Santa Barbara SIPE Joint Powers Self Insurance

(805) 922-8003

Workers' Compensation


Overview
What to Report
When to Report
How to Report
Medical Treatment
Temporary Disability
Report Fraud


Overview

Workers' Compensation Administrators is the third party administrator for the Schools of Santa Barbara S.I.P.E. whose members are self-insured for their workers' compensation claims.

The links will provide brief descriptions of what Workers' Compensation Administrators (WCA), as your third-party administrator, will need from you as the employer to properly and effectively administer your workers' compensation claims.

Donovan St.
Santa Maria, CA 93454
Phone: (805) 922-9157
Fax: (805) 349-2816
Contact: Bruce White, Claims Administrator Email


What to Report

The Labor Code requires that ALL work-related injuries that are not first aid cases to be reported to your third-party administrator or insurance carrier. Labor Code section 3208 defines an injury as "any injury or disease arising out of the employment, including injuries to artificial members, dentures, hearing aids, eyeglasses and medical braces of all types; provided that eyeglasses and hearing aids will NOT be replaced, repaired, or otherwise compensated for, unless injury to them is incident to an injury causing disability."

Section 14311 of Title 8, defines "First Aid" as, "Any one-time treatment, and any follow-up visit for the observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require medical care. Such one-time treatments, and follow-up visits for observation, are considered first aid even though provided by a physician or registered professional personnel."

As a general rule of thumb, any injury where the injured employee is treated by a physician or loses time beyond the date of injury should be reported to Workers' Compensation Administrators.

If you are unable to determine if the injury is covered under workers' compensation or not, speak with a designated representative that handles workers' compensation for your employer or call Workers' Compensation Administrators for assistance. We will guide you in determining whether the case is reportable and whether it should be sent to us for further handling.

If you are not clear that the alleged work injury is covered under the workers' compensation laws, it should be reported to us so we may investigate the case and make a determination of whether the case is covered (compensable).

When to Report an Industrial Injury

An industrial injury should be reported to Workers' Compensation Administrators as soon as the employer has acknowledged that an injury has occurred. Labor Code section 5402 emphasizes that knowledge of an industrial injury can come from any source on the part of the employer, not just the employee.

Under the Reynolds decision, once an employer has knowledge of an industrial injury, the statute of limitations does not begin to run until the injured employee has notice of their right to workers' compensation benefits. Therefore, the sooner an injury is reported to WCA the sooner we can notify the injured employee of their benefits and start the statute of limitations running.

A simple rule of thumb is to report a work injury whenever one of the following occurs:

• Treatment is beyond first aid.
• Employee is losing time from work as a result of a work injury.
• Employee indicates they want to file a work injury.


How to Report Industrial Injuries

When the employer receives notice, in any form, that an industrial injury has occurred, the following should be done:

A. Employee's Claim For Workers' Compensation Benefits (DWC-1)
Administrative Rule 10119, requires the employer to provide to the employee the "Employee's Clam For Workers' Compensation Benefits" within one working day of the employer receiving notice of knowledge of an industrial injury which results in lost time from work beyond the date of injury or which results in medical treatment beyond first aid (L.C. U5401). The "Employer's Claim for Workers' Compensation Benefits" is also referred to as the "Claim Form."

The procedure for properly administering the Claim Form is as follows:

1. The Employer provides the Claim Form to the employee.
Within one working day of receiving notice or knowledge of an industrial injury, the employer must provide the Claim Form to the employee. Failure to provide the Claim Form within 24 hours of the employee's request for the claim form, may result in a penalty up to $5,000.00 (A.D. Rule 10108 (d) (4)).

If the Claim Form is not personally delivered to the employee, a cover letter should be sent to the employee providing them with the Claim Form. The cover letter will serve to prove that the Claim Form was provided to the employee.

2. The Employee Completes the Top Part of the Claim Form.
After completing the top part of the Claim Form, the employee should retain the green copy entitled "Employee's Temporary Receipt" for their records.

3. The Employee Files the Claim Form with the Employer.
This is accomplished when the claim form is personally delivered to the employer, mailed to the employer by registered mail with the return receipt requested, or upon receipt of the employer's knowledge when mailed to the employer by first class mail.

4. The Employer Completes Bottom Part of the Claim Form.
The most important item the employer must fill out is the date the employer received the claim form from the employee, and the name and title of the person who received the claim form. Failure to put the date the Claim Form was received from the employee may result in a penalty up to $100.00 for each occurrence. (A.D. Rule 10108 (a) (3))

5. The Employer Distributes copies to the Employee and WCA.
The employer provides the employee with the pink copy marked "Employee's Copy" and sends the yellow copy marked "Insurer/Claims Administrator" to Workers' Compensation Administrators. Keep the copy marked "Employer Copy" for your records.

It is recommended that the "Employee's Copy" be sent to the employee with a cover letter. This will help prove that the confirmed copy of the Claim Form was provided to the employee.

If the employee does not return the Claim Form to the employer, the employee will be precluded from receiving any late penalty that may be due and will be precluded from pursuing further legal remedies. It should be noted that even if the employee does not file the Claim Form, the employer is still obligated to provide benefits in a timely manner to the injured worker. (A.D. Rule 10116.1)

B. Complete the "Employer's Report of Injury" (Form 5020).
Injury Reporting Forms for Employers
Upon notice of an industrial injury, the employer should immediately complete the "Employer's Report of Occupational Injury or Illness" form which is also known as the "Employer's Report" or the "5020". This form is required by section 14001 Title 8 and is ONLY a report of the injury and is not an admission of liability and cannot be used against the employer as evidence. Section 14001 requires the form to be filled out within five days after the injury or illness has been reported to the employer.

Section 1A of the "Employer's Report of Injury" should be left blank since there is no policy number because you are self-insured.

Sections 29, 30, 30B, 34 and 35 of the "Employer's Report of Injury" should be filled out very carefully. The answers provided in these boxes will give WCA an indication of whether the claim should be accepted, delayed, or denied. These answers will also help us determine whether there is a subrogation potential against a negligent third party.

The form should be filled out in triplicate with one copy going to the employer, another to WCA and the original to:

Workers' Compensation Administrators
Donovan St.
Santa Maria, CA 93454
Again, the "Employer's Report of Injury" form should be filled out as soon as notice of an industrial injury is received and sent to WCA. Do not wait for a report from the doctor or receipt of the Claim Form from the employee.

C. Questionable Injuries
If you are concerned regarding whether a claim should be covered by workers' compensation, put your concerns in writing and send it to WCA.

1. Give "Facts for Injured Workers" pamphlet to Injured Employee
When an industrially injured employee reports an injury, give them the pamphlet entitled "Facts for Injured Workers" (red pamphlet).

Section 9882 of the Administrative Rules requires that the employer, upon receiving knowledge of an injury to an employee, advise the employee within 5 days of their workers' compensation benefits. The "Facts for Injured Workers" pamphlet serves this purpose.

2. Serious Injury or Death
In the event that an employee suffers an industrial injury that is serious or results in death, notify Workers' Compensation Administrators immediately by telephone.

The employer/representative is required to notify the nearest district office of the California Division of Occupational Safety and Health when an industrial injury is serious or results in death.

Medical Treatment

An injured employee is entitled to all medical treatment reasonably required to cure or relieve the effects of the injury. This includes all reasonable transportation expense. Liability for medical benefits cannot be apportioned to non-industrial events, and therefore the employer is responsible for all reasonable and necessary medical costs of treating the employee.

Treatment during the first thirty days after the date of injury is controlled by the employer if the employer has notified the employee by posting in a conspicuous place at the employee's place of employment, the name, and address of the medical clinic or hospital where the employee is to go for treatment when an employee has been injured. As long as the above requirement is met and the employer is offering medical treatment to the employee, the employee must go to the employer's doctor unless the employee has provided written notice prior to the date of injury of their desire to be treated by their personal physician or if the case is an emergency.

It should also be understood that the employee has the right to one change of physician under Labor Code 4601.

WCA has printed the "Employee Selection of Personal Physician" form that may be used when an employee wishes to designate a personal physician to treat within the event of a work-related injury. It is recommended that the form be used, but not specifically required by law.

Temporary Disability

In order for proper integration of salary continuation benefits under the Education Code both the employer and WCA must work together. As stated earlier, the employer is likely to know when an employee has returned to work before WCA does. One of the reasons for this is that the doctor will give the employee a return to work slip and then dictate a letter to WCA. The employee then reports to work with the return to work slip while the letter is still in dictation.

For WCA, the most efficient method of paying temporary disability benefits is to have the employer notify WCA in writing whenever an employee has:

• Missed any time from work due to an on-the-job injury
• Salary continuation benefits are less than the TD rate
• Have exhausted all of their salary continuation benefits
• Returned to work
• Has resigned or terminated from employment


Forwarding Material to WCA

Whenever any of the following are received, please send the original to WCA:

• Medical Reports
• Correspondence from injured workers' attorney
• Any forms from the Workers' Compensation Appeals Board (WCAB)
• Any material from the Employment Development Department
• Subpoenas
• Any other information related to the workers' compensation claim