How is a claim initiated?

There are two ways to file a Workers’ Compensation claim:

• An injured worker gets medical treatment (it does not matter where)
• An injured worker chooses to file a claim

When an employer learns about a possible work-related injury or illness, they must send the worker a Workers’ Compensation Claim Form (also known as a DWC1) within one business day. This is why, when an Employee Injury/Illness Report is completed, the injured worker gets an email from Workers’ Compensation advising them: 1) to contact Occupational Health if they need treatment and 2) to complete and return the DWC1 form if they wish to file a claim.

This does not mean that the only way to file a claim is to complete a DWC1 form. Workers’ Compensation will file a claim if an injured worker gets treatment because a claim is needed to cover all injury-related expenses, including medical care.

What happens after the claim is filed?

The University of California is self-insured and partners with a Third Party Administrator (TPA) called Sedgwick CMS (the CMS stands for “Claims Management Services") to manage claims. 

When a claim is transmitted to Sedgwick, it is assigned to an examiner (also known as an adjuster) who investigates the injury to determine if it arose out of employment or course of employment (AOE/COE).

While the examiner is reviewing the claim, they will speak with the injured worker, their supervisor and any other relevant parties (like any witnesses to the injury). To rule out that the injury is not the result of a pre-existing condition, the examiner will request and review medical records. 

If the claim is accepted, Sedgwick has determined that the injury or illness was work-related. 

If the claim is denied, Sedgwick has determined that the injury or illness was not work-related. A claim may also be denied if medical records or statements from the injured worker or their supervisor are not available.

What happens if the claim is denied?

Sedgwick will notify claimants that their claim is denied, with the reason(s) for the denial. They can appeal for the denial to be reversed.

Even if a claim is denied, the employee can still seek treatment from their primary care provider (PCP) and should provide the denial letter to their health insurance and PCP so treatment can be covered by private insurance.

Sedgwick will pay up to $10,000 in medical treatment expenses until a claim is denied, so the injured worker will not be responsible for those bills.

What happens if the claim is accepted?

Sedgwick will notify claimants that their claim has been accepted, and that Sedgwick will continue to coordinate their care. Most injured workers continue their regular work and receive treatment until they recover. Workers' Compensation benefits are only available if the claim is accepted and the employee cannot work due to their injury. In such cases, Workers' Compensation coordinates with Sedgwick, the department, and relevant service channels to ensure the employee receives appropriate pay and benefits.