Workers' Comp In-Depth

The basic idea of workers’ compensation insurance is simple: if you are injured on the job or while performing work-related duties off the job site, your employer’s workers’ comp insurer must cover you for your injuries and loss of income. But the details of what kinds of benefits are available, how to successfully apply for them, and when you can return to work following an injury are far from simple.

We will look at all this and more in the article below, but first, here is a quick summary of the basic benefits available under workers’ comp:

• Reimbursement for all medical care provided to treat the work-related injury or medical condition.
• Temporary disability (TD) benefits to pay for your recovery period.
• Permanent disability (PD) benefits to pay for permanent injuries and the loss of earning ability that they cause.
• Supplemental displacement benefits, which is a voucher that helps to cover the costs of job retraining or skill enhancements made necessary by permanent disability.
• Return to work supplement program benefit, which is a one-time payment when you return to work.
• Death benefits, payable to the one’s spouse or other loved ones after losing his or her life in a workplace accident or due to an illness caused by working conditions or activities.

You may not realize it, but it’s not always allowed to use just any physician or medical service for treatment of conditions covered under workers’ comp. For non-emergency visits, you need to have already predesignated a doctor or medical group ahead of time to be used in the case of a work-related injury. This pre-designation has to be done in writing: a mere verbal agreement won’t count.

Also, the rules for pre-designating a doctor are different if your employer or his insurance company has a contractual agreement with an HCO. Your employer must provide you with a form to request a specific doctor if you wish, but if you fail to fill it out and turn it back in, then you can be enrolled automatically in the HCO and will have to see an HCO-network doctor instead.

However, if you are in need of emergency or urgent medical care, you can call 911 or visit an ER. It will be covered by workers’ comp regardless of which hospital or provider you use. You should be sure to inform the caregiver, however, that your injury is work-related so the proper paperwork can get underway without delay.

You should immediately report any work-caused injury to your employer. The sooner you do so, the faster your case can move. Within 30 days of the injury or the date of discovery of the injury, you need to file form DWC 1. Your employer is required to give you this form or mail it to you within one business day of your reporting your injury and requesting the form.

You fill out only the employee section of the form. You will need to give a full description of the injury and mention any other details that may affect your claim. The form must be filled out fully and correctly to avoid possible delays, and you turn it in directly to your employer. After filing the form, your employer fills out the remaining sections of it and turns it in, to workers’ compensation claims administrator, who will handle your claim.

If the claim administrator does not respond within 90 days, your claim will be treated as if accepted. But you do not have to wait 90 days for treatment: you can receive up to $10,000 in insurance-covered care even before a decision is made. If your claim is denied, you will need to file an appeal. As soon as you receive a denial letter, you should contact a good lawyer and get started on the appeals process so you won't violate any deadlines and lose your right to appeal.

You should not worry about your employer firing you or otherwise punishing you for filing a workers’ comp claim. That is illegal and can be grounds for fines and a discrimination lawsuit. It is also illegal for coworkers to be fired or punished for testifying in your behalf if the case goes to trial. Additionally, you are permitted 12 weeks of leave without losing your job anyway under federal and state-level legislation.

Finally, to ensure your claim stays on track, it is essential to keep good records. This means keeping a copy of the claim form you filed and of all other important forms you file throughout the process. It also means keeping detailed financial records of doctor’s bills and of all expenses arising from the work-related injury. You should also consider writing down everything you remember about the work condition and the cause of your injury and its nature and severity as soon after the accident as possible. Then keep a diary of your recovery process as well. These kinds of notations can become valuable evidence if a case goes to trial or even during a settlement process.

You should not have to pay the medical bills for a work-related injury or illness. That is the job of your employer through his workers’ compensation insurer. Let it be understood: the claim administrator should be paying all the bills so that you never even receive a medical bill in the mail. It is an unlawful act for the doctor or hospital to bill you if they are aware of the fact they treated a workplace injury. That’s why you need to inform them of that fact when you are treated so there will not be any mix up on this point.

All medical care that is “reasonably required” for the alleviation or cure of the injury is to be covered. There are officially published medical treatment guidelines issued by the state of California that doctors are to use to understand which treatments are and are not covered. Once a doctor recommends a treatment not in the official guidelines, however, it can still be covered. The doctor must inform the claims administrator, and then an obligation will arise for the funds to be disbursed in most situations.

There are some limitations to the medical care you can get as benefits. For example, chiropractic care and certain types of therapy may have caps on them. Normally, you can only have 24 visits covered for this type of treatment unless additional visits are authorized due to an evident need.

Again, you can get emergency care of up to $10,000 immediately, but for non-emergency care, you have to get it authorized by the insurer. You can ask for even non-emergency treatments to be authorized before the claim is approved, and it’s possible the insurer will agree if it’s deemed a reasonable request. You can appeal decisions of the claims administrator or even get a second opinion from a different doctor if your current doctor won’t approve a treatment you believe is necessary.

In most cases, you will apply for temporary disability (TD) benefits once your doctor confirms you are unable to perform your normal work duties due to the injury. If you are unable to work at all, then you can get temporary total disability benefits to replace lost wages; if you can work but not to the pre-accident level, then you may receive temporary partial disability benefits.

The benefits will equal two-thirds of your lost wages, with wages being based on the average of your pre-accident income. This income is not taxable, and you receive payments every two weeks until you fully recover. Also, realize that you can get TD benefits for two jobs or seasonal work if applicable, and if your wages rose or fell significantly not long before the injury, this can complicate the calculation of your income (and a good lawyer will be needed to ensure the calculation is done fairly.)

If you are approved for TD benefits and the payment is delayed through no fault of your own (all your paperwork was done properly and on time), then there is a penalty against the insurer so that they must add an additional 10% to your first payment. In more extreme cases of delay, you could get as high as 25% extra on multiple payments.

If you are able to work but not at full capacity, your physician will send a set of work restrictions with you, which the insurer and employer must be made aware of. If the treating physician declares you are unable to work at all, for the time being, you cannot do so even if you want to or think you are up to it. That would not only be a medical risk but could risk your workers' compensation benefits as well.

Permanent disability (PD) benefits exist because injured workers do not always 100% recover to the point they can perform at pre-injury levels. When you treating physician for a workers’ comp covered injury gives his or her opinion that you have a permanent disability, then you are qualified to receive PD benefits of some kind. Once your condition is considered permanent, in part at least, in the P & S report and you are deemed to have reached your MMI (maximum medical improvement) level, it’s time to consider seeking PD payments going forward.

The P & S report forms the basis for the disability rating, which is a percentage telling to what extent your injury prevents you from performing your ordinary work duties and affects your life overall. You have the right to challenge the P & S report and/or the disability rating, and a good lawyer can help you do so successfully. Note that it is rare for a PD rating of 100% to be issued except in very extreme cases such as paralysis. Most cases get only TD and not PD benefits, and when PD benefits do apply, it’s normally between 5% and 30% on the disability rate, which then multiplies by your former average income to determine the dollar amount you receive in regular installments. Experienced workers’ comp attorneys can fight to increase your rating to the maximum possible, and even a small increase can make a big difference in the long run.

If you are currently getting TD benefits, then your first PD  benefit would come within two weeks of the TD benefits ending. And if you are not getting any benefit now, then the first PD benefit would come two weeks after the insurer learns of your work-caused permanent disability. You only get benefits for a set number of weeks, in two-week intervals, the time limit depending on the type of disability you have. However, a total permanent disability makes you eligible to keep getting PD benefits for life. If you are offered a job by your employer at 85% or more of your former wage, or a job by another employer at 100% or higher of your pre-injury wage, then you have to wait for workers’ comp judge to decide on your benefits before receiving anything. Otherwise, you can get advance payments.

Most cases end up settled so that you get a lump sum amount at some point. If this occurs, the lump sum is reduced by the amount you have already received in PD benefits. If the payments come late, you could get awarded a 10% or 25% bonus, depending on how late they are.

There are two major ways PD benefit settlements can proceed: by a stipulation and request or compromise and release program. With stipulations and request, you agree on how long to receive a specified bi-weekly PD benefit. The insurer must continue to pay for your medical care expenses from the injury so long as they are needed. This approach leaves the possibility of benefit amounts changing (up or down) in the future as the situation demands. As far as 5 years after the injury, you can request an increase in benefits to meet rising medical needs; but the employer can request to have the reduced if your medical condition improves so that your medical bills reduce.

Under compromise and release, the other major PD settlement type, you get a single, lump-sum payment. This simplifies matters and brings closure to the matter, but it disallows changes to the benefit later on in most instances. A settlement is negotiated out between your lawyer and your employer's insurance company. The judge will not usually approve the settlement unless an experienced workers' comp lawyer is representing you and the settlement seems reasonably fair to you.

Regardless of whether your disability is temporary or permanent and what other benefits you are getting from workers’ comp, you can still qualify for supplemental job displacement benefits. This benefit consists in a “voucher” that will foot the bill for education, training, and other costs of enhancing your skills set following a work-related injury so that you will be able to make a good living going forward in life. A job placement agency and back to work counseling services are also covered by this benefit up to a $600 limit. And a thousand dollars can be used to buy computer equipment and $500 for other miscellaneous job-retraining related expenses. You can get up to $6,000 total under this program - and the amount is not based on your disability rating.

To get this benefit included in your overall settlement, you have to have a permanent partial disability. Your current employer must have failed to offer you your old job, a modified position or alternative work 60 days after his insurer received a return to work report concerning you from your doctor. If you have not heard from your employer or his workers' comp claims administrator for some time despite being ready to return to work, be sure to contact them and to talk to us to get this process on track. Your employer doesn't have the right to ignore you till it basically is equivalent to firing, so act quickly to get a job offer or to get supplemental job displacement benefits.

The voucher lets you get retrained at a California public school or at another school that is approved for this state-run program. You can find the list of eligible educational institutions by clicking this link. Simply show your voucher to your desired school or employment counselor so the school can contact the insurance company to receive the actual payment for your tuition. You can also pay for the school bills and other eligible expenses yourself, keep the receipts, and then get reimbursed later by presenting your voucher within 45 days of the payment. Also, the voucher has to be used within 24 months of receiving it or within 5 years of the date of your injury or it becomes invalid. Thus, you want to move as quickly as possible to get started on your retraining efforts before the benefit expires.

In addition to all the other workers’ compensation benefits mentioned above, there is another benefit that was started in 2015, called the return to work supplemental program. This is a one-shot payment to injured workers who return to work but see their post-accident income level drop significantly. Many people injured from 2013 on and who have been eligible for the supplemental job displacement benefit also qualify for the return to work one-time benefit. You have to apply for this benefit, however, within a year of receiving your job displacement voucher or you could risk losing eligibility for it.

You can apply for the return to work supplement in only one place - online, at the following website link. You can use an Internet-connected computer at a local Department of Workers’ Compensation office if you don’t have access to one or if you are unsure how to apply and need help from an expert assistant. You also have the right to use the printer and scanner in the office so you can upload documents in the application process and print out a copy of the application for your records.

If your application is accepted, you will normally receive a lump sum payment of $5,000 to help make up for your loss of income as you first get back to work. If your application is rejected or you receive a smaller amount and think you should have gotten the full amount, don’t hesitate to contact a good workers’ comp lawyer so the issue can be clarified and resolved.

While we have gone somewhat in-depth in the above sections on how California’s workers’ compensation systems and benefits work, there is obviously much more involved. Being well informed and having a knowledgeable workers’ comp lawyer fighting on your side from beginning to end is key to receiving your maximum benefits, getting your old job back or an adequate new job, and ensuring the process is navigated without undue delays. At Workers’ Compensation Attorney, we make sure your rights are protected every step of the way!

Don’t hesitate to contact us for immediate help and a free, no-obligation consultation anytime 24/7 by calling 310-956-4277!