Workers' Comp Basics
COMPENSATION - Types of compensation include:
Medical Treatment = all necessary treatment to recover from an injury, with no deductibles and no maximum dollar limitation (whether you keep working for the same employer or not)
Temporary disability = payments for lost wages caused by the injury; paid at 2/3 of average wages, tax free
Permanent disability = payments for permanent disability or body impairment
Retraining assistance = receive a $6000 voucher to spend at a school you choose
Death benefits = cash payments for dependents, if a worker dies from the effects of a work injury
It does not matter who was at fault in causing the injury, or if no one was; a work injury is covered by California law. However, if a work injury is caused by an outside company or person, you may have a personal injury suit against that party in addition to your work comp case against your employer's insurance company.
For a valid worker’s compensation claim all you have to show is:
You were injured.
While on the job.
California law covers physical and psychological injuries. Symptoms may develop after work hours or a day or two later, but the injury is still covered if the symptoms were caused by activities or exposures at work.
Injuries can be "specific" or "cumulative". A specific injury happens in a moment, like a fall that breaks a bone. A cumulative injury develops over months or years from repetitive movement or stress, like wearing out a knee from constant kneeling or crawling.
All legal cases have time limits. It is important to report an injury to your employer as soon as possible. Your employer should give you a claim form (DWC-1) to fill out, describing the injury. That form should go to the insurance company.
If an injury is disputed by the insurance company, there will be strict time limits to take action or you may lose all of your rights. A written "Application" starts a case with the worker's compensation court system and stops the time limits from running against you. Even if some benefits are provided, failure to take certain legal actions may be a legal waiver of your rights to other benefits. Each case is different, so an analysis of legal time limits for your specific case is important.
Most insurance companies have networks of doctors for treatment of work injuries. When an injury first occurs, an employer or insurance company sends the worker to an industrial clinic. These clinics are frequently pressured by the insurance company to minimize medical expenses and force an employee back to work prematurely after an injury. However, after 30 days from an injury, the worker can and should change treating doctors to one whose priority is the patient and not cost containment. This means looking up doctors on the MPN (insurance network) (Some exceptions allow the employee to change doctors before waiting 30 days. Ask an attorney if you qualify.)
QME (QUALIFIED MEDICAL EXAMINER)
A QME doctor does not provide treatment, but gives very important opinions about legal and medical issues in a work injury case. They can determine whether a medical condition or injury was caused by work, which parts of the body are involved, and whether the worker is entitled to temporary and permanent disability payments.
It is very important to seek legal advice before you start the process of obtaining a “QME” list or selecting a physician from the QME list to evaluate your case. Not all QME doctors are fair to injured workers. Many are cozy with insurance companies. Do not let the insurance company pick the QME before you act to protect yourself. It is critical that the injured worker take control of getting a good QME doctor, before the insurance company does.
An attorney can give you critical strategies to get a good QME doctor and to avoid a negative one.
Workers’ compensation attorneys work on what is known as a “contingency” basis. This means that they will not get paid unless you successfully obtain compensation. If you do not obtain compensation, you owe the attorney nothing for their efforts.
We do not charge for an initial attorney consultation. The client does not pay upfront money to retain us. A judge will order the insurance company to pay your attorney out of a settlement or award; generally 15% of the money recovered.
Even though California laws are supposed to protect the injured employee, it might be an expensive mistake to trust an insurance company without talking to an attorney. Workers’ compensation in California has become very complex, with many procedural requirements, nuances, time limits and special forms. A common mistake is to give up because the insurance company said your claim is not covered. Always talk to an attorney to get an objective, honest opinion. The insurance company will try to save money by hoping you just go away.
You need an experienced workers’ comp attorney who knows the law and knows how to present the evidence that can prove all aspects of your case.