ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R) I.
NUMBER: III-5-1
PAGE: 1 of 22
Purpose The purpose of this Administrative Instruction is to provide a policy statement and procedures for uniform response and handling of claims of work related injuries and illnesses.
II.
Scope These procedures apply to cases where a City employee or community service worker becomes injured or ill while working or claims injury or illness due to job duties.
III.
Definitions A. Work related injury or illness: An injury or illness believed to have been caused or aggravated in the course and scope of employment. Also known as a compensable injury or illness. An injury or illness where the employer is found to be liable for benefits under the provisions of the applicable sections of the California Labor Code for Workers’ Compensation. B. Employee: A person who renders service to the City for pay, excluding independent contractors. Employee includes persons in probationary, permanent, as-needed and temporary status. Reference definitions in California Labor Code §3351 et seq. C. Community Service Worker: A person referred to the City by the courts to perform volunteer work in lieu of fines and/or incarceration. Such persons are entitled to workers’ compensation benefits provided through the City’s program. The City will recover its costs from the referring agencies. D. Volunteers: A person authorized to render service to the City without receiving compensation in the form of wages or other forms of remuneration. Such persons are provided a separate accident medical policy by the City.
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
NUMBER: III-5-1
PAGE: 2 of 22
E. Self-Insured: An entity that sets aside funds within its own budget to pay its loss costs associated with injuries and illnesses claimed by its employees. The City is a selfinsured entity. F. Lost work time claim: An injury or illness that causes the employee to lose time from work beyond the date of injury as authorized by a City approved physician. G. Supplemental Salary: 1. The difference between the statutory required temporary disability payment and the employee’s gross weekly wages. The employee’s governing Memorandum of Understanding references whether or not there is entitlement to supplemental salary benefits. An M.O.U. imposed mandatory waiting period may be specified within the M.O.U. Waiting periods are equal to the employee’s usual workday. The supplemental salary payroll code is 33 (WCP). If the employee’s disability absence exceeds the available salary continuation benefits, the employee may be eligible to supplement the workers’ compensation temporary disability indemnity benefit received under statutory law with available accrued sick leave, vacation leave, or accrued leave time. The total number of leave hours, along with the workers’ compensation benefits shall not exceed the employee’s base pay for each day of absence. For this purpose, accrued leave hours can only be used in one-hour increments. 2. Calif. Labor Code § 4850: Police Officers and Fire Fighters are entitled to salary continuation for authorized absences for a period of one year (365 days). No waiting period applies. This statutory benefit is incorporated in the applicable M.O.U.s for police officers and fire fighters. If the employee is a police officer or fire fighter and is found to be substantially incapacitated from the performance of duties because of a job related injury or illness, in accordance with the contractual agreement with CalPERS, the City Manager will recommend the employee’s retirement after the expiration of Calif. Labor Code Section 4850 benefits and the expiration of accrued sick leave, vacation, and compensatory time unless the employee has been returned to duty or has consented to a retirement date earlier than the expiration of these benefits. Refer to the applicable M.O.U. as the use of sick leave to extend paid leave time may have been modified.
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
NUMBER: III-5-1
PAGE: 3 of 22
H. Acknowledged or Disputed Claim: Acknowledged claims are those that have been admitted as job related injuries or illnesses and allowed workers’ compensation benefits. Disputed claims are those which have not been admitted and are being investigated or that may be in litigation pending settlement disposition. I.
IV.
Permanent and Stationary: A workers’ compensation term of art describing the point at which an injured worker’s condition has achieved maximum benefit from medical treatment per the treating or evaluating physician.
Policy It is the goal of the City of Santa Monica with the cooperation of the departments to facilitate the prompt reporting of injuries and illnesses sustained or claimed by employees in accordance with this policy. The City intends is to provide quality medical care promptly to employees in need and will timely disseminate workers’ compensation benefits in accordance with statutory regulations as set forth in the California Labor Code. The City shall control the claims activity through positive intervention and encourage the return to work of injured employees. The City shall retain responsibility for and control of all medical treatment and associated benefits as stipulated in the governing sections of the California Labor Code. For purposes of workers’ compensation, the City of Santa Monica is self-funded public agency which has been duly authorized to self-insure claims by the California Department of Self-Insurance, certificate #4-7183-13-007, issued January 1, 1976. The Risk Management Division is responsible for managing the workers’ compensation fund and adjusting claims.
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 4 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
1. Reporting Injuries/Illnesses: Employees are responsible for reporting their claims of job related injury or illness to their supervisor when the incident occurs or in any case no less than within one year from the occurrence or knowledge of the injury or illness. The report of injury or illness shall be made on the City’s internal report form RM-WC-01, Employee’s Report of Industrial Injury/Illness.
Employee
2. Follow up Investigation: The supervisor or manager of the Division shall immediately investigate the employee’s injury or illness to corroborate the occurrence. Supervisors are required to complete the City’s internal report form RM-WC-02, The Supplemental Report of Investigation, RM-WC-02A, may be completed to provide further information regarding the incident. Reports shall be forwarded to the Risk Management Claims staff within 24 hours of knowledge of an occurrence claimed by an employee. Reports may be personally delivered, transmitted via electronic mail as an attachment or by facsimile to the Risk Management claims staff (with originals to follow by mail). The Workers’ Compensation Claims Administrator (or his/her designee) is available by pager during non-business work hours.
Supervisor or Manager
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 5 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
3. Employee’s Claim for Workers’ Compensation Benefits, DWC Form 1: This form will be provided to the injured employee by the workers’ compensation claims unit staff in compliance with statutory regulations.
Workers’ Compensation Claims Unit
4. Medical Treatment: Medical treatment will be authorized and coordinated by the workers’ compensation claims unit staff. All medical treatment will be pre-authorized with the exception of emergency room treatment. The Workers’ Compensation Administrator together with the claims staff is responsible for developing and monitoring the City-approved occupational medicine centers and providers of specialized care.
Workers’ Compensation Claims Unit and Administrator
5. Serious Injuries & Illnesses: In the event of serious injuries and illnesses, supervisors or co-workers should dial 911 for assistance without regard to whether the injury or illness is work related. The Workers’ Compensation Administrator shall be notified in all cases when employees are transported to hospital emergency rooms for treatment or observation. Risk Management pager numbers are on file with the Police Department Watch Commander. The supervisor shall secure the injured worker’s personal tools and/or equipment and shall advise the immediate family of the employee’s health status and location to which the employee has been transported for treatment or observation.
Supervisor/Workers’ Compensation Administrator
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 6 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
6. Accident Involving City Owned Vehicles: If a City owned vehicle is involved in an accident, follow procedures in Administrative Instruction II-3-6 for reporting such incidents. Forward copies of any available police reports to the Workers’ Compensation claims unit together with photographs or other documents that relate to the accident. If no police report was taken, every attempt should be made to identify the name of the adverse driver, the owner of the vehicle, make, model and license number of the vehicle involved, and the insurance that covers the vehicle, if any.
Supervisor
7. Securing Evidence: If a machine, tool or piece of equipment is believed to have contributed to the employee’s injury, it shall be taken out of service until properly inspected by Risk Management staff or professional consultants engaged for this purpose. Risk Management staff will assist in determining if there is potential for recovery of costs from third parties, e.g. manufacturing defects or improper maintenance or training. The machine, tool or equipment should not be put back into service until all potential defects or malfunctions have been identified and corrected and Risk Management staff has given approval to resume use of the equipment. Risk Management staff will notify the City Attorney’s office of occurrences in this category of loss.
Supervisors/Managers/ Risk Management Staff
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 7 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
8. Lost Time From Work: Employees who miss time from work due to compensable job related injuries or illnesses must advise their supervisors of their work status after every visit to the treating physician and prior to resumption of full duty or temporary modified duty by submitting work status notes from the treating physicians to their supervisors after every visit. The original work status notes are to be forwarded by the supervisor to the Risk Management claims staff. Employees must keep appointments arranged for them by the claims unit or their treating physician or legal counsel until discharged from treatment as permanent and stationary.
Employees/Supervisors/Risk Management Claims Staff
9. Time Cards: If the employee’s M.O.U. provides for salary continuation, the employee’s time card must be completed with the appropriate payroll code to denote authorized absences from work after the applicable waiting period, if any, has been noted. Code 33 (WCP) is to be used only for full day or authorized partial day absences. Waiting periods can be covered with sick leave, vacation or other forms of accrued leave. If none is available, code 40, leave of absence without pay is to be noted. Employees who do not have salary continuation must use all forms of available accrued sick leave, vacation, or other leave to cover absences. Such use of accrued leave is to be coordinated with the payment of statutory rates of pay for temporary disability leave and in no event may an employee earn more than his or her normal gross weekly wage.
Supervisor or time card keepers
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 8 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
10. Medical Follow Up Visits: Code 06 (SCP) is to be used on time cards for follow up visits to the treating physician, appointments for physical therapy or diagnostic testing as required by the treating physician. Employees should make every attempt to schedule all follow up examinations and other appointments outside their normal working hours. If appointments cannot be made on off duty hours, they should be scheduled at the beginning or end of the work shift. Departments are encouraged to allow flexible work schedules for employees continuing with medical treatment following their return to work. If the employee cannot schedule such appointments off duty, payment of Code 01 (REG) will be allowed for the absences. Supervisors may encourage such scheduling of appointments but may not penalize employees whose appointments conflict with on duty hours by disallowing code 01. Risk Management claims staff can assist supervisors in verifying the physician’s or practitioner’s business hours. There shall be no wage compensation paid to employees for medical visits or treatments obtained during off duty hours.
Employees/Supervisors/Risk Management Claims Staff
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 9 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
11. Return to Work Program: In accordance with Administrative Instruction III-5-3, temporary modified duty is to be explored for each injured employee with medical work restrictions. The Workers’ Compensation claims staff will work with the supervisor, employee and the treating physician to explore possible options for resumption of duty with work restrictions. The claims unit staff will assist in coordinating employee’s return to temporary modified duty and must be notified when the employee is returned to full duty or when the Division declines to continue providing temporary modified duty. Employees declined temporary modified duty by the City shall receive payment of statutory rates of indemnity or salary continuation, whichever is applicable for the individual case. Employees who refuse to accept viable temporary modified duty assignments are subject to declination of salary continuation and of statutory rates of indemnity.
Workers’ Compensation Claims Staff/Supervisor/ Treating Physician
12. Overpayment Remedy: In accordance with California Workers’ Compensation laws, it is sometimes necessary to estimate payments of temporary or permanent disability. When documentation is received leading to calculation of an actual amount owed which is less than what was paid to the employee, permanent employees covered by bargaining agreements shall reimburse the City for any overpayment of wages or benefits, including workers’ compensation benefits. Reference overpayment remedy provisions in each M.O.U.
Employees/Workers’ Compensation Claims Staff
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 10 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
13. Permanent Disabilities: When an injured employee has been declared permanent and stationary by the treating physician and has work restrictions preventing him/her from resuming full duties, it may be necessary to examine the possibility of job accommodation within the employee’s physical work restrictions. See Administrative Instruction on Americans with Disabilities III-4-3. If permanent accommodation cannot be provided by the City, it may be necessary to refer the employee for vocational rehabilitation services.
Workers’ Compensation Claims Staff/Department/ Division/ADA Accommodation Committee
14. Investigation: If there is doubt as to the validity of a claim for job related injury or illness, it may necessary to engage the services of an independent investigator to gather facts and information about the claim. The investigator will be authorized by legal counsel to contact the employee making the claim, the supervisor and coworkers, as well as other persons who may have knowledge about the accident or contributing causes to the illness. City staff is instructed to refrain from discussing the claim with anyone unless expressly authorized by the Workers’ Compensation Claims Staff.
Workers’ Compensation Claims Staff/Supervisors/ Employee’s Physician
15. Contact with Employee: Supervisors and managers are encouraged to remain in contact with their employees during the employee’s absence from work. It is recommended the supervisor or manager limit discussion only as to the health status of the employee and potential return to work date. The Workers’ Compensation Claims staff can provide information to the supervisor or manager about the employee’s status with the exception of medical information which is protected by medical privacy laws.
Supervisors/Managers/ Workers’ Compensation Claims Staff
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
NUMBER: III-5-1
PAGE: 11 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
16. Reporting Exposures, Incidents and First Aid Cases: The employee is responsible for reporting all incidents in these categories that do not constitute a workers’ compensation claim of injury or illness. Exposures are cases where the employee has been exposed to a blood borne or air borne pathogen but has not contracted an illness. See Administrative Instruction on Blood Borne Pathogens Exposure Control, III-5-8. The Employee’s Report of Industrial Injury/Illness, WCRM-01, and the Supervisor’s Report of Accident Investigation, WC-RM-02, should be used to document such exposures, in addition to the Communicable Disease Exposure Report form (see AI). Incidents where an event took place but no medical treatment is being requested by the employee are documented using WC-RM-01 and WC-RM-02. This is known as a “record only” report and will be maintained by Risk Management for a period of one year following the date of occurrence. The employee must request medical treatment from the Workers’ Compensation Claims staff within the one year time period. All requests must be made to the Workers’ Compensation Claims unit staff. First Aid cases are documented using the same forms. Costs incurred with first aid treatment rendered by medical professionals are paid by the City through the Risk Management Division.
Employees/Supervisors/ Workers’ Compensation Claims Staff
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
V.
VI.
NUMBER: III-5-1
PAGE: 12 of 22
Procedure and Responsibilities Procedures
Responsible Person(s)
17. Reporting Injuries to Community Service Workers or Volunteers: Forms for reporting injuries or illnesses to this category of worker are found on the City’s Intranet site. Injuries/illnesses claimed by Community Service Worker are to be reported in the same manner as for employee of the City. Injuries/illnesses sustained by Volunteers are to be reported for information only to the Risk Management Division. Volunteers may request claim forms to file reimbursements through the City’s accident medical policy. This accident medical policy covers above any medical coverage the volunteer has available.
Community Service Worker & Coordinator/Volunteer & Volunteer Coordinator
Report Forms 1. Employee’s Report of Industrial Injury/Illness, RM-WC-01. Current version available on the City’s Intranet. 2. Supervisor’s Report of Accident Investigation, RM-WC-02. Current version available on the City’s Intranet. 3. Supervisor’s Supplemental Report of Investigation, RM-WC-02A. Current version available on the City’s Intranet. 4. Confirmation of Temporary Modified Duty Status, RM-WC-04. Current version available on the City’s Intranet. 5. Employee’s Claim for Workers’ Compensation, DWC Form 1. Example provided for reference only.
ADMINISTRATIVE INSTRUCTION SUBJECT:
Work Related Injuries and Illnesses
EFFECTIVE DATE: July 1, 2001 (R)
NUMBER: III-5-1
PAGE: 13 of 22
6. Community Service Worker’s Report of Industrial Injury or Illness, RM-CSW-01. 7. Community Service Worker (CSW) Coordinator’s Report of Accident Investigation, RM-CSW-02. 8. Volunteer’s Report of Industrial Injury or Illness, RM-VR-01. 9. Volunteer Coordinator’s Report of Accident Investigation, RM-VR-02
VII.
Sources of Additional Information 1. Administrative Instruction on Temporary Modified Duty, III-5-3. 2. Administrative Instruction on Americans with Disabilities Act, III-4-3. 3. Administrative Instruction on Blood Borne Pathogens Exposure Control, III-5-8. 4. Administrative Instruction on Vehicle Accident Reporting Procedures, II-3-6. 5. Municipal Code section 2.04.570 on use of sick leave. 6. Risk Management Workers’ Compensation Claims Staff.
VIII. Authorized By
Susan E. McCarthy, City Manager City Manager