Faculty/Staff Disability Management
Chapter 3: Workers’ Compensation Claims
The Claims Process
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 supervisor or manager must report the injury or illness through the online Injury and Illness Reporting Tool (IIR).
- Disability Management notifies the University's third-party Administrator, Sedgwick, of this incident.
- Sedgwick contacts the injured employee, employee’s supervisor, and employee’s treating physician. An initial decision is usually made within the first 14 days. If there are questions regarding compensability, Sedgwick will send a “Delay" notice to the injured worker and proceed with a claims investigation.
- If approved, temporary disability (TD) benefits are paid until the employee returns to work or the medical condition reaches Maximum Medical Improvement (MMI).
- 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 the department in consultation with Disability Management.
- 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.
Some claims require further investigation by the University's third-party administrator Sedgwick 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).
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.