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Topic: WORKERS' COMPENSATION CLAIMS
INVESTIGATION/ADMINISTRATION Date Issued: June 29, 1994
Section: WORKERS' COMPENSATION Date Revised:
To provide County departments with an understanding of the process involved
in determining eligibility for Workers' Compensation benefits.
Division 4 of the Labor Code of the State of California, and California
Civil Code, Part 2.6, Chapter 2, Section 56.10(c)(8)(A)
I. The County is mandated by the State to provide specified benefits to
employees with work-related injuries.
II. The definition of a work-related injury is an injury which arises out
of employment (AOE) and/or occurs in the course of employment (COE).
Each claim for Workers' Compensation benefits must be reviewed to
determine whether it meets these criteria. If the information provid-
ed on the injury reports is unclear, steps must be taken to gather
sufficient information to make this determination. This section out-
lines procedures followed by Risk Management and the Workers' Compen-
sation claims administrator in gathering the data needed to either
directly determine eligibility, or to provide to a medical evaluator
who will make this determination.
I. Claims Review and Followup
When Risk Management receives the required documents supporting a
Workers' Compensation injury, the documents are first reviewed for
completeness and proper signatures. The documents would include orig-
inals of Employee's Claim for Workers' Compensation Benefits; Supervi-
sors' Report of Accident and, if the employee received medical atten-
tion and/or lost work time, the Employer's Report of Occupational
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Injury/Illness. If the injury and causation are described in suffi-
cient detail to leave no doubt that the injury happened at work and
appears to have a connection to work duties (example: a Building
Maintenance Worker who cut his/her hand while repairing a broken win-
dow), Risk Management forwards the paperwork to the claims administra-
tor without further action.
II. Questionable Claims
In some cases, the relationship of the injury to the job is unclear.
An example of this would be an office worker who has been on vacation
for two weeks, who files a Workers' Compensation claim on the morning
s/he returns, reporting fever, sore throat and nasal congestion which
s/he claims are the result of the air handling system. In this case,
Risk Management would check with the supervisor to confirm there had
not been any ventilation problems that morning in that work area, and
relay that information, along with the claim, to the claims adminis-
trator. The claims administrator would send a notice to the employee
that his/her claim was being delayed, and request that s/he provide
medical documentation to support his/her claim. Ultimately, in a case
of this type, medical records would determine whether the work envi-
ronment caused the injury. In the absence of a positive work connec-
tion, this claim would be denied.
A. Stress Claims
Stress claims are a special type of questionable claim. They are
automatically considered questionable because, unlike the Build-
ing Maintenance Worker who was cut on a piece of window glass,
it is difficult to determine the cause, or even if there is an
injury. Current Workers' Compensation laws require that actual
events of employment must be the predominant cause of the psychi-
atric injury. This means that personal factors, as well as
work-related issues, must be included in the data gathered to
make a determination. All stress claims, unless the cause was
clearly a traumatic work event (such a being a victim of a vio-
lent act, or from direct exposure to a significant violent act),
will be fully investigated.
1. To assist the claims administrator in evaluating the claim,
the supervisor completing the Supervisor's Report of Acci-
dent should attach a memo outlining any relevant informa-
tion, or send the memo separately in a CONFIDENTIAL envelope
to Risk Management.
2. Risk Management will contact the department personnel liai-
son to gather information and determine which staff members
should be interviewed by the outside claims investigator.
3. The claims administrator will contact the claimant to find
out the circumstances surrounding the claim, and explain the
process for investigating a Workers' Compensation stress
claim. The claims administrator will mail the claimant a
notice that benefit determination is delayed pending inves-
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tigation, that the claimant may be contacted by an outside
claims investigator, and that final determination will be
made within 90 days. They will also send the claimant a
medical release to complete and return, so that they can
request records from all medical providers consulted by the
employee over the past five years.
4. The claims investigator will take statements from the claim-
ant, claimant's supervisor, and co-workers having knowledge
of the claimant's work and personal situation. Records in
the claimant's departmental personnel file and central per-
sonnel file in the Personnel Department will be copied to be
included with the investigator's report. The County pre-
employment physical records will also be requested.
5. The claimant is then scheduled for a psychiatric evaluation
with a specialist knowledgeable in criteria for evaluating
Workers' Compensation stress claims. This evaluator will
review all medical records, the investigative report, and
any other pertinent information, and perform a comprehensive
psychiatric evaluation of the claimant before issuing a
written report. If the evaluator finds that work factors
(other than "lawful, non-discriminatory, good faith person-
nel actions") represented less than the preponderance of
causation, the claims administrator will send a notice of
denial of benefits. If the evaluator feels the claim is
compensable, benefits will be paid retroactive to the first
day of disability.
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