Definition - An injury or disease that was caused by, or a direct result of, a work place accident or long time exposure to hazardous materials.
When does it qualify as a Worker's Compensation Claim?
-Were you performing the job you were hired for? If the activity falls under the course and scope of your job it will most likely be eligible for Worker's Compensation (WC).
- You were at an out of town conference and there was an uncovered electrical cord you tripped over and hurt your knee
- You were hurt in a car accident driving on official business - this does not include participating in other non-official activities while at a conference (i.e. golfing, jogging, site-seeing)
- You were performing field research studies and got stung by a hive of wasps
- A file drawer was left open and you ran into it lacerating your arm
- Your finger was penetrated by a needle when emptying the trash and you developed Hepatitis C
All the above scenarios would qualify as a worker's compensation injury and as long as you are performing your official job duties, (including official business that takes you out of town) you are eligible to file a WC claim.
When is an injury not eligible for Worker's Compensation?
-There are several scenarios that would make a claim ineligible for Worker's Compensation. These include but are not limited to:
- You are not on the clock but are on campus when you get injured. Coming to and leaving work, lunch break and other breaks, exercising on campus....etc., these are not covered by worker's compensation.
- If you are injured while talking on your cell phone with personal calls or texting while performing your job duties you will be ineligible for worker's compensation. Being on personal calls or texting is not paying attention to your work, is on personal time and increases the chances for injury considerably. If your job requires you to make a phone call or text, stop what you are doing complete the communication and resume your duties.
- Horseplay- if you are playing around on your job an hurt yourself you will be denied worker's compensation coverage.
- Pre-existing condition- often times we have health issues that are manifesting in our bodies that we are unaware of until something triggers the symptoms. If you get hurt on the job and it is determined that the accident was caused by a pre-existing health condition, worker's compensation benefits will be denied or worker's compensation will cover the area that was injured but not the area that shows where a pre-existing condition has occurred.
Examples of pre-existing condition are:
- You fell on your knee and strained a muscle, however tests show there is arthritis in the knee, WC will cover the cost of bringing the muscle back to health but chances are that the knee may continue to be a health issue because of the arthritis and WC will not pay for treatment of this pre-existing condition
- Back injuries can be problematic in that as we age our spine deteriorates but may not be noticed until something happens and it doesn't heal like a younger, healthier back. This is called "condition of life" and again worker's compensation will cover the injury portion only but not any pre-existing deterioration.
How do I file a claim?
A) Minor injuries: No profuse bleeding, able to walk, talk and answer questions, no excruciating pain.
- Report the injury immediately to your supervisor - within a work shift
- The supervisor will report the injury to the Environmental Health, Safety, and Risk Management Department (EHSRM or Safety Dept.) by filling out a "24 hour Quicklink report" located on the Safety Dept. website, sfasu.edu/safety top right corner of the webpage.
- If the injury is minor and filing a claim is not desired by the employee at the time, the employee has 30 days to go to the doctor and file a claim if they choose to. No claims will be accepted beyond the 30 day window. The employee's supervisor will still need to fill out a "24 hour Quicklink report" at the time of the injury to document an injury occurred.
- If medical treatment is needed, then a claim needs to be processed and the injured employee and his/her supervisor will come to the Safety Department to fill out the required claim forms and receive worker's comp information and instructions, unless the employee is in such pain that treatment is urgent (In this instance the employee and supervisor can go to the WC clinic and may file a claim immediately after medical treatment has been given).
- You will be sent to an urgent care facility for medical treatment and a drug test.
- You may also go to your own doctor only IF your doctor takes worker's compensation. If you choose to go to a doctor that doesn't take worker's compensation, then you will be responsible for payment of the medical treatment with your own funds and insurance.
- Once the Safety Dept. WC adjuster files the claim you will be contacted by an assigned State Office of Risk Management (SORM) WC adjuster who will be your first point of contact if there are any medical issues, pre-authorizations for specialized treatment or reimbursements that need to be managed.
B) Serious injuries: Profuse bleeding, unable to move, walk, talk and answer questions, excruciating pain, vomiting, dizziness, pale or yellow pallor
- Call 911 and get a first responder immediately to the scene.
- Supervisors will follow the first responders to the hospital ER to help check-in the employee and provide any details and information to the hospital ER admitting desk.
- Supervisors should, if possible, ask for a drug test to be performed on the injured employee to help with the accident investigation. (Note: If the first responders suspect drug or alcohol use they will usually perform the tests automatically or request a drug test be given)
- As soon as possible the supervisor will contact the Safety Dept. to report the injury and relay the status of the employee, also if necessary, connect with the employee's emergency contact.
- The supervisor will also fill out a "24 hour Quicklink report" located on the Safety website at sfasu.edu/safety, top right corner of the webpage
- IF the employee is mobile after they have received medical treatment and have been released by the hospital, they will come to the Safety Dept. accompanied by their supervisor and fill out the WC claim forms, otherwise
- The Safety Officer WC adjuster will go to the hospital and start the claim process there. If the employee is so injured that they are unconscious or are unable to comprehend the claim process, then the claim process should be started by proxy with the employee's authorized emergency contact.
- For follow-up medical treatment you may go to your own doctor only IF your doctor takes worker's compensation. If you choose to go to a doctor that doesn't take worker's compensation, then you will be responsible for payment of your medical treatment with your own funds and insurance.
- Once the Safety Dept. WC adjuster files the claim you will be contacted by an assigned State Office of Risk Management (SORM) WC adjuster who will be your first point of contact if there are any medical issues, pre-authorizations for specialized treatment, equipment and/or reimbursements that need to be managed.
After Medical Treatment
-As a WC injured employee you are required to follow all medical instructions and restrictions the doctor has prescribed including follow-up care.
- You will need a work release or work restriction form from your WC doctor for you to give to your supervisor and a copy to the Safety Dept. This form should be given to you each time you have an appointment; you will not be released for full work duties without this form.
- The form is called a Work Status Report and it details the restrictions and limitations of the work duties that can be performed by an injured employee. This form will be the basis of the Bone Fide Job Offer you will receive if there is light duty work available.
- If you have been put on restrictive duties and light duty is available, you will then need to work out the task details with your supervisor and Human Resources in accordance with your job description. Once the amended job duties have been outlined you will receive a Bone Fide Job Offer. Not all departments offer light duty and not all job descriptions allow for any kind of physical limitations.
- Once you receive your Bone Fide Job Offer you will either accept the terms or reject the terms. Note that if you reject the terms of a Bone Fide Offer without a reasonable or valid concern you may seriously compromise the availability of Worker's Compensation benefits given to you.
- This Bone Fide Offer will be valid until the WC doctor releases you for full duty or if light duty is no longer available.
- If no light duty is available, then you will be out on sick time until that runs out at which time you will move on to WC benefits. It takes about 10-14 days for the benefits to begin. Benefits are a weekly check at a reduction of approximately 30-35% of your normal pay to help you get through the downtime until you can get back to work. You will be required to exhaust all your sick time before WC benefits begin.
- These weekly benefits stop when you are fully released for regular duty, however your medical benefits will always be paid for, as it relates to the injury, for as long as you need them.