After being injured at work your primary concerns should be getting the medical care and rest you need to recover fully. However, the complexity of the worker’s compensation system in the United States can cause significant stress and uncertainty. The state of California has a significant number of requirements, guidelines, and laws that are focused on protecting the rights of injured workers. This article will summarize the guidelines provided by the State of California Department of Industrial Relations (DIR) the agency that is focused on workers’ compensation laws. The full set of guidelines broken down into chapters can be found on their website. This article will discuss the basics of workers’ compensation in California and summarize the information provided by the DIR.
Workers’ compensation may cover any injury or medical condition that is the result of a single workplace incident or multiple repeated minor injuries or exposures. Workers’ compensation is a general term that refers to:
Workers’ compensation does not exclusively cover workers that are employed and get a W-2 from a company. Many other types of contract, temporary, and conditional workers are also covered. If you sustain an injury at work ***
One of the most important things to understand about workers’ compensation is that there are many people involved in every decision. A primary doctor, medical specialists, a specialized insurance company known as a claims administrator, your supervisor, and possibly lawyers will all be closely examining the details of your injury, medical care, and recovery. In the following sections, we will discuss each of these individuals’ contributions to your care in detail.
If you have a sudden and serious injury at work you must follow these steps.
After these steps are followed your supervisor is required to provide you with a claim form in person or by mail within one working day. Fill out and return this form as soon as possible. This form will then be provided to a claims administrator, a company that is responsible for coordinating all medical care, payments, and job modifications related to workplace injuries. They have 90 days to either accept your claim, deny your claim, or ask for additional information. This decision must be made within 90 days.
Non-emergency injuries also go through a similar process. The key difference is that going to an emergency department or urgent care is not always the best first step. Contacting your supervisor, reporting the injury, and filling out the form describing your injury should be done first. The claims administrator will then direct you to a specific physician to begin examinations and treatment for your injury.
In the event of a work-related injury employers in California are legally required to provide, free of charge, all medical care that is “reasonably required to cure or relive” the injury that the employee sustained.
The process of obtaining medical care for a work-related injury is more complex than a typical doctor’s appointment or emergency room visit. If you had a serious injury that required an ER visit, you would have to follow up with a specific doctor or group of doctors that contract with your jobs claims administrator. If you have an injury that is not an emergency, your first visit will be with a doctor provided to you by your claims administrator.
There are several terms you should be familiar with that will be frequently used by supervisors, lawyers, and doctors in relation to your medical care under workers’ compensation.
Medical treatment utilization schedule (MTUS): A handbook that is used to determine what sort of care, studies, and follow-up is recommended for a specific type of injury. It can be reviewed at the Department of Industrial Relations website.
Medical provider network (MPN): A network of medical providers that your claims administrator uses to provide medical care for work-related injuries.
Health care organization (HCO): Similar to an MPN but structured differently. How you get care, transfer between doctors, and seek approval to see doctors outside of the network will differ under an HCO and MPN.
The benefits of this system are that all care is free of charge to the injured worker. Seeing a doctor that your claims administrator chooses can simplify documentation requirements, minimize paperwork, and ensure that bills are not accidentally sent to you when they are your employer’s responsibility.
Most people who have a regular doctor trust and prefer that doctor. Being forced to see another doctor you do not have a relationship with can be offputting and uncomfortable. Since the claims administrator chooses the doctor, some people are also concerned that the doctor may minimize the severity of the injury or otherwise be unfair to the injured worker. These situations are rare, but extremely difficult to detect or prove. Later in this article, we will discuss some of the rights you are entitled to and what to do if you feel that your medical care is inadequate or unfair.
If you want the legal and financial protections of the worker’s compensation system you must follow the processes outlined by your claims administrator. An option for some workers is a process known as “predesignation.” Predesignation is a legal process where you identify a specific doctor that you wish to provide medical care in the case of a work-related injury. This is not offered at all jobs and needs to be done prior to your injury. You should be provided information about designation if it is an option at your company.
One of the most frustrating parts of workers’ compensation is waiting for approval for medical care, seeking additional care if what you have been provided is inadequate, and dealing with issues surrounding the accuracy and timely delivery of medical reports. There are entire fields of law and medicine that are focused around workers’ compensation. Attempting to understand all of the rules, regulations, and standards of care is impossible for a single individual. Luckily, there are several groups that you can seek help from if you have an issue with the medical care you are receiving.
Some of the issues that people encounter with workers’ compensation are related to poor communication between claims administrators, medical providers, and job supervisors. The most common of these are:
Delayed approvals for care
Receiving bills for care covered by workers’ compensation
Difficulty scheduling appointments around work responsibilities
Being asked to perform forbidden job responsibilities
Feeling unsafe at work due to your injury
If you are encountering these issues discuss them with both your supervisor and the claims administrator. In most cases, they will be open to feedback and will make adjustments to ensure that your needs are met and your plan of care is being followed.
Problems related to the actual medical care you receive can be attributed to overworked medical providers, limited healthcare resources in a given area, or in rare cases, intentional misrepresentation of your health in order to limit the benefits that you receive. These issues may result in the following:
If you have any of these issues or concerns about your care bring them up with the primary doctor that your claims administrator has assigned you and the claims administrator themselves. They may be open to changing your plan of care to better meet your needs.
Unfortunately, if you have one of the issues above, the ability of your supervisor, claims administrator, and primary physician to fix the issues may be limited or they may be unwilling to do so. In this situation, you should seek outside help to ensure that your rights are being respected and to learn about any alternative options to get the care you require.
Information assistance officers are employed by the California Department of Industrial Relations (DIR) and assist everyone involved in a workers’ compensation case with information on workers’ rights and responsibilities. They can be contacted through the DIR website and asked questions about any part of the workers’ compensation process.
Union representatives are only an option for workers represented by a union. While every union is unique, they will all have officials dedicated to ensuring that the rights of their workers are being respected. Union representatives can be especially helpful in ensuring that you are treated fairly if your job responsibilities are adjusted as a result of your injury.
Workers’ compensation attorneys can assist will all stages of the worker’s compensation process. They directly represent you, as opposed to representing the state of California or your employer. Unfortunately, attorneys must be paid with money you will likely require to support yourself while injured. Attorneys also have a wide range of specializations and skills making it difficult to compare attorneys effectively.
The financial compensation you receive while recovering from your injury is known as temporary disability benefits (TD). TD is completely separate from the cost of medical care which should always be paid 100% by your employer. TD benefits are provided if you cannot work for 3 or more days or are hospitalized overnight. These benefits will be provided throughout your recovery if your employer does not offer work that you can safely complete with the limitations you have from your injury.
The exact amount that temporary disability pays is complicated. The goal of disability is to provide 2/3rds of the pre-tax wages that you lose due to your disability. Maximum and minimum amounts apply and are calculated on a weekly basis. The amount you get will also change based on the following:
Due to the complexity of calculating TD benefits it is recommended to seek assistance from a State of California information assistance officer or an attorney if you have questions about your TD pay. The claims administrator is responsible for providing TD pay and processing all paperwork related to TD.
If you are injured at work and cannot perform your usual job duties safely and comfortably it is your employer’s responsibility to offer you another position, pay you temporary disability benefits equal to 2/3rds of your income, or a combination of the two. The job duties that you are allowed to perform will be decided by your physician with input from the claims administrator, work supervisor, and possibly your attorney.
There are many legal requirements relating to the amount of pay, job responsibilities, seniority of the position, and the amount of time they must hold your previous job. These requirements can vary based on your personal work situation and are best discussed with your claims administrator, an information assistance officer, and an attorney.
Discrimination as a result of sustaining or reporting an injury is forbidden by California law. Discrimination can take many forms from aggression or being given a poor schedule to outright termination of employment. Proving discrimination can be extremely difficult. If you suspect that you have been discriminated against or retaliated against for your workplace injury, contact a lawyer who specializes in workers’ compensation and workplace discrimination.
If your injury has resulted in changes in your overall health or bodily function that are not expected to resolve or improve, you will be classified by your primary doctor as having a “permanent and stable” injury. This means that your temporary disability benefits will end and you will be given permanent disability benefits. Almost all disability benefits last for a set amount of time and then expire; lifelong payments for a total disability are very rare. The three key things to understand about permanent disability are disability ratings, settling cases, and supplemental benefits.
Disability ratings are percentiles that are assigned to your injury. This percentile is used to quantify the overall severity of your disability for the purposes of calculating permanent disability payments. The higher the disability rating percentage, the greater the overall disability. Disability ratings of 100% are extremely rare; almost all injuries will be assigned a rating between 1 and 99%.
The disability rating is determined by your primary physician with input from medical specialists, therapists, and test results. The rating is not arbitrary, it is created by reviewing all of the permanent effects of your injury and comparing those effects to a table that assigns a percentage to each injury. If you feel the disability rating you are assigned is unfair, you have the right to request a repeat examination by another physician.
Settling a workers’ compensation case is most commonly done when a permanent injury exists and the claims administrator is determining permanent disability benefits. Settlements come in two primary forms.
The first option is a lump sum payment that is intended to cover everything related to the injury. In this type of settlement, all benefits stop after the payment is made and the decision cannot be reversed or changed by either party after the fact. These types of settlements can be risky as injuries can have unexpected or unseen effects that result is significant medical issues later in life.
The second option is a settlement that alters the amount and duration of disability payments. These benefits are given in addition to ongoing medical care. Unlike a lump sum payment, the award amounts for this form of settlement can be adjusted if either party can show reasonable proof in court that the condition for which the payments are being made has changed in a significant way.
The supplemental job displacement benefit is a lump sum payment that is offered to victims of a workplace injury who cannot continue to work in the same job due to their injury and their employer has no alternative job duties to provide. This is a one-time 6,000 payment that can be used for job retraining and education. This voucher can only be spent in certain ways and expires if unused for 2 years.
Entire books could be filled with all of the details, exceptions, and special cases that are taken into account during a workers’ compensation claim. Seeking help with your claim is critical to ensuring that time-sensitive forms, critical details, and complex processes are all followed correctly. Begin your search for help on the website of the California Department of Industrial Relations workers’ compensation page. If you have additional questions or a particularly complex case, contact an attorney who specializes in workers’ compensation cases in your local area.
