California Self-Insurance Examination Review Flashcards

Comprehensive practice vocabulary flashcards covering the California Self-Insurance examination transcript, including legal definitions, administrative timelines, medical terminology, and statutory frameworks.

Self Insurance Administrator’s Exam (SIAE) Passing Score

The exam consists of $100$ multiple-choice questions with a required passing score of $70\%$ and an average pass rate of $55\%$.

Administrative Director

The official responsible for prescribing rules and regulations to comply with Labor Code statutes, regulating compliance audits, and overseeing benefit notice enforcement and timeliness of payments.

Profile Audit (PAR)

A DWC audit conducted every $5$ years on insurers, self-insured employers, and TPAs to ensure accurate and prompt compensation for injured workers.

Incurred But Not Reported (IBNR) Liabilities

An estimate of liability for claims that have already occurred but have not yet been filed at the time of the annual report.

Allocated Loss Adjustment Expense (ALAE)

Specific costs assigned to a claim, including legal fees and investigation costs.

Unallocated Loss Adjustment Expense (ULAE)

Program costs that cannot be assigned to a specific claim, such as MPN fees, bill review, UR, and TPA fees.

Surety Bond

A third-party agreement acting as a line of credit to guarantee claim payments if the principal employer fails to fulfill its obligations; the surety seeks reimbursement if they pay losses.

Irrevocable Letters of Credit

A financial guarantee issued by a bank that acts as an interest-accumulating loan the state can call upon if a self-insured contractor defaults.

Specific Excess Insurance

A policy that caps losses involving a single occurrence; self-insured employers are allowed credit against their security deposit for this type of coverage.

Aggregate Excess (Stop Loss) Insurance

Coverage that addresses loss frequency once a cumulative limit is breached; self-insured employers receive NO credit against their security deposit for this policy.

Solvency Requirement (Post-2017)

The requirement for private applicants to have $3$ calendar years in business, $3$ years of CPA-audited financial statements, and $3$ years of acceptable credit ratings.

Self-Insurer’s Annual Report Due Dates

Private Employers and Self-Insured Groups must file by $\text{March 1st}$; Public Employers and Joint Power Authorities must file by $\text{October 1st}$.

Exacerbation

A temporary flare-up of an original medical condition that is expected to return to its base level; it is handled strictly on the original claim file.

Aggravation

A permanent worsening of an original condition resulting in a new level of disability; it is handled as a new injury requiring a separate claim file.

Bunkhouse Rule

A doctrine stating that the employer’s premises include living quarters provided to the employee when an injury there is incidental to employment.

California Insurance Guarantee Association (CIGA)

A state agency that assumes handling and benefit payments for claims after an insurance company is found insolvent and placed in liquidation.

Subsequent Injuries Benefits Trust Fund (SIBTF)

A fund providing additional compensation for workers with a previous disability when a new industrial injury results in a combined permanent disability of at least $70\%PD$.

Serious and Willful Misconduct (S&W)

An action that results in a $50\%$ increase or decrease in compensation, though no reduction is allowed if the injury results in death or $PD \ge 70\%PD$.

Subrogation

The legal right of an employer or insurer to seek financial recovery or credit for benefits paid when an injury was caused by a negligent third party.

LC §4060 Examination

A medical exam used specifically to resolve disputes regarding the AOE/COE (Arising Out of Employment/Course of Employment) compensability of a claim.

LC §4061 Examination

A medical exam used to resolve disputes regarding Permanent Disability (PD) ratings and Apportionment.

LC §4062 Examination

A medical exam used to resolve disputes regarding medical opinions from the Primary Treating Physician (PTP), excluding PD and apportionment issues.

Utilization Review (UR)

The process to approve, modify, delay, or deny treatment requests; only a licensed physician can modify or deny such requests.

Medical Treatment Utilization Schedule (MTUS)

The set of guidelines presumed correct regarding what constitutes reasonable medical treatment for workers' compensation claims.

Supplemental Job Displacement Voucher (SJDV)

A benefit for injuries on/after $1/01/13$ provided if the employer does not offer a position paying at least $85\%$ of previous wages; it is capped at $\$6,000$.

Average Weekly Earnings (AWW) Formula

The value calculated as $\text{AWW} = \text{TTD} \times 1.5$, used to determine the rate of temporary disability benefits.

Three-Day Waiting Period Waiver

The mandatory waiting period for TD is waived if the employee is hospitalized overnight as an inpatient or if the disability exceeds $14\,\text{days}$.

Scapula

The shoulder blade bone that connects the clavicle to the humerus.

Arthrodesis

A surgical procedure involving the fixation or fusion of a joint.

Paresthesia

A burning or prickling sensation usually felt in the hands, arms, legs, or feet.

Aphakia

A medical condition defined as the loss of the eye's natural lens.

Synovial Fluid

A thick fluid in the joints that provides lubrication for smooth motion and cushions against bone-on-bone contact.

Ganglion Cyst

A fluid-filled lump that often appears on the wrist or hand, typically near a joint.

Navicular Bone

A bone located in the hand (part of the carpal bones).

Shall

A claim term defined as being mandatory.