Workers’ Compensation

Procedures | Forms | Helpful Links

The University of Hawaiʻi provides Workers’ Compensation benefits to eligible UH employees and volunteers. For information on eligibility, benefits, and procedures for reporting a work-related injury or illness, contact the Workers’ Compensation Coordinator in your college personnel office.

Procedures

What to do for Work-related Injury/Illness

You need to immediately notify your supervisor or your college personnel office about your work-related injury/illness and intend to file for workers’ compensation. You must provide complete and accurate information, including outside (non-university) employment and prior similar injury/illness. You must obtain and submit the following forms to the Workers’ Compensation Coordinator (WC Coordinator) in your college personnel office :

• UH Form 79, Report of Work-Related Injury/Illness – Section I
• UH Form 41, Sick/Vacation Pay During Receipt of Workers’ Compensation Disability Benefits (If you do not complete and submit this form, you will be placed on LWOP – Industrial Injury and receive only wage loss benefits, as applicable.)

In the event a work-related Death/Catastrophic Event involving a University of Hawai‘i employee, official University of Hawai‘i volunteer, or University of Hawai‘i student participating in a UH-approved work-based learning program sponsored by the University of Hawai‘i occurs, please refer to this notice for guidance.

Bills/Reports from Medical Providers

Have your medical providers submit billings and reports directly to the following third party administrator (TPA)/insurance carrier (IC).

For Injuries February 1, 2001 through June 30, 2007:

First Insurance Company of Hawaiʻi, Ltd. (FICOH)
P.O. Box 2866
Honolulu, Hawaiʻi 96803
For All Other Injuries:

TRISTAR Claims Management Services
P.O. Box 2805
Clinton, IA 52733-2805

Certificates of Disability

If you are unable to return to work, you are responsible for instructing your attending physician to fax a certificate of disability for each period of disability to TRISTAR at (808) 470-0862. Your attending physician must notify TRISTAR of the estimated date of return to work. The employee must submit a disability certificate to his/her supervisor for each period of disability and the supervisor must immediately forward the disability certificate to the WC Coordinator.

Absence from Work

In accordance with Section 386-31, HRS, Total Disability, there is a three (3) calendar day waiting period during which Workers’ Compensation wage replacement benefits are not paid. You need to submit a leave request (UH Form 1, Request for Leave) to your supervisor to request sick and/or vacation leave or leave without pay (LWOP) to cover your absence from work for these days.

If you will be absent from work due to your work-related injury/illness, account for your absence as sick/vacation leave or leave without pay. There is a three-day waiting period during which you are not eligible for wage loss replacement benefits. For those cases requiring additional review before determination of compensation eligibility, you will need to similarly account for your absence during the period for which you are not yet receiving wage replacement benefits.

If your claim is deemed compensable and you require time-off during working hours for medical treatment, submit via your supervisor to your WC Coordinator a completed UH Form 83 (PDF), Time-Off for Treatment of Work-Related Injury/Illness.

Change of Medical Provider

You may select for treatment of your injury/illness any physician who is practicing on the island where the injury/illness was incurred. However, should you decide to change to another physician, you must:

• Prior to making a change, first inform your physician and claim adjuster of your desire to change and furnish both with the name of the selected physician.
• Before seeing a new physician, receive the approval of the claim adjuster or the Director of Labor, upon application and justification of the requested change.

Note: The TPA/IC may also appoint a physician of its choice, for purpose of examination.

Changes in Personal Contact Information

Notify your WC Coordinator and the TPA/IC of any change in mailing address or phone number; failure to do so may delay receipt of benefits.

Additional Information

Read the copy of the “Highlights of the Hawaiʻi Workers’ Compensation Law” brochure provided by your WC Coordinator.