The Workers' Compensation Claim Process

The first step toward getting your workers’ comp benefits is to notify your employer of a work-related injury or illness. The notice should be in writing and should follow the employer’s protocol for reporting injuries. It should also be signed by the injured employee or another individual (such as an attorney) acting on behalf of the employee. Under California law, the employer is obligated to provide the employee with a claim form after becoming aware of the work-related injury or receiving notice, but only if the employee needs medical attention beyond first aid, or the employee lost time beyond the work shift as a result of the injury.

It’s important to report the injury to your employer within 30 days of the injury, failure to which you risk losing your right to make a workers’ comp claim. Despite the requirement for providing written notice of an injury, an employer is considered to have received notice when they learn of the injury’s occurrence. For instance, if a supervisor witnesses the work-related injury it’s presumed that the employee has reported the matter, so the employer cannot claim to have been prejudiced because of the lack of a report. The employer must provide the injured employee with a claim form within one working day after learning about the injury. Nonetheless, employees should not rely on the employer’s knowledge of the injury. Writing a formal written notice as soon as possible is the safest practice.

Some injuries and occupational illnesses occur over time as the result of repeated exposures or actions. These are known as cumulative injuries. Filing a claim when this type of injury occurs can be challenging because of how difficult it is to identify a specific date on which the injury occurred. Under California law, the date of a cumulative injury is when the employee first suffered a compensable disability as a result of the injury and realized or should have realized that the disability was directly related to his/her employment. In this case, the employee must give notice of the cumulative injury within 30 days of the date that the employee knew or should have known that the injury was work-related.

The claim form provided by the employer must include a notice of the employee’s eligibility for workers’ compensation benefits as well as the following information:

• The workers’ compensation collection procedure
• Details of the different forms of workers’ comp benefits
• From whom the employee can obtain treatment
• How to get medical care before the claim is approved
• The primary treating physician’s role and obligation
• The employee’s rights to change the primary treating physician
• What happens to the claim once filed
• The employee’s protection against discrimination

To continue with the workers’ compensation process, you need to complete the “Employee section” of a DWC-1 Claim Form. You can also download the can download the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility if your employer does not provide the claim form. Claim forms are available from the Division of Workers’ Compensation website as well as the offices of the Employment Development Department. In completing the form, the employee is required to provide contact information and basic information about the injury. This includes:

• The employee’s name, social security number, and address,
• The date and time of the injury,
• An email address if the employee wants to be notified by email,
• A description of the injury and the affected part(s) of the body,
• Date and time of the injury, and
• A signature.

It’s important to keep track of all problems that arise and could be directly related to the injury. In some cases, however, an injured employee may find it challenging to provide the required information. If you have any doubt about how to fill out the form, contact us for advice.

What’s more, you should seek immediate medical attention to minimize the risk of being accused of facilitating any consequent injuries. This also helps you know the extent of the injury or any possible disability as well as determining how much time you need off from work. It may not be possible to provide a description of the injury before getting appropriate medical care. It’s important to document your situation and write down every part that seems to have been affected by the workplace incident. For instance, if you have a sore neck but the primary complaint is back, you can include both neck and back in the form. Be sure to also document every interaction with a health care provider, including hospital visits and calls.  

In most cases, employees learn about the work-related injury once they occur, and quickly report to their employer. But when you complete and return a DWC-1 Claim Form, it acts as a written notice of the injury and your need for coverage.

Filing a workers compensation claim typically involves providing your employer with a completed claim form. You’re deemed to have filed a claim when you personally deliver the form to the employer or the employer receives it through certified or first-class mail. The employer will then fill out the “Employer section” of the form and then submit it to the employer’s workers’ compensation insurance company. In addition, the employee must also be given a dates copy of the completed form one day after the employee has submitted the form. You should keep a copy of the completed claim form because it can provide evidence that you actually filed a claim properly. The form also contains pertinent information that will be needed by an attorney should you decide to retain legal counsel to help pursue your benefits.

As already noted, an employee has the obligation to submit a written notice within 30 days of the injury. Filing a claim, therefore, assures the employee of entitlement to seek workers’ comp benefits even if the employer does not voluntarily provide them. In addition to wage and medical benefits, injured employees are also entitled to benefits that will cover

• Temporary disability: paid to an employee who takes time off work as a result of the injury
• Permanent disability: paid to an employee who has suffered an injury that has left them permanently disabled and unable to work.
• Retraining: This helps retrain and re-introduced an injured disabled employee to the job market if he/she is unable to return to their regular position.
• Return to work fund: one-time payment for employees who cannot return to work after a permanently disabling injury
• Death: Benefits paid to surviving dependents and any spouse of an employee killed in a job-related activity

Once the claim form has been submitted, the claims administrator has 90 days deny the claim without the presumption that the claim is compensable. In addition, the employer is required to authorize up to $10,000 for necessary medical treatment within one working day after receiving the employee’s claim form. This is usually done as the claims administrator decides whether to approve or reject the claim. If the claim is accepted, medical treatment continues and the dollar limit is lifted. If rejected, treatment stops unless the employee decides to appeal the denial. Either way, the employer must still pay up to $10,000 for allowable treatment expenses incurred until the rejection date.

After filing a claim, it may be disputed by your employer and their insurance carrier, especially concerning the degree of your injury. California has a Mandatory Settlement Conference (MSC) provision that requires the involved parties to participate in settlement discussions. As such, most contested workers’ compensation claims are settled without a contested hearing involving a workers’ compensation judge. This is usually the case when the injured employee is represented by an attorney. Even so, a settlement must be approved by a workers’ compensation judge. There are generally two types of workers’ compensation settlements in California:

• Stipulated Finding and Award: This is an agreement between the employer and the injured employee and typically has the same effect as a judge’s decision. Both parties agree on payments for weekly future medical care. This isn’t imposed on any party involved and the settlement is then reviewed by a workers’ compensation judge. Much of the review revolves around the percentage of disability and the need for further medical care as determined by the treating physician. Once ordered by the judge, the employer will be responsible for providing the employee’s medical treatment if needed. As such, the employee may have to contact the claims administrator before receiving medical care. The amount is not paid in a lump except in situations when payments for previous weeks are determined to be overdue. If
• Compromise and Release: This settlement completely closes the case when the employer makes a lump sum payment that covers the estimated value of any future medical treatment and/or disability award rather than awarding payments on a weekly basis. Once paid, the employer will not be responsible for any further medical treatment related to the work injury. This agreement is usually possible if you’re no longer working for the same employer with which you were injured.

Employers are usually willing to settle a case if the employee accepts a Compromise and Release because this type of settlement relieves the employer of the obligation to pay future medical benefits. However, an employer will not consider this form of settlement with an employee who still works for them because it doesn’t effectively close the case. The form of settlement that’s best for your situation will depend on the facts of your case. For this reason, it’s important to seek legal advice before settling a claim.

If a cumulative injury claim is brought against multiple employers, a compromise and release settlement may allow an employee to enter into an agreement with one of the employers concerning the part of the claim that’s the employer’s responsibility, and then pursue the rest of the claim against any other employers.

If a settlement is not possible, then the case will have to go before an administrative law judge.

The State of California encourages parties involved in workers’ compensation cases to discuss and settle the case out of court. However, some cases cannot be resolved through negotiation and need to go to trial before the Workers' Compensation Appeals Board (WCAB). In this case, the injured employee must file an Application for Adjudication of Claim with the WCAB within one year of:

• The date of injury,
• The last date on which medical benefits were paid, or
• The last date medical treatment ended.

Generally, the one year limitations period for adjudication is tolled if the employer voluntarily provides benefits, including temporary disability benefits or medical treatment since the employee might rationally assume that the claim is undisputed. But if the employer denies the claim, the time period in which an application for adjudication is filed is no longer tolled since the employee will not have the assumption that the employer is not disputing the claim. It’s also worth noting that filing the claim form tolls the time limit until the claim is denied.

After a review, the Worker’s Compensation Appeals Board will add a date of filing and a case number to the application and then send a copy to the injured employee or the employee’s attorney. If the employee is represented, a copy of the application will be served upon the attorney by an employee’s attorney, but if not represented, the Worker’s Compensation Appeals Board will serve the application. The employer will have 10 days after service to file an answer.

The parties may then engage in discovery, which must be completed before the mandatory settlement conference. This helps prepare for a contested hearing. Before proceeding to a hearing, the injured employee is required to file a Declaration of Readiness to Proceed with the Workers’ Compensation Appeals Board pursuant to Labor Code 4906 (g). The board will then schedule a mandatory settlement conference to encourage further discussions. The workers’ compensation referee or judge who presides at the conference has the authority to issue a stipulated finding and award or approve a compromise and release. If no settlement is arrived at, the judge will determine disputed issues that can be resolved in a contested hearing. The employee and employer must each file pretrial statements indicating the specific issues in dispute, the witnesses who’ll testify, the exhibits that will be introduced into evidence, and the proposed permanent disability rating of each party.

A hearing must be held within 75 days of filing the declaration of readiness. The judge will consider evidence provided by each party about disputed issues. Evidence might include reports prepared by a qualified medical evaluator, the P&S report, reports by other physicians, the injured employee’s testimony, the testimony of other witnesses, reports of vocational experts, and hospital records. An examination by a qualified medical evaluator may also be requested by the Workers’ Compensation Appeals Board if it will help resolve disputes about certain medical issues.

The workers’ compensation judge will decide the disputed issues after reviewing the evidence. The judge will decide if the injury sustained is compensable and, if so, the amount of compensation that the employee should receive. The judge must issue the decision 30 days after the trial has ended. From that point, the case is considered “submitted” to the Workers’ Compensation Appeals Board. If either party is not satisfied by the decision, they can seek review of the decision in an appellate court. This review does not include a second trial.

The review does not address the correctness of any factual finding but instead, it looks at the lawfulness of the order given by the Appeals Board. The appellate court will not second-guess the decision made by the Workers’ Compensation Appeals Board although it can determine if the facts used are supported by substantial evidence.

The appellate court in most cases is asked to determine whether the board misapplied the law when deciding the case. The hearing and appeals are subject to strict time limits and evidentiary and procedural rules. Taking the right steps well in advance before filing for adjudication will better position you to prevail.

How long the workers’ comp claim process will take will be determined by several factors, including how quickly your employer accepts responsibility, the time that the insurance company will take to authorize treatment, and how quickly you recover. In general, a case can be resolved in 6 months to 6 years. But when you work with a competent Los Angeles workers’ comp attorney, your case can be resolved faster, typically within a year.

Workers’ compensation law has complex language and the paperwork for your claim will include unfamiliar abbreviations, terms, titles, and concepts. This means that there are too many things to consider, too many things to know, too many rules to follow, and too many time limits to worry about. Filing the claims documents may come off as a bit intimidating and can be quite stressful. What’s more, insurance companies take advantage of these complexities and use them to delay and deny benefits to injured employees. For this reason, it’s important to hire a skilled and experienced attorney.

At Workers Compensation Attorney Law Firm in Los Angeles, our lawyers can guide you through the minefields and obstacles of the workers’ compensation process. We also play a role in ensuring that you get proper medical treatment. We represent injured employees in the Los Angeles County area. We take pride in our ability to resolve a host of workers’ compensation cases and helping our clients steer their worker’s comp claims to a successful conclusion.

Let us discuss your case and evaluate your claim free of charge. Call our Los Angeles work injury lawyer at 310-956-4277 or fill out our online contact form to schedule an appointment or to learn more about how we can help you with your claim.