a medical examination. If your treating doctor takes you off work because of your injury or illness, she will review how to account for your time off work. If you are able to work modified or light duty, she will review your work restrictions with your manager to determine if a temporary modified or transitional work assignment is available.
Please remember that 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 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.
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.
Who is Sedgewick 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.
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.
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 an 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. 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:
- Complete the QME panel request form
- Mail the form to the Administrative Director
- Select a doctor and schedule the appointment
- Notify Sedgwick CMS of the doctor you have chosen and the date and time of the appointment.
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 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 utilization review.
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
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.
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 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 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.
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.
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. You may fill out a Pre-designation Form from the Forms file on the website or go to Physician Pre-designation
Employees bear the responsibility of keeping their physician Pre-designation current.
If you have pre-designated a physician but are unable, at the determination of your supervisor, to drive due to the extent of your work-related injury/illness or to arrange timely transportation to that location, your supervisor will arrange for you to be transported to a St. Jude Health Services location.
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 will not 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. 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 or illness requires medical treatment beyond first aid, and you are unable to drive or unable to arrange timely transportation to your pre-designated physician, or you have not pre-designated a physician, your manager or supervisor will arrange transportation to one of the following St. Jude Heath Service locations.
Brea Urgent Care
395 W. Central Avenue
Brea, CA 92821
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
If you are at the Irvine Center, go to:
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
Hoag Hospital Irvine
16200 Sand Canyon Ave.
Irvine, CA 92618
Phone: (949) 764-4624
(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 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 occupation, your age and your diminished future earning capacity.
The amount of permanent disability is based upon your treating doctor's or a qualified medical evaluator's description of your medical problems and limits on the work you can perform. Your doctor's description is based on guidelines published by the American Medical Association (AMA) and outlined in a written permanent and stationary report.
If you do not agree with the medical report written by your treating doctor you may contact 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.
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. The treating physician will declare your injury to be “permanent and stationary.”
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.” 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. In addition, usually 15% of your total award will be used to pay your attorney’s fees.
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.