Understanding the Workers’ Compensation System

In California, if you get hurt or sick on the job, your employer is required by law to carry Workers’ Compensation insurance and to provide workers” compensation benefits to you. The most important basic benefits are medical care, temporary disability benefits, and permanent disability benefits.

Are my employer and the insurance company working on my side to make sure I receive the maximum amount of worker’s compensation benefits?
Your employer and the insurance company have to provide you with some basic benefits under the law. However, they have an interest in providing only the basic benefits required by the law because they want to save money. They are not “on your side” and they know how to use the laws in their favor.

Instead of making sure a claim is filed and that the injured employee is cared for immediately, they may ignore an injury. And if they do accept your claim, they will often move quickly to accept the first medical evaluation performed by a doctor that the employer’s insurance company has chosen! The injured worker most times doesn’t know that he or she has the right to an objective evaluation and how to obtain one that is truly objective.

Do I need an attorney to help me enforce my rights?
An attorney can help you obtain the care and treatment you need to treat your injury and to maximize the value of your case.

Even thought the workers compensation system should be easy and fast, it often is far from that. Many injured workers are confused by the process that buries them in rules and paperwork so that they never get the money and medical care they are entitled to receive.

Although you are not required to hire an attorney, it helps to have somebody who knows the system and who has dealt with the insurance companies, the adjusters and the courts. An attorney can make the confusing and difficult process easier so that you and your family can deal with your injury.

What should I do if I am injured at work?
Report your injury to your supervisor immediately! Your employer is required by law to provide you with a claim form (DWC-1) within 24 hours after you report your injury.
Remember, during the first 30 days your employer controls your medical care and directs you to a health care provider. After that 30 days, you have the right to go to any doctor on the employer’s medical provider network (MPN) or, if the employer has no MPN to a doctor of your choice.

Can I get fired if I file a claim for a work injury?
It is illegal for your employer to fire you based on the fact that you filed a work injury claim and you should consult an attorney. However, if you are fired because you filed a claim, you have one year to take action in the workers’ compensation court system to obtain back pay, benefits, and penalties against your employer.

When I File a Claim, When Will I Receive Money if I Cannot Work?
The insurance company can take up to 90 days to decide whether to accept your claim. No payment is due to you until that decision is made. But, during the time it takes to accept or deny your claim, the insurance company is responsible for paying up to $10,000 for reasonable medical treatment. If your claim is denied, you should consult an attorney.

What Kind of Money am I Entitled to?
Temporary disability: If your claim is accepted, temporary disability payments will act as a wage replacement while you can’t work due to your injury. “TD” pays you two thirds of your wages you were earning at the time of your injury. Some employers have programs to make up the other third and some employers might use your vacation or sick leave time. You are limited to 104 weeks of TD within 5 years from the date of your injury. You do not receive TD if your employer has modified duty for you or if the doctor says you have reached “maximum medical improvement” which means you have fully recovered from your injury or your medical condition has reached a point that no major medical (or emotional) change is expected.

Permanent Disability: Once you have reached “maximum medical improvement” a doctor will evaluate you and provide a “whole person impairment” number. Based on that number, once it is put into a formula, your permanent disability will be worth a certain dollar amount.

When and How Does My Worker’s Compensation Case End?
Once your permanent disability value is determined, your case can settle. There are two ways a case can settle and both require a workers’ compensation judge to approve the settlement.

Compromise & Release (C & R) closes your entire case forever. It is a one-time lump sum payment. It settles your permanent disability amount and provides money for any future medical treatmen the evaluating doctor says you might need. Usually a C&R is used if you no longer work for the employer you had when you were injured.

Stipulations and Request for Award (Stip) pays your permanent disability in every other week payments and allows you to continue to receive medical care for your injury through the workers’ compensation insurance company. Also, if you get worse because of your injury, you can file a petition to reopen your claim as long as you are within 5 years of the date of your the original injury.

I would be happy to assist you with your claim and to bring to your case my education in the law, my “inside information” about how employers and insurance companies think, and my many years working as a registered nurse.

* These questions and answers do not constitute legal advice and do not create an attorney client relationship.