Quiz questions

What were the common law defenses available to employers in "the old days" against workers' compensation claims?

1. Assumption of risk 2. Fellow servant rule 3. Contributory negligence

What are the advantages of self insurance?

1. No insurance company overhead/profit 2. greater control over the claims handling process 3. vested interest in claims management

In California, employers may finance workers' compensation coverage by

1. Purchasing insurance from a private insurance company 2. Purchasing insurance from the State Fund 3. May Self - Insure

What are the disadvantages of self-insurance?

1. Risk uncertainty 2. External clients/lenders may be uncomfortable. 3. regulatory constraints, reserve 'rules' and bond

What are the categories of indemnity benefits?

1. Temporary Disability 2. Permanent Disability 3. Death Benefits

In CA, an independent medical evaulation is called ?? or ??

QME or AME

What is a rebuttable presumption vs a conclusive presumption?

Rebuttable is one that can be overcome by facts or evidence while a conclusive presumption has no argument

What does SOAP stand for?

S - Subjective (employee complaints) O - Objective (Measurable findings) A - Assessment (Diagnosis) P - Prognosis/Plan (treatment and work status)

What does SI/SA stand for?

Self-insured, self administered

If an employee is injured while on a work related special mission, it is considered AOE/COE unless there was a ??

Material Deviation

What is MMI?

Maximum Medical Improvement. The point at which a medical condition has stabilized and is unlikely to change, with or without treatment

What does Labor Code (LC) 4600 state?

Medical Treatment reasonably required to cure OR relieve from the effects of the injury shall(must) be provided by the employer

Is form 5020 - Employers Report of Occupational injury or illness (or FROI)- discoverable?

NO, it is not discoverable.

Is an injury sustained due to an "act of nature" generally considered compensable?

No, a injury sustained by an act of nature is NOT compensable.

While an acupuncturist is considered a physician, can they determine disability?

No, an acupuncturist cannot determine disability but can render treatment to an IW.

OSIP

Office of Self Insurance Plan - Authorizes qualified employers to provide their own coverage for work comp claims

How many PTP can be on any given claim at one time?

One, there can be no more than one PTP on a claim.

Can a NP and PA treat an injured worker and take them off work?

Yes, these physician extenders can render treatment to an IW and may take an IW off work for 3 calendar days only.

What does ADL stand for?

activities of daily living

What are the two most appropriate reasons why we follow up with a doctor?

(1) to identify the treatment plan; (2) to coordinate prompt return to work

The employer is required to provide a DWC1 Claim Form to the employee within ?? day(s) of the date of knowledge (DOK) of occupational injury or illness?

1 working day

What percentage of employment contribution is required for the aggravation to be found compensable?

1%

Compensable Consequence

injury that arises out of a compensable claim (Subsequent injury/illness or Secondary injury)

What does q.d., b.i.d, and q.i.d. stand for?

q.d. - daily b.i.d. - twice daily q.i.d. - four times daily

LC 3208 states an injury to artificial members, dentures, hearing aids, eyeglasses, and medical braces of all types is covered, however eyeglasses and hearing aids will not be replaced, repaired or otherwise compensated for, unless....

the injury to them is incidental to an injury causing disability.

Define LC 3202

this labor code states that the WC laws in CA should be construed in favor of the IW. This does NOT mean we must accept all claims. All reasonable doubts will be in favor of the IW.

What are the 5 things that establish a person is an independent contractor?

1. individual has own business card with license number 2. individual provides own tools 3. individual sets own hours of work 4. individual hires/fires employees or subcontractors at will 5. individual determines how and when the work will be done

Coverage must be determined and documented by the claims rep within how many business days of the date the claims was reported?

10 business days

The treating physician must complete a FROI (5020) within ?? days of the initial examination?

5 working days

IAP Colleagues must achieve ?% overall in order to successfully complete Phases I and II of Training

85%

What is an idiopathic fall?

A fall precipitated by an underlying non-occupational condition (ex, diabetes, pregnancy, sleep disorders)

According to Sedgwick's Best Practices, WHEN should the examiner follow up with the PTP?

After each appointment

what is a cumulative trauma injury?

An injury caused by repeated events or exposures

Which regulation number deals with the reporting responsibilities of the PTP?

CCR 9785

What is CSI?

Client Service Instruction. These are specific instructions from clients as to how they would like to have their claims handled.

What does DOI/DOL stand for

Date of Injury/Loss

What does DOK stand for?

Date of Knowledge

DEU

Disability Evaluation Unit - Issues permanent disability ratings for use by judges, injured workers, and claims administrators (advising only)

DWC Audit Unit

Division of Workers Compensation Audit Unit - Verifies proper benefits are delivered accurately and in a timely manner.

What is the coming and goinds doctrine?

Employer has no control over environment when coming or going to work therefore it is not covered. Exception is special missions/errands and parking lot injuries

What is "En Banc" and how many commissioners review the decisions?

En Banc (on bench) is heard by all 7 commissioners and decision are considered new case law.

As a result of workers compensation reform - the "Grand Bargain" - employees lost the right to sue their employers (with exception) in exchange for workers' compensation benefits. What is the name of this concept?

Exclusive Remedy

What are the 4 ways a new claim can be reported to Sedgwick?

Fax, Call Center, Web-based, and mail from the applicant attorney

What major event brought about the need for workers compensation laws in the USA?

Industrial Revolution

I&A Officer

Information & Assistance Unit - Provides information, forms and helps to resolve claims. Also provides assistance to IW's w/out attorneys.

The "no fault" aspect of workers' compensation is of benefit to?

Injured worker/employees

If it is not documented, ???

It didn't happen.

Why is the DOI on a WC claim important?

It drives the laws, benefit rates, SOL, caps, and coverage applied.

What is excess insurance?

It provides a secondary layer of coverage on top of either an insured or self insured program.

Per LC 5412, the DOI for a CT or occupational illness/disease is established at the intersection of ?? and ??

Knowledge and Disability

What does CCR 2592.02 describe

The state of California requires training for workers' compensation claims examiners. CCR 2592.02 explains the requirements and outlines the curriculum in detail.

What is TPA?

Third Part Administrator - ex. Sedgwick

What is a Retention Level or Large Deductible?

This refers to the dollar amount that the employer is responsible for paying on a claim

What is my role as a claims representative?

To investigate, manage, evaluate, and conclude workers' compensation claims.

Indemnity claims

Usually involve lost time from work