Leave And Worker's Comp - Glossary

Front 1

Accepted claim

Back 1

A claim in which the
insurance company agrees that the injury or
illness is covered by workers' compensation.
Even if the claim is accepted there may be
delays or other problems. Also called
admitted claim.

Front 2

ACOEM

Back 2

American College of
Occupational and Environmental Medicine.
Until the state Division of Workers'
Compensation (WC) adopts medical
treatment guidelines, the guidelines published
by ACOEM, called "Occupational Medicine
Practice Guidelines," are the guidelines used
in most cases to decide the type and amount
of treatment approved for a work injury or
illness.

Front 3

Agreed medical evaluator (AME)-

Back 3

Ifyou
have an attorney, an AME is the doctor your
attorney and the insurance company agree
on to conduct the medical examination that
will help resolve your dispute. If you don't
have an attorney, you will use a qualified
medical evaluator (QME). See QME.

Front 4

American Medical Association (AMA

Back 4

A
national physician's group. The AMA
publishes a set of guidelines called "Guides
to the Evaluation ofPermanent
Impairment." If the permanent disability is
rated under the 2005 rating schedule, the
doctor is required to determine the level of
impairment using the AMA's guidelines.

Front 5

Americans with Disabilities Act (ADA)

Back 5

A
federal law that prohibits discrimination
against people with disabilities.

Front 6

AOE/COE

Back 6

(arising out of and occurring in
the course of employment)-An injury that
is caused by and happens on the job.

Front 7

Compromise and release (C&R)-

Back 7

A
type of settlement in which you receive a
lump sum payment and become
responsible for paying for your future
medical care. A settlement like this must
be approved by a workers' compensation
judge.

Front 8

Crime victim-

Back 8

A person against whom one
of the following crimes has been committed:
(1) a violent felony, (2) a serious felony, (3)
a felony provision oflaw proscribing theft
or embezzlement.

Front 9

Cumulative injury (CT)-

Back 9

An injury
that was caused by repeated events or
repeated exposures at work; for example,
a wrist injury caused by performing the
same motion over and over or a loss of
hearing caused by constant loud noise.

Front 10

Delay letter-

Back 10

A letter sent by the insurance
company that explains why payments are
delayed. The letter also tells what
information is needed before payments will
be sent and when a decision will be made
about the payments.

Front 11

Disability Evaluation Unit (DEU)-

Back 11

A unit
within the DWC that calculates the percent
ofpermanent disability.

Front 12

Division of Workers' Compensation
(DWC)-

Back 12

A division within the state
Department of Industrial Relations
(DIR). The DWC administers workers'
compensation laws, resolves disputes
over workers' compensation benefits and
provides information and assistance to
injured workers and others about the
workers' compensation system.

Front 13

Emergency rescue personnel-

Back 13

Any
officer, employee, or member of a fire
department or fire protection or firefighting
agency of the federal government, the state
of California, a city, county, city and county,
district, or other public or municipal
corporation or political subdivision of this
state, or of a sheriff's department, police
department, or a private fire department,
whether that person is a volunteer or partly
paid or fully paid, while he or she is actually
engaged in providing emergency services.

Front 14

Essential job functions-

Back 14

"duties crucial to job
such that position exists to perform job
function."

Front 15

Fair Employment and Housing Act
(FEHA)-

Back 15

A state law that prohibits
discrimination based on protected
characteristics.

Front 16

Family and Medical Leave Act (FMLA

Back 16

A
federal law that provides certain employees
with serious health problems or who need to
care for a child or other family member with
up to 12 we,eks ofunpaid, job-protected leave
per year. Itilso requires that group health
benefits be maintained during the leave.

Front 17

Findings and award (F&A)-

Back 17

A written
decision by a workers' compensation
administrative law judge, including
payments and future care that must be
provided to the injured worker. The F&A
becomes a final order unless appealed.

Front 18

Health care organization (HCO)-

Back 18

an
organization certified by the Department of
Industrial Relations to provide managed
medical care within the workers'
compensation system.

Front 19

Health care provider-

Back 19

An individual holding
either a physician's or surgeon's certificate or
any other individual duly licensed as a
physician, surgeon, or osteopathic physician or
surgeon in another state or jurisdiction,
including another country, who directly treats
or supervises the treatment of the serious health
condition, or any other person who meets the
definition of others "capable of providing
health care services," as set forth in FMLA and
its implementing regulations.

Front 20

In loco parentis-

Back 20

In the place of a parent;
instead of a parent; charged with a parent's
rights, duties, and responsibilities. It does
not require a biological or legal relationship.

Front 21

Injury and illness prevention program
(IIPP)-

Back 21

A health and safety program
employers are required to develop and
implement. This program is enforced by
CallOSHA.

Front 22

Impairment rating

Back 22

A percentage estimate
ofhow much normal use of your injured body
parts you've lost. Impairment ratings are
determined based on guidelines published by
the American Medical Association (AMA).
An impairment rating is used to calculate a
permanent disability rating but is different
from the permanent disability rating.

Front 23

Lien

Back 23

A right or claim for payment against a
workers' compensation case. A lien claimant,
such as a medical provider, can file a form
with the local Workers' Compensation
Appeals Board to request payment ofmoney
owed in a workers' compensation case.

Front 24

Maximal medical improvement (MMI)

Back 24

The
injured worker's condition is well
stabilized and unlikely to change substantially
in the next year, with or without medical
treatment. Once MMI is reached, a doctor can
assess how much, if any, permanent disability
resulted from the work injury.

Front 25

Medical-legal report-

Back 25

A report written by
a doctor that describes a medical condition.
These reports are written to help clarify
disputed medical issues.

Front 26

Medical provider network (MPN)-

Back 26

An
entity or group of health care providers set
up by an insurer or se1f-insured employer
and approved by DWC's administrative
director to treat workers injured on the job.

Front 27

Modified work

Back 27

The existing position of
an injured worker with some changes that
allow him or her to do it. If the treating
physician says the employee will not be able
to return to the job at the time of injury, the
employer is encouraged to offer modified
work instead of supplemental job
displacement benefits or vocational
rehabilitation benefits.

Front 28

Nontransferable voucher-

Back 28

A document from
the insurance company that must be completed
by both the injured worker and the insurance
company. This is the document used to provide
payment for education under the supplemental
job displacement benefit program.

Front 29

Paid family leav~

Back 29

Ca1ifomia state law
program providing wage replacement
benefits to eligible employees for time off
due to seriously ill family members and
administered by the Employment
Development Department.

Front 30

Parent

Back 30

Biological, foster, or adoptive
parent, a stepparent, a legal guardian, or other
person who stood in loco parentis to the
employee when the employee was a child.

Front 31

Permanent and stationary (P&S)-

Back 31

the
condition when the employee's medical
condition has reached maximum medical
improvement.

Front 32

Permanent disability rating (PDR)-

Back 32

For
workers' compensation insurance purposes,
percentage that estimates how much a job
injury permanently limits the kinds ofwork
an injured employee can do. It is based on
medical condition, date of injury, age when
injured, occupation when injured, how much
ofthe disability is caused by the job, and
diminished future earning capacity. It
determines the number of weeks allowed for
permanent disability benefits.

Front 33

Permanent Disability Rating Schedule
(PDRS)-

Back 33

A DWC publication containing
detailed information used to rate permanent
disabilities. One of three schedules will be
used to rate the disability, depending on the
date ofthe injury.

Front 34

Pre-designated physician-

Back 34

A physician
that can treat a work injury if the employee
has advised the employer in writing prior to
the work injury or illness if certain
conditions are met. See pre-desiguation.

Front 35

Pregnancy disability leave (PDL)-

Back 35

A
leave taken for disability on account of
preguancy, childbirth, or related medical
conditions.

Front 36

Primary treating physician (PTP)-

Back 36

The
doctor having overall responsibility for
treatment of a work injury or illness. This
physician writes medical reports that may
affect benefits, also called treating physician
or treating doctor.

Front 37

Qualified injured worker (QIW)-

Back 37

For
workers' compensation purposes, entitled to
vocational rehabilitation benefits. This
benefit applies only if the injury occurred
before Jan. 1,2004.

Front 38

Qualified medical evaluator (QME)-

Back 38

An
independent physician certified by the DWC
Medical Unit to perform medical evaluations.

Front 39

Registered domestic pa~tner-

Back 39

Two adults
who have chosen to share one another's
lives in an intimate and committed
relationship of mutual caring and who file a
Declaration of Domestic Partnership with
the Secretary of State as defined in Section
297 of the Family Code.

Front 40

Rehabilitation consultant-

Back 40

A DWC
employee who oversees vocational
rehabilitation procedures, makes decisions
about vocational rehabilitation benefits and
helps resolve disputes.

Front 41

Serious and willful misconduct (S&W)-

Back 41

A
petition filed if an injury is caused by the
serious and willful misconduct of your
employer.

Front 42

Serious health condition-

Back 42

For purposes of
CFRA, this includes the following categories:
(l) inpatient care in a hospital, hospice, or
residential medical care facility (including
any period of incapacity and any subsequent
treatment in connection with the inpatient
care); (2) continuing treatment or supervision
by a health care provider; (3) a period of
incapacity qf more than three consecutive
calendar days, and any subsequent treatment
or period of incapacity relating to the same
condition that also involves either treatment
two or more times by a health care provider or
treatment by a health care provider on at least
one occasion that results in a regimen of
continuing treatment; (4) a period of
incapacity or treatment due to a chronic
serious health condition requiring periodic
visits for treatment, continues over an
extended period of time and may cause
episodic rather than continuing incapacity; (5)
a period of incapacity that is permanent or
long-term due to a condition for which
treatment may not be effective; and (6) a
period of absence to receive multiple
treatments by a health care provider, either for
restorative surgery after an accident or injury,
or for a condition that would likely result in a
period of incapacity of more than three
consecutive calendar days in the absence of
medical intervention or treatment.

Front 43

Sick leave--

Back 43

As defined by Labor Code
Section 233, accrued increments of
compensated leave provided by an
employer to an employee as a benefit of
the employment for use by the employee
during an absence from the employment
when medically necessary, the employee is
physically or mentally unable to perform
his or her duties due to illness, injury, or a
medical condition of the employee, or the
absence is for the purpose of obtaining
professional diagnosis or treatment for a
medical condition of the employee.

Front 44

Spouse

Back 44

A partner in a legal, documented
marnage.

Front 45

State Disability Insurance (SDI)-

Back 45

A statemandated
wage replacement program that is
typically funded through an employee's
payroll deduction and is administered
through the Employment Development
Department (EDD).

Front 46

Supplemental job displacement benefit
(SJDB)-

Back 46

voucher for payment to employees,
injured in or after 2004 with permanent partial
disabilities preventing them from performing
their former job where employer does not
offer other work, for educational retraining
and/or skill enhancement at state-approved or
state-accredited schools.

Front 47

Utilization review (UR)-

Back 47

The process used
by insurance companies to decide whether to
authorize and pay for treatment
recommended by a treating physician or
another doctor.

Front 48

Vocational and return to work counselor
(VRTWC)-

Back 48

Specialist who evaluates
injured worker with permanent disability
rating and develops return to work strategy.

Front 49

Vocational rebabilitation (VR)-

Back 49

Workers'
compensation benefits, including job
placement counseling, retraining and
maintenance allowance to employees,
injured prior to 2004 with permanent partial
disabilities preventing them from
performing their former job where employer
does not offer other work.

Front 50

Vocational rehabilitation maintenance
allowance (VRMA)-

Back 50

Payments to help
with living expenses while an injured
worker participates in vocational
rehabilitation.

Front 51

Work restrictions-

Back 51

A doctor's description
of the work an injured employee can and
cannot do. Work restrictions help protect the
employee from further injury.

Front 52

Workers' Compensation Appeals Board
(WCAB)-

Back 52

Consists of 24 local offices
throughout the state where disagreements
over workers' compensation benefits are
initially heard by workers' compensation
judges. The WCAB Reconsideration Unit in
San Francisco is a seven-member, judicial
body appointed by the governor and
confirmed by the Senate that hears appeals
of decisions issued by local workers'
compensation judges.

Front 53

Workers' Compensation Insurance
Rating Bureau (WCIRB)-

Back 53

An agent of the
state Department of Insurance and funded by
the insurance industry, this private entity
provides statistical and rating information
for workers' compensation insurance and
employer's liability insurance, and collects
and tabulates information to develop pure
premium rates.