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Glossary

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

AOE/COE

"Arising out of and in the course of employment," or caused by a worker's job and occurring while working. An injury or illness must be AOE/COE to be covered by workers' compensation.

Accepted Claim

A workers' compensation claim in which claims administrator agrees that the worker's injury or illness is covered by workers' compensation. Even if a claim is accepted, there may be delays or other problems. Also called "admitted claim."

Alternative Work

If treating physician reports that worker probably won't be able to return to the same job/working conditions they had before being injured, employer is allowed to offer worker alternative work instead of vocational rehabilitation benefits. It is work different from what employee performed before being injured, must last at least 12 months, pay at least 85% of the wages and benefits the worker was paid at time of injury and within reasonable commuting distance where worker lived at time of injury.

AMA

American Medical Association

AME

Agreed Medical Evaluator - doctor selected by agreement between the injured workers' attorney and claims administrator to conduct a medical examination and prepare a medical-legal report to help resolve a dispute.

Appeals Board

Board consisting of seven commissioners who review/reconsider decisions of workers' compensation administrative law judges.

Authorization

Permission given to physicians/medical facilities allowing the employee to be treated within the fee schedules applicable for workers' compensation cases.

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B

 

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C

Challenge

Disagree with, object to, or place in dispute.

Change of Physician Prior to MPN (Medical Provider Network)

Any worker who has not previously received treatment from a physician or chiropractor of their choice at the employer's expense, gains the right to select the treating physician after 30 days from the date of the injury was reported to the employer. This right can be exercised immediately upon expiration of the 30-day period, or at any future time when treatment is required for the injury.

Claims Coordinator

Key contact within the school district who gathers all pertinent information regarding an industrial injury or illness. The Claim Coordinator transmits the claim information via modem to CCCSIG and assists the CCCSIG claims staff with the injured worker's return to work, in either a full or modified/bridged capacity.

Claims Examiner

A claim professional, who researches, investigates, evaluates and manages claims. The examiner coordinates and analyzes the medical aspects of the injured worker's case, reviews medical reports, factual information and legal issues to establish the potential financial liability of a claim. They are also responsible for determining compensability matters and implementing the timely administration of benefits.

Claim Form (DWC1)

Within one working day of receiving notice or knowledge of an injury resulting in lost time or medical treatment, employer shall provide personally, or by first class mail, a claim form and notice of potential eligibility for benefits to the injured worker. The claim form is deemed filed when it is personally delivered to the employer or received by the employer by first class or certified mail. A dated copy of the completed form shall be provided by the employer to CCCSIG and to the worker/dependent who filed the claim. Benefits and Notices are determined from the date the claim form is filed, which is why it is so important for CCCSIG to receive the claim form and employer's report immediately.

Communication

The sharing of information (verbal and written) with individuals regarding situations and/or circumstances, on an on-going basis. Open communication between all individuals is essential in the handling of our claims.

Compensability

The acceptance of liability, without regard to negligence, when a claim has been filed for workers' compensation. Determining factors:

  1. The parties are subject to the provisions of the Labor Code, AND
  2. The employee is engaged in his/her employment at the time of the injury, AND
  3. The employment is the proximate cause of the injury.
Contacts

Key individuals within a group, organization or facility who provide timely information, upon request.

C & R

Compromise and Release - type of settlement where the worker receives a lump sum payment - may become responsible for paying for future medical care for the injury.

Cumulative Injury

Injury caused by repeated tasks/exposures at work.

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D

Date of Injury

If a specific injury - date the specific injury occurred. If a cumulative injury, date worker knew or should have known the injury was caused by work.

Death Benefits

Payments to spouse, children or other dependents of a worker who dies from a job-related injury or illness.

Delay Letter

Letter sent by Claims Examiner to injured worker explaining why payments are delayed, what information is needed before a decision will be made, in order to provide benefits.

Denied Claim

Claim the Claims Examiner believes the worker's injury or illness is not covered by workers' compensation and for which the Claims Examiner has notified the worker.

Description of Employee's Job Duties (RU-91)

Form completed by both the injured worker and the Claims Examiner to enable the treating physician to determine whether the worker is able to return to their usual job and working conditions.

Diagnosis

Identification of a disease or condition by evaluating the history of the disease process, the signs and symptoms present, laboratory data, and special tests such as x-rays and scans.

Doctor's First Report Of Injury Or Illness (5021 )

Initial medical report provided by the doctor/chiropractor who is the first provider of medical treatment for the industrial injury/illness.

DWC

Division of Workers' Compensation - State agency that administers worker's compensation laws in California and provides information and assistance to injured workers and others about the workers' compensation system.

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E

Early Return To Work (ERTW) Specialist

Obtains from the treating physician the injured worker's work restrictions on all new lost time injuries, in order to return the injured worker to work as soon as physically possible. The ERTW Specialist assists in bridging a temporarily disabled worker at various stages of recovery until the injured worker is able to return to their usual and customary occupation, or is determined to be a Qualified Injured Worker (QIW).

Employer's First Report Of Injury (5020)

State-required employer's report to be filed whenever the employer has knowledge that a worker has either sustained, or is alleging to have sustained an industrial injury or illness. The report is mandatory for admittedly compensable injuries, as well as for cases where the employer questions or denies liability for compensation. Self insured employers are required to file a copy of their reports with the State within a MAXIMUM period of five days of first knowledge of a claim.

Ergonomic Evaluation

Ergonomics is the science of arranging and adjusting the work environment to fit you and your body, not just adjusting your body to fit the work environment. An ergonomic evaluation is performed to identify and fix potential causes of injury.

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F

Filing

Sending or delivering a document to an employer/governmental agency as part of a legal process. The date of filing is the date the document is received.

Findings and Award

Written decision by a workers' compensation administrative law judge about an injured worker's case, including payments and future medical care that must be provided to the worker by the employer.

Fraud

The California Labor Code anti-fraud clause that states, "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." One thing to keep in mind is that there is a difference between fraud and abuse within the workers' compensation system.

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H

Hearing

Legal proceeding/event where a workers' compensation administrative law judge holds a meeting to discuss issues or receives information from parties in order to make a decision about a dispute or a proposed settlement.

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I

IMC

Industrial Medical Council - State agency that certifies and oversees qualified medical evaluators (QMEs) in California and provides educational materials about the medical evaluation process.

I & A Officer

Information & Assistance Officer - employee of the State DWC who answers questions, assists injured workers, provides written materials, conducts informational workshops and holds meetings to informally resolve problems with claims. Most of the I & A Officer's services are designed to help workers who do not have an attorney.

Investigation

Certain claims, because of limited information or circumstances surrounding the injury require an investigation. An investigation may consist of one or more of the following: a statement from the Employee; co-workers and/or Employer; medical evaluation, subrosa. A determination as to whether a claim is accepted needs to occur within 90 days from the date of the employer's knowledge of the claim, or the filing of the claim form.

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J

Job Description (JD)

A formal, detailed job description that includes the essential functions of the job can provide a sufficient basis for the determination of benefits. It is usually necessary to know the frequency and/or duration of specific work tasks, such as lifting or keyboarding.

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L

Litigation

A claim is deemed litigated when an injured worker becomes represented by an attorney. Not all litigated cases require the employer to seek representation. CCCSIG will retain a defense attorney, primarily on cases involving disputed issues. The proceedings for adjudication of the rights and liabilities before the Workers' Compensation Appeals Board (WCAB) are initiated by the filing of the Application for Adjudication .

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M

Medical-Legal Report

Report written by a doctor describing an injured worker's medical condition to help clarify disputed medical issues.

Medical Treatment

Workers' Compensation benefit offered to injured worker that is "reasonably required to cure or relieve from the effects of the injury."

Medical Status

Medical information on the current status of a condition, treatment plan, disability and prognosis, to be provided by the treating physician.

MPN (Medical Provider Network)

A group of health care providers (physicians and other types of providers) set up by self-insured employer such as the school districts and approved by the Division of Workers' Compensation's Administrative Director to treat workers injured on the job.

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N

Nurse Management

Registered nurse who "manages" the medical aspects of a claim and coordinates care, in an effort to assure the injured worker is provided the best possible care. A case manager may visit with the physician to review the injured worker's progress, specifically with regard to their return to work ability.

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O

Objective Factors

Measurements, direct observations and test results that a treating physician (QME or AME) describes as contributing to an injured worker's permanent disability.

Offer of Modified or Alternative Work Form RU-94

Claims Examiner sends to an injured worker if the treating physician reports that the worker probably will never be able to return to their job or working conditions, with the offer of modified or alternative work.

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P

Penalties

Monetary assessments against CCCSIG and/or the district for late reporting, late provision of notices of benefits, etc. For example, the penalty for not having a completed claim form in the claims file, or documentation that the form was provided to the employee within 24 hours of the injury, benefit notices sent after 14 days of the employer's knowledge.

Permanent Disability benefits

PD - Payments to a worker whose injury permanently limits the kinds of work that they can do.

Permanent Partial Disability Benefits

PPD - Payments to a worker who can still work but whose ability to compete in the open labor market is reduced.

Permanent Total Disability

PTD - 1/1/05 - PD determinations will be based on a formula that reflects the injured worker's future loss of earning capacity rather than their ability to complete in the open labor market.

Permanent Disability Rating

Percentage that estimates how much a job injury permanently limits the kinds of work the worker can do. Based on the worker's medical condition, date of injury, age when injured and occupation when injured.

Permanent and Stationary

P & S - point at which a doctor reports that the injured worker's condition has stabilized, or is not expected to get any better or any worse.

P & S Report

Medical report written by a treating physician describing the injured worker's medical condition when it has stabilized.

Personal Physician

Doctor licensed in California with an MD (medical doctor) or DO (osteopath) degree who has treated the injured worker in the past and has their medical records.

Physician

Medical doctor, osteopath, psychologist, acupuncturist, optometrist, dentist, podiatrist or chiropractor licensed in California.

Pre-Designated Physician

Employees have the right to pre-designate a qualified "personal physician" at any time BEFORE injury occurs. Personal physician qualifications are:

  • Must be a licensed MD, DO or DPM
  • The physician must have previously directed medical treatment of the employee
  • The physician must possess the employee's past medical records
  • The physician must possess the employee's medical history

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Q

Qualified Injured Worker

QIW - injured worker who probably will never be able to return to their usual job and working conditions, and who probably could find a suitable job after receiving vocational rehabilitation services.

QME

Qualified Medical Evaluator - Doctor who is selected by either the injured worker, the worker's attorney or the Claims Examiner to conduct a medical examination and prepare a medical-legal report to help resolve a dispute. QMEs are certified by the State Industrial Medical Council.

QRR

Qualified Rehabilitation Representative - person trained and able to evaluate, counsel and place disabled workers in new jobs.

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R

Reconsideration

Legal process for appealing a decision made by a workers' compensation administrative law judge.

Reconsideration of a Summary Rating

Process for determining whether mistakes were made in the permanent disability rating of an injured worker who does not have an attorney.

Rehabilitation Consultant

Employee of DWC who oversees vocational rehabilitation procedures, makes vocational rehabilitation benefit decisions and helps resolve disputes.

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S

Schedule for Rating Permanent Disabilities

State publication detailing information used to rate permanent disabilities.

SDI

State Disability Insurance - short-term financial assistance for disabled workers in California. Workers with job injuries may apply for SDI when workers' compensation payments are delayed or denied. These benefits are administered by the State Employment Development Department.

Serious and Willful (S&W)

A statute that allows for an increase in compensation by one-half to an employee when the employee is injured by reason of the serious and willful misconduct by the employer. An employee must prove that the employer's conduct involved the intent to injure or was a reckless disregard for the safety of the employees. The employer is responsible for the payment of an S&W penalty. The penalty is not insurable, although the defense of the action would be covered.

Settlement

Agreement between injured worker and Claims Examiner about the workers' compensation payments and future medical care that will be provided to worker. Settlement must be reviewed by a workers' compensation administrative law judge to determine whether it is adequate.

Social Security Disability Benefits

Long-term financial assistance for totally disabled persons. These benefits are administered by the US Social Security Administration. They may be reduced by workers' compensation payments that an injured worker receives.

Specific Injury

Injury that was caused by one event at work.

State Average Weekly Wage

Average weekly wage that was paid in the previous year to employees in California who were covered by unemployment insurance, as reported by the US Department of Labor.

Statute of Limitations

A restriction on the period of time in which relief may be sought for industrial injuries. Various Labor Code sections provide time limitations that apply to the legal remedies of employers, as well as employees. Example: one year statute from the date of injury for the filing of a claim. A five year statute for the filing of new and further benefits.

State Division of Workers' Compensation

Administers workers' compensation laws and provides information and help to injured workers. Listed in the telephone book in the Government pages - State Government Offices/Industrial Relations
Also at www.dir.ca.gov/dwc

Stipulations

Once an injured worker has reached a permanent and stationary (P&S) medical status, stipulations are used to settle the injured worker's claim for any ratable PD. Once approved by the workers' compensation judge, any remaining PD benefits are paid out every two weeks to the injured worker, until the award is paid in full. If at the time of settlement it is determined that the injured worker will require on-going medical care, this too will be documented in the award.

Subjective Factors

The amount of pain and other symptoms reported by an injured worker, which cannot be directly measured or observed, that a doctor describes as contributing to the worker's permanent disability.

Subrosa

Surveillance and video footage of an injured worker's actual physical abilities. Subrosa may also be used in evaluating compensability issues, but is generally used when an injured worker's subjective complaints greatly outweigh objective findings.

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T

Temporary Disability Payments (TD)

Paid to an injured worker who loses wages because the injury prevents the worker from doing their job while recovering.

Temporary Partial Disability Benefits (TDP)

Paid to a worker who can do some work while recovering, but who earns less than before the injury.

Temporary Total Disability Benefits (TTD)

Paid to worker who cannot work at all while recovering.

Temporary Work Assignment

Temporary job assignment to aid and assist injured workers to a more successful re-entry into the work environment. To utilize the temporary work assignment to the fullest, the injured worker should be moved to the next temporary work assignment level (based upon the restrictions), every two weeks. If the restrictions remain the same, the objective would be to move the injured worker to a different worksite in the same temporary work assignment position.

Timely Reporting

If an injury occurs, the Employer is required to provide the Employee's Claim for Workers' Compensation Benefits Form (DWC-1) to the employee within 24 hours of an employee reporting. In addition, the employer must file the Employer's First Report form (5020) with CCCSIG immediately, no later than the next five days. On the district's behalf, CCCSIG files the Employer's Report of Injury with the State.

Treating Physician

Doctor responsible for managing overall care of injured worker and medical reports that affect the worker's benefits.

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V

Vocational Rehabilitation (VR)

Benefit for injured worker who is permanently unable to do their usual job and whose employer does not offer other work. Includes job placement counseling to help worker find another job. May also include retraining and a vocational rehabilitation maintenance allowance.

Vocational Rehabilitation Maintenance Allowance (VRMA)

Payments to help with living expenses while participating in vocational rehabilitation.

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W

Wage Loss

Wages lost due to an industrial injury when the injured worker has recovered to the extent they are physically capable of working reduced hours. These partial earnings are deducted from the injured worker's normal earnings, not to exceed the statutory maximum earnings for determining workers' compensation benefits.

Wage Statement (WS)

Required if the injured worker is less than a maximum wage earner for workers' compensation benefits. The WS reflects the injured worker's earnings from the date of injury and the 12 months prior. The WS will be used to calculate the TD and PD rate payable to the injured worker.

Work Restrictions

Doctor's description of clear and specific limits on an injured worker's job tasks, usually designed to protect the worker from further injury.

Workers' Compensation Appeals Board (WCAB )

Appeals Board and workers' compensation administrative law judges. The judicial section of the Division of Workers' Compensation, in which proceedings before a trial judge result in the issuance of formal findings, decisions, orders or awards for workers' compensation claims.

Workers' Compensation Administrative Law Judge

Employee of the State Division of Workers' Compensation who makes decisions about disputes and approves settlements. They hold hearings at WCAB offices; their decisions may be reviewed and reconsidered by the Appeals Board.

Wrongful Termination (Labor Code 132a)

Labor Code that states an employer shall not discharge, threaten to discharge, or in any manner discriminate against an employee because he/she has, or intends to file a claim for workers' compensation benefits. The employee's compensation shall be increased by one-half, but not more than $10,000 if in fact it is determined there was a violation of Labor Code 132a.

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