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If an employee is injured on the job, they should report the injury to their employer as soon as possible and seek medical treatment. The employee may file a claim for workers' compensation benefits with the California Division of Workers' Compensation.
AREAS OF LAW > WORKERS' COMPENSATION
Work Injury Claims In California
What is workers' compensation?
Workers compensation is a program that provides benefits to certain workers or their dependents who suffer a work-related injury or disease. Workers’ compensation benefits may include
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wage replacement,
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medical treatment,
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vocational rehabilitation, and
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other benefits
This country's workers' compensation system evolved quickly after the turn of the 20th century. Along with the industrial revolution came bigger, faster, and more complex machinery and many more workplace hazards. Congress passed the Workers' Compensation Act for federal employees in 1908. Each state has passed workers' compensation laws providing workplace injuries and illness benefits.
While the workers' compensation program is national, the states are responsible for implementing it, which means that important aspects of the program vary according to the laws of your state.
These laws were initially put in place to balance the rights of workers and employers and provide a way to settle differences quickly and privately. Both the employer and employee give up some legal rights under the workers' compensation laws of the various states. The employee gives up the right to go to court and sue his employer for on-the-job injuries which, in some states, could be for unlimited amounts of damages (although many states have passed laws capping the amount of damages). Instead, the worker is entitled to receive a definite award, based upon fixed maximums set by the various states.
In return, employers give up the right to deny responsibility due to potential negligence by the employee that may have contributed to the injury. The workers' compensation systems are considered "no-fault" systems. Employers finance the system primarily through insurance premiums, although in some states, companies may self-insure, which means that they pay all claims themselves.
What types of injuries are covered?
There are four different types of work-related injuries that qualify for workers’ compensation. You may be eligible for compensation for any of the injuries listed below:
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Any physical injury on the job, which can include exposure to dust, toxins, hearing loss caused by workplace and repetitive motion injury - such as carpal tunnel.
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Preexisting conditions that the workplace accelerates or aggravates. Examples may include a back injury, even though you do not notice the pain from the injury until later.
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Injuries caused during breaks, lunch hours, and work-sponsored activities (such as a company picnic), and at-work injuries caused by company facilities, such as a chair in the company lunchroom.
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Injuries resulting from mental and physical strain brought on by increased work duties or work-related stress. In some states, this includes employees who develop a disabling mental condition because of the demands of the job and a supervisor's constant harassment. Mental distress caused by something other than an initial physical injury is sometimes excluded from workers' compensation completely, depending on your state.
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Employer's Responsibilities
Q. What the employer's responsibilities under California workers' compensation laws?
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A. Your employer's responsibilities start before an injury even happens, your employer must:
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Purchase a workers' compensation insurance policy or apply to become self-insured
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When hiring new employees in California, your employer must provide a workers' compensation booklet that explains in detail the employee's rights and responsibilities
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Post a workers' compensation poster in a location where all the employees can see it.
After an injury on the job, your employer must:
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Provide a workers' compensation claim form to the injured employee within one working day immediately after a work-related injury
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Return a completed copy of the claim form to the employee within one working day of receipt
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Send the claim form, along with the employer's report of the work injury to the workers' compensation claims administrator within one working
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Within one day of receiving your work injury claim, authorize up to $10,000 in medical expenses to treat your work injury
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Provide any type of work accommodations so the employee can work while being treated.
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If you are the victim of a crime that happened on the job, your employer must provide you with a notice of workers' compensation eligibility within one working day after the crime occurred.
Q. Is my employer allowed to take part of my paycheck to cover workers' compensation premiums?
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A. No. Workers' compensation insurance is part of the cost associated with doing business. Your employer cannot ask employees pay for the insurance fees.
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Q. Isn't there supposed to be a workers' compensation notice posted at my workplace?
A. Yes. Your employer must post the workers' compensation notice to in a visible place where all the employees can see it. This poster provides employees with information on workers' compensation coverage and where to find help in the event of an injury. If your employer fails to post this notice it is considered a misdemeanor that can result in a civil penalty of up to $7,000 per violation.
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Q. What happens if my employer is does not have workers' compensation insurance and I'm injured on the job?
A. If this is the case, your employer is breaking the law. Failing to have workers' compensation insurance is a misdemeanor punishable by either a fine of up to $10,000 or imprisonment in the Los Angeles county jail for up to one year, or both. Additionally, the state of California issues penalties of up to $100,000 against employers who fail to provide workers' compensation insurance to their employees.
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If you have a work-related injury and your employer does not have workers' compensation insurance, your employer is responsible for paying all bills associated with your injury.
If your employer fails to provide you with workers' compensation insurance and you have a work-related injury, you have the right to file a civil action against your employer. After filing a civil lawsuit against your employer you can still file a workers' compensation claim.
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Your workers' compensation attorney can file a claim on your behalf with the state's Uninsured Employers' Benefit Trust Fund (UEBTF).
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Q. How does the Uninsured Employers' Benefit Trust Fund work?
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A. The UEBTF is a special department within the Division of Workers' Compensation that may pay benefits to injured workers who get injured on the job. The UEBTF goes after employers to reimburse all medical bills associated with your work injury.
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Q. What type of medical treatment will I receive for my injuries when I use my workers comp benefits?
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A. Doctors in California's who work the workers' compensation benefits are required to treat your injuries based on standard of care available. That means they must select the best medical treatment proven to cure your work-related injury.
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To make sure Doctors adhere to these medical standards of evidence-based medical treatment, the state of California has a medical treatment utilization schedule (MTUS) in place. The MTUS serve as a guide to treat specific body parts adopted from the American College of Occupational and Environmental Medicine's (ACOEM) which include practice guidelines for acupuncture, chronic pain and rehabilitation after a surgery. The DWC has a committee that evaluates new medical findings about best treatment practices and incorporates that evidence into its guide.
Q. Are these guidelines applicable even if my workers comp case has settled?
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A. This guidelines are considered valid even in workers comp cases that settled prior to the the guidelines being implemented to workers' comp law in 2003. Your workers comp lawyer will coordinate with the claims administrator to continue to pay for medical treatments for your work injury.
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If your medical treatment has been rejected you can ask your workers comp lawyer to request an expedited hearing before a workers' compensation panel to get the issue resolved. Your corkers comp lawyer is experienced in these type of scenarios and will be able to seek the best course of action.
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Q. The claims coordinator hasn't approved or rejected my workers comp claim , but I need medical treatment for my work injury right now. What do I do?
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A. Your workers comp lawyer will make sure that your medical treatment is approved within one working day after you file a workers comp claim form with your employer, even while your claim is being reviewed. The total cost of the treatment provided while your claim is under review is limited to $10,000. In the event your workers comp claim is not authorized, you must speak with your supervisor at work about the law requiring immediate medical assistance. your workers compa lawyer will also assist you to get the medical treatment authorized now, while your case is under review.
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Q. Are there any limits on the types of medical treatment I can receive?
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A. Yes there are some limits. If work injury took place in 2004 or later, you are limited to a 24 chiropractic treatments, 24 physical therapy treatments, and 24 occupational therapy visits. Any additional treatments that go beyond these limits must be authorized by the claims administrator.
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Q. How long am I allowed to receive treatment for?
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A. You may receive medical treatment for as long as it's necessary to treat your injury. There are some treatments that are limited by law and the medical treatment you receive must be absolutely necessary based on your treatment plan.
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The MTUS has a set of guidelines scientifically proven to treat work-related injuries. It also specifies the length of time and the frequency, among other things.
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If your doctors decides that your treatment goes beyond what is recommended by the MTUS, your doctor must use evidence to show the treatment is absolutely necessary to treat your work injury.
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Your doctor's medical treatment plan may be reviewed by a third party selected by the workers' comp claims administrator. This process is referred to as utilization review (UR). All workers comp administrators are required by law to have a UR program and they use these to determined if additional treatment is necessary.
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Q. What does utilization review mean (UR)?
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A. UR is the set of guidelines the workers' comp claims administrators use to make sure the medical treatment treatment you receive is necessary to treat your injuries. All workers comp administrators in California are required by law to have a UR program. This guide is used to determine whether or not to authorize medical treatment suggested by your physician.
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The state of California has specific rules about how UR must be used and if you feel. If you believe your doctor's plan is not following those rules your workers' comp lawyer can file a complaint with the DWC.
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Q. If my doctor's treatment isn't authorized, what are my options?
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A. There are timelines you must meet to avoid loosing your rights. This is why is important to work with a qualified workers' comp lawyer who is well versed in California workers' comp laws. As of July 1, 2013, medical treatment disagreements for all dates of injury must be sorted out by physicians through the process called (IMR) which stands for "independent medical review". If UR does not approve your doctor's request for treatment because the treatment is not necessary, your workers' comp lawyer can file a petition for a review through IMR.
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Q. What happens if the claims administrator does not pay for my treatments?
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A. In this situation, your doctor and the claims administrator need to reach an agreement, it's very unlikely that you'd have to pay for the treatment.
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Q. Can you explain what a medical provider network is?
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A. (MPN) is a group of selected medical professionals set up by your employer's workers' comp insurance and approved by DWC's director to treat employees who were injured on the job. Each network has a different doctors specializing in work-injuries and physicians with who specialize in general medicine.
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Q. What's a health care organization?
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A. (HCO) is an organization certified by the DWC to provide managed medical treatments to injured employee who have been injured on the job.
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Q. Who is a primary treating physician (PTP)?
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A. (PTP) is the physician who has the main responsibility to monitor your treatment. Usually, your employer chooses the PTP on your behalf and this will be the doctor you will see the first 30 days of your treatment.. If a our doctor determines that you still need to be treated after 30 days, you may be allowed to to change to the doctor of your choice. There are different rules that apply depending on wether your if your employer is using an HCO or a (MPN).
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Q. What does predesignating a personal physician mean?
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A. This is an option where you tell your employer you want to use your personal physician to monitor work injury treatment. You can select or "predesignate" your personal doctor (M.D.) or a doctor of osteopathy (D.O.) only under the following conditions:
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A written notice must be submitted selecting the employee's personal physician group is to the employer prior to the date of injury for which treatment is required, the written notice must include the doctor's name and address;
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The employee has healthcare benefits for non-occupational injuries on the date of injury; and
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The employee's personal doctor agrees to treat the employee prior to the date of injury.
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Q. I would like to be seen by my own chiropractor or acupuncturist. Is this possible?
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A. If your employer doesn't have a MPN, you may request to change your treating doctor to your personal chiropractor or acupuncturist to treat your work-related injury. You must provide your employer with the name and address of a personal chiropractor or acupuncturist by submitting a written request prior to the injury.
If your injury occurred on or after Jan. 1, 2004, a chiropractor isn't allowed to be your treating doctor after 24 chiropractic treatments. Once you have received 24 treatments if you still need medical treatment, you will have to choose a new doctor who issn't a chiropractor.
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Q. Does the 24 limit on chiropractic visits apply to all workers' comp cases?
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A. The 24 visit limit rule does not apply to injuries that took place before Jan. 1, 2004. Also, the limit does not apply if your employer authorizes more treatments in writing. Additionally, the limit doesn't apply to visits for specific post-surgical rehabilitation treatments.
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Q. What happens if I don't agree with the MPN doctor's treatment plan?
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A. You can change to another doctor on the MPN network. You can also request for a 2nd and 3rd opinion from different doctors. If you still not in agreement, you can have an IMR to sort out the dispute.
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Q. What if I don't agree with the MPN doctor's opinion about my ability to go back to work?
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A. If you disagree with your doctor's decision on wether or not you should go back to work or any other issues other than diagnosis or treatment, you must ask your workers' comp lawyer to request a qualified medical examiner (QME).
Q. What happens if the MPN doctor's request for treatment is rejected by the worker's comp claims administrator?
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A. If you disagree with the claims administrator decision, you must sign and submit this form to begin the IMR process.
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Q. Who determines what type of work I perform while recovering?
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Your treating physician is responsible for putting together a medical report with the following information:
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The kind of duties you can perform on the job while recovering from your injuries.
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The accommodations needed in your schedule or duties.
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You, your treating physician, your employer and your workers' comp lawyer should assess your job description and talk about the changes needed in your job.
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If you do not agree with your treating physician, you must immediately write to the workers' comp claims administrator the reasons of your dispute.
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