Workers' Compensation Basics

A Guide for Injured Workers in California

California workers' compensation is a system that provides insurance benefits to people who are injured in the workplace. The law requires employers to carry insurance for their employees.

Since it is a no-fault system, employees do not have to prove that their employers are to blame for the injuries in order to receive their benefits for on-the-job injuries. It is rather a trade-off between employers and their employees, whereby employers provide prompt limited statutory benefits and the employees agree not to sue employers or co-workers for negligence that caused the employee's injuries. Employees whose negligence causes injuries to their own employees may be vulnerable to a case of negligence file against them in superior Court.

However, injured employees may sue third parties (other than the employer) for negligence that leads to a work-related injury. Strict statutes of limitation apply to third party claims. Claims against private third parties should be filed within two years from the date of injury, and claims against government entities must reach the appropriate entity within six months of the date of the incident.

It is best to get advice from a workers' compensation specialist about the exact time frames that are applicable to your specific case. Accurate legal analysis and advice will ensure that your case reaches the correct court of competent jurisdiction within the correct time frame.

When worker's compensation came into effect early in the 20th century, negligence suits were prevalent. Today, most cases hinge upon two issues:

• whether an injury is in fact work-related;
• the amount of benefits to which the injured worker is entitled.

About the Workers' Compensation System

The workers' compensation scheme consists of three basic elements, namely the benefit structure, benefit delivery system and the benefit financing system.

Benefit structure

This benefit structure of the system defines an injured worker's entitlement to benefits when sustaining an injury because of or during executing tasks relating to their employment. Some of the basic benefits available to injured workers include:

Medical treatment:  An injured worker is entitled to all reasonably required medical care to cure or at least relieve the injury without incurring any copayments or deductibles. Employers usually control medical treatment for the first thirty days after the employee reports the injury, after which the employee may select any facility or physician. If the employee has informed the employer of his or her personal physician prior to the injury, that physician may attend to the worker from the date of the injury. If the employer and employee opted for a managed care program, the choice of treating physician will differ.

Temporary disability benefits: If the worker is unable to go back to work in the three days following the injury, he or she is entitled to temporary disability benefits, which partially replace lost wages resulting from the injury. Benefits typically amount to two-thirds of the lost wages, capped at $728 per week and are paid out every two weeks until the injured employee returns to work, or until his or her status changes to permanent and stationary.

Vocational rehabilitation services: When an injury prevents a worker from returning to his or her former vocation, they may become entitled to vocational rehabilitation services, provided such services can reasonably be expected to help the worker to obtain suitable gainful employment. Vocational rehabilitation benefits include:

• development of a suitable rehabilitation plan;
• training costs;
• and a maintenance allowance.

Permanent disability benefits:  When an injury leaves an individual with a permanent handicap, they are entitled to permanent disability benefits for the rest of their lives, capped at $728 per week. A Qualified Medical Evaluator or treating physician will determine the worker's limitations and permanent impairment and that will determine how much compensation a worker with a permanent partial disability receives. The amount received and the period for which it is paid will depend on the percentage of disability. Individuals who have permanent partial disabilities of more than 70% will also receive a small pension of up to $257.67 per week commencing after the final permanent partial disability payment is made.

Supplemental job displacement benefits:  The insurer may offer a non-transferable voucher payable to a state-approved, accredited school which enables the worker to a maximum value of $10,000 of retraining. This option is available to workers who sustained permanent disabilities that deem them unable to return to work:

• within sixty days of the end of temporary disability;
• because the employer is unable to provide modified or alternative work.

Death benefits:  When a worker is killed in a work-related accident, their family is entitled to reasonable burial expenses, capped at $5,000. Additionally, dependents may be entitled to temporary support payments of at least $224 per week. The payments are calculated in the same way as temporary disability benefits. The number of dependents and the extent of dependency determines the aggregate amount payable. In the event of three or more total dependents generally the maximum is capped at $160,000. If dependent children remain after the payment of the basic death benefit, additional benefits may still be payable.

Benefit delivery system

Unlike unemployment compensation and social security, California's workers' compensation is not government-administered, but it is managed by authorized private insurance companies and employers that are secure enough to self-insure this type of liability. They require special authorization. The state of California:

• oversees the benefit delivery;
• provides employers and employees with information and assistance;
• resolves any disputes that may arise.

The moment an employee reports a workplace injury, the employer must initiate the benefit process, which is paid by the authorized self-insuring employer, or by the insurance company.

Small workers' compensation claims are typically administered expeditiously and without any disputes or litigation. Such cases typically only require medical care, or a few days worth of temporary disability. Small claims make up more than 75% of the thousands of on-the-job injuries that occur every month in California.

Litigation is common in the balance of claims, which often involve either significant periods of disability, or permanent disability.

Benefit financing system

Employers can finance their workers' compensation liability by means of:

• Self-insurance - Large, stable corporations and government agencies self-insure. In order to do that, they must be certified by the Department of Industrial Relations, and post post security.
• Private insurance - The Department of Insurance has licensed many private insurance companies in California. Prices are not strictly regulated.
• State insurance - The State Compensation Insurance Fund which is a non-profit state-operated entity that operates as the assigned workers' compensation insurance risk pool. The fund actively competes with the private insurance companies for business.

How to Claim Workers' Compensation After an On-the-Job Injury

California workers' compensation law states that an injured worker must immediately notify their employer when an incident occured, and notify them of an injury. You should also immediately seek medical attention. Any injury that arises from your job should be covered by workers' compensation insurance, with a few limited exceptions.

Your employer must provide a claim form, which you have to complete and return. Your employer will fill in the appropriate portion of the form and submit it to the claims administrator, who has to accept or deny the claim within a reasonable time frame. You should be granted with up to $10,000 in medical treatment coverage within one business days.

The insurance company should let you know within 14 days whether your claim has been accepted, denied or delayed.

If your claim is accepted, the injury is covered by worker's compensation and the insurance will cover your medical care. Additionally, you may be eligible for compensation to recover lost wages.

If your claim is denied, you may challenge the claims adjuster's decision. Do not delay your appeal, because there are deadlines.

Delayed claims typically require investigation into your injuries, which is common for psychological injuries. Since there is no physical injury that can be diagnosed, and because the insurance company cannot determine that the work conditions are 51% or more to blame for the injury, it requires investigation into other causal factors. They will investigate your work and your private life, including your marriage, financial situation, criminal record, substance abuse, and other sensitive areas of your life before coming to a decision as to whether the claim will be accepted or denied. It may take up to 90 days to conclude the investigation.

Your doctor will provide a medical report that explains:

• the kind of work that you may do while you are recovering;
• whether you will require changes to your assignments of work schedule.

You should review your job description with your doctor, employer and with your attorney to discuss any changes that will be required while you recover. At this point, your employer might recommend a reduced work schedule.

Many injured workers fear that they may lose their jobs because of a work-related injury. However, it is illegal for employers to punish workers for:

• sustaining work-related injuries;
• filing workers' compensation claims.

Additionally, employers may not punish co-workers who testify in work-related injury cases on behalf of their colleagues.

Likewise, if you fail to make a full recovery after the work injury, your employer may not discriminate against you because of the disability, according to the California Fair Employment and Housing Act (FEHA) and Americans with Disabilities Act (ADA).

Workers' Compensation: How to Ensure Fair Compensation

While many injured employees receive their benefits quickly, others experience delays and other problems. Use these tips to ensure that you receive a fast, fair settlement.

• Keep comprehensive records of the many forms you are required to fill out, including:
• envelopes that show postmarks
• notes of discussions with claims officials
• medical records that track your condition
• copies of all medical reports from your claims administrator
• timesheets and pay stubs from before and after the injury, including dates worked and off days
• receipts for out-of-pocket expenses, including prescriptions and travel costs for attending medical appointments.
• Speak up about any concerns you may have and if the claims administrator and your employer can't resolve the problem, speak to a workers' compensation attorney.

When you involve a workers' compensation attorney in your matter, the company may suddenly offer you a settlement, and after dragging on for months, you may be tempted to take what you can get and end the struggle. However, companies rarely offer fair settlements that take into account:

• potential future medical expenses;
• your ability to return to and stay gainfully employed in your existing job;
• future career prospects.

It's not uncommon for injured workers to return to work after a serious injury, just to find that they are no longer able to fully function or perform job duties that used to be easy for them. This may lead to future injuries that will require further medical treatment or a change in work load or a different job altogether, which will likely result in a significant reduction in your income. If you sign a settlement agreement before fully understanding your situation, you may effectively sign away your right to any future claims for the existing injury. That could well leave you and your family out of pocket and devastate your financial future in the event of complications from your injury, or in case of permanent disability.

Before signing any agreements, speak to a specialist workers' compensation attorney, who will do a proper case analysis and ask the right questions to understand your claim. The right representation will also safeguard your vulnerabilities to ensure a fair settlement to give you the best chance of a secure financial future in light of your injuries and future career prospects. 

Need Help with a Workers' Compensation Claim?

If you have been injured at work, get in touch with Orange County Workers Compensation Attorney today, and schedule an initial case review. We will provide you with a professional opinion from an attorney who deals with these cases on a daily basis. Call now on 949-423-3212.