Workers' compensation is a very limited system only intended to provide benefits to those employees injured during the course and scope of their employment. In certain cases, 1099 or contract employees may also be covered under workers' compensation. The reason for this is due to employer attempts to misclassify workers to avoid the costs of workers' compensation insurance and the workers' compensation system. In California, workers' compensation is generally speaking a no-fault system. This means that an injured employee is eligible for workers' compensation even if the employer is not negligent. That being said, injuries sustained due to the fault of third parties (for example, negligent drivers in motor vehicle accidents) allow for you to receive workers' compensation benefits as well as possibly recover compensation from negligent third parties. The workers' compensation laws in California allow for you to make two sorts of claims: specific trauma claims and cumulative trauma claims.
What Is A Specific Trauma Claim?
A specific trauma claim is the most common type of workers' compensation claim. Some common examples of specific trauma injuries include: (1) involvement in a motor vehicle accident; (2) injuries to your back due to heavy lifting; (3) injuries due to falls from a ladder or a roof; (4) burns received in a fire; or (5) injuries due to falling objects.
What Is A Cumulative Trauma Claim?
A cumulative trauma injury is a repetitive motion injury. The most common cumulative trauma injury claim made, is usually orthopedic in nature. This cumulative trauma injury develops from repeating the same motions over and over at work. Such injury can even come about due to repeated bending or because of work tasks performed in awkward physical positions. Due to the repetitive motions performed, our bodies wear down resulting in injuries. Many common orthopedic cumulative trauma injury claims include: carpal tunnel syndrome, cubital tunnel syndrome, tendinitis, neck pain, and lower back pain (often involving sciatic nerve pain). In addition to the common orthopedic injuries, there are many other cumulative trauma claims including headaches, high blood pressure, cardiovascular or heart-related matters, upper gastro intestinal cases, including acid reflux, and lower gastro intestinal such as irritable bowel syndrome (IBS) or hemorrhoids. Cumulative trauma can also involve toxic exposure, hearing loss, skin rashes, sleep issues, sexual dysfunction and urological disorders. Cumulative trauma can also involve psychological and emotional disorders including stress, anxiety and depression.
What Benefits May An Injured Worker Receive?
In California, workers' compensation is comprised of four primary benefits. These include:
Temporary total disability compensation
Permanent disability compensation
Medical treatment for a work-related injury
Job voucher or qualified injured worker compensation
If death results from a work-related injury, then the surviving dependents (total or partial) may be entitled to any benefits that accrued while the injured employee was alive. Surviving dependents may also be entitled to workers' compensation death benefits, including burial expenses if the death was job related. Questions as to causation and the amount of such benefits vary with each case. Similarly, there are specific time limitations to file a death claim with the workers' compensation appeals board. Because each case is different, you should address such questions with an experienced workers' compensation lawyer. It is important to note that the above benefits are not the same as those one may receive in civil cases. For example, there is no compensation for pain and suffering under workers' compensation law.
What Is Temporary Total Disability Compensation?
An injured worker may be entitled to receive disability compensation when they are permanently unable to work or are temporarily disabled. You may also be eligible to receive disability compensation when your employer is unable to accommodate your restrictions and will not take you back to work. If this occurs, you may be able to sue your employer in the superior court, as well as file a discrimination claim under Labor Code 132a. Injured workers are eligible for two years of temporary total disability compensation within a five-year period. The exact amount you receive depends on the amount of wages you receive. It may also vary depending upon who the employer is. If at any point, you are not receiving temporary total disability compensation, then you may be able to apply for state disability.
What Is Permanent Disability Compensation
This is the way that an employee receives compensation if they suffer permanent residual effects from their injury. The basis for determination of the extent of permanent disability involves a review of the medical evidence, which can include records from physicians reporting. The percentage of disability you receive depends upon the degree of impairment as defined by the American Medical Association, and this may be payable even if the worker returns to his or her usual and customary occupation. The actual monetary value of any settlement is a computation from a disability schedule adopted by California.
What Is Meant By Medical Treatment For A Work-Related Injury?
There have been many changes in the laws with regards to medical treatment over the recent years. As the laws often favor insurance companies, there are often denials of medical treatment claims under the workers' compensation system. If workers' compensation is not authorizing treatment, you may treat outside the workers' compensation system and treat through your personal insurance. In any case, the workers' compensation system is often frustrating for injured workers due to denials of medical treatment. As originally designed, an injured worker was entitled to have the employer and workers' compensation insurance carrier pay for all medical treatment that is reasonable and necessary to relieve the effects of the injury. Medical care can include doctor's consultations/visits, hospitalization, surgery, physical therapy, medications, laboratory and diagnostic testing, nursing care, psychiatric treatment, and mileage costs for travel to and from doctors, therapists, etc.
What Is A Job Voucher Or Qualified Injured Workers' Compensation?
Employees injured on or after Jan. 1, 2013, with injuries that result in permanent partial disability, and whose employer does not offer other regular, modified or alternative work, may qualify for the a voucher. The offer must be made within 60 days after receipt by the claims administrator of the Physician's Return-to-Work & Voucher Report (Form DWC-AD 10133.36). The voucher amount is $6000 for all levels of permanent disability and can be used for training at a California public school or any other provider listed on the state's eligible training provider list. It can also be used to pay licensing or certification and testing fees, to purchase tools required by a training course, to purchase computer equipment of up to $1,000 and to reimburse up to $500 in miscellaneous expenses. Up to 10 percent, or $600, may be used to pay for the services of a licensed placement agency or vocational counselor. No more than 10 percent of the value of the voucher can be used for vocational & return to work counseling.
Am I Eligible For Vocational Rehabilitation Services?
If you were injured prior to January 1, 2004, and you find that as a result of your injury, you are unable to return to your usual and customary occupation, your employer is obligated to provide vocational rehabilitation services up to a maximum of $16,000 in costs and payments. For those injured after January 1, 2004, vocational rehabilitation does not exist. If you are unable to return to work, you may be entitled to a "job displacement allowance" ranging from $4,000 to $10,000, which is payable in a voucher form to a school or training. In certain instances, you are able to receive cash in place of this voucher (this is the most common requested form of payment by injured worker).
Is There A Network Of Treating Doctors Within The Workers' Compensation System?
All employers may create a medical provider network (MPN) to control medical treatment for your work-related injury. If your employer creates a MPN, you must treat within the network for your injuries. However, if the employer is not authorizing treatment, then it is possible to treat outside the network through your personal insurance or through a doctors' lien set up through an attorney. The Workers' Compensation Appeals Board regulates one's ability to go outside of the MPN on a case-by-case basis. If you pre-designate a doctor to treat you for a work-related injury, this doctor likely will be able to act as your primary treating physician — even if outside of the MPN. This would mean that the doctor needs to be willing to accept payment per the workers' compensation system. While many injured workers receive chiropractic care, it is important to note that there is a lifetime limit of 24 physical therapy and chiropractic sessions concerning the injury. While a claims examiner may approve more therapy, there is no appeal process if denial of such treatment for going beyond this limit occurs. Additionally, a chiropractor may only act as a primary treating physician for 24 visits. After that, you will need to visit an orthopedic doctor instead.
What Are The Time Limits For Filing A Claim?
There are various statutes of limitations that apply to filing a workers' compensation case, and these can be extremely complex. Because of the complexity, it is always best to speak with an attorney to review your personal circumstances and answer your questions.
What Does It Mean When A Workers' Compensation Claim Is Denied?
Most workers' compensation claims are denied. This means that the employer is denying all responsibility for a work-related injury. In the event of a denial, you should consult with an attorney. Do understand that when there is denial of a workers' compensation claim, you will likely not be receiving any workers' compensation benefits. In the event you cannot work and also are not receiving wages, contact the Employment Development Department (EDD) or any other company/system to check your eligibility for benefits.
What Other Causes Of Action Are Available To Me Besides Workers' Compensation?
In most cases when injured on the job, you are limited to recovering workers' compensation benefits. You may not sue your employer for damages in a separate civil action, and thus workers' compensation is referred to as the employee's exclusive remedy. That being said, there are various exceptions to the exclusive remedy rule which do allow you to sue the employer in court, and recover general and special damages. These exceptions generally cover situations where the employer may have intentionally caused the injury or violated some public policy when the injury occurred (i.e. discrimination, harassment or wrongful termination). If on-the-job injuries were the result of the negligence of a third-party, you may proceed with a civil action independent of the workers' compensation claim. This can include injuries from a rear-end accident while you are on the job. There are limits placed upon workers' compensation benefits by statute. However, additional benefits may be available in a personal injury accident, including obtaining reimbursement for loss of wages and overtime pay, loss of future earning capacity, certain out-of-pocket expenses, and compensation for pain and suffering. As with all legal actions, time limitations apply in filing separate civil actions against an employer and/or a third party. It is therefore important to speak with an attorney about such claims. Additionally, please note that you are not entitled to double recovery (receiving money from both a workers' compensation claim and a civil lawsuit). The workers' compensation carrier can be entitled to a credit for the net recovery the injured worker receives outside the workers' compensation system such as from a personal injury case. However, negotiations are sometimes possible to help maximize net recovery. For this reason, coordinating the workers' compensation case and the personal injury case is an extremely prudent strategy.
Contact Us With Any Additional Questions
Workers' compensation is a highly complex topic, and we can only begin to describe its enormity here. If you have any additional questions, please contact Larson, Larson & Dauer, in Mission Hills, California, by calling 818-830-1910. We provide representation in Los Angeles County, Santa Barbara County and Southern California.
WHAT DOES IT MEAN WHEN MY WORKERS’ COMPENSTION CLAIM IS DENIED?• Many people do not understand what it means when their workers’ compensation claim is denied.• Please note that this is just a quick explanation and not meant to be a comprehensive explanation of what a denial means in every case. However, this is applicable to the average workers’ compensation case. • You usually become aware that you claim has been denied when you receive a “Notice of Denial of workers’ compensation benefits” in the mail. (SHOW SLIDE 1 “DENIAL OF WORKERS’ COMP BENEFITS (While me still taking)• Please understand that this is VERY common. I tell a majority of my clients, especially if they have filed a workers’ compensation cumulative trauma claim, that their claim will be denied at the beginning. • For a quick refresher of the two types of workers’ compensation injury claims you can make, please see my other YouTube videos. Back to me• This Denial means that you will not be getting any workers’ compensation benefits at the start. You will likely start to receive benefits as the case progresses, if not, at the conclusion of the case. However, every case is different. • Please remember that most insurance companies, especially workers’ compensation insurance companies, are extremely cheap. • For example, if you file for injuries to your hands for repetitive typing for 10 years, they will likely deny your workers’ compensation claim. Even if it is this straight forward. This is because they do not want to pay you anything and are hopeful that you will give up and go away. Do not give up!• When your claim is denied, this simply means that you have to show that your injuries are due to work, at least in part. This is commonly handled and done AFTER you file your workers’ compensation claim.• Again, in the example of you filing for injuries to your hands for repetitive typing for 10 years, it is always better if you have seen a doctor in that 10 year period, BUT if you have not, this is okay. Many people are unable to, or do not want to see a doctor for whatever reasons. • However, while this might be one of the many reasons they denied your claim, you can simply go to the doctor, usually through an attorney and show that the injuries are in fact connected to work. Again, this can be done AFTER you have filed the workers’ compensation claim.______________________________________________________• If the claim is denied, you might be wondering how you see a doctor. • Your attorney will find a doctor for you that will treat you on a lien. This doctor will then start connecting your claimed denied injuries to your employment and the process begins. • The insurance will want to get involved as treatment begins because this reporting or “medical evidence” by the doctor will show that the claimed and denied injuries are in fact connected to your employment. • At this point, the only option for the insurance, is to go to a PQME or an AME to try to prove otherwise. This is a non treating, neutral expert doctor. • A PQME is a Panel Qualified Medical Examiner that is given to us by the workers’ compensation system.• An AME is an Agreed Medical Examiner. This is a doctor that your attorney and the defendant are comfortable with using and feel that will give a truly neutral opinion. • You must always be careful with an AME, because an AME’s opinion is final in the case. • This is in contrast to a PQME, who’s opinion goes against your treating doctor. If the two doctors disagree, then if necessary, this would proceed to a workers’ compensation trial. • If you have an AME doctor, this is your whole case in that medical speciality. Whatever they say, goes. We can fight their opinions, but their FINAL word is what a Judge will agree with 99.9% of the time. Your primary doctors opinion really does not matter next to an AME. • Once you have the PQME and/or AME on your side, and they have finalized their opinions, then this is USUALLY when the insurance company starts to pay benefits. Some insurance companies still fight, but they ultimately lose a majority of the time. • Once you have final opinions from the AME and/or PQME in all the applicable medical specialites, this is when settlement usually happens. • If disagreements continue, a workers’ compensation trial is set. This involves only a workers’ compensation Judge, no jury. This takes place at the workers’ compensation appeals board. ____________________________________________• If you claim is denied, please understand that you are not alone. Many cases are initially denied. Please make sure that you fight for the workers’ compensation benefits that are rightfully yours. ... See MoreSee Less