1) What is Workers' Compensation? 

     

    Workers' Compensation is a system of various benefits for workers injured on the job. These benefits include medical treatment, temporary disability, permanent disability, supplemental job displacement benefits and death benefits. A work injury can be a specific event such as a slip and fall or it can be the result of repetitive motion, activity or exposure to a part of your body over a period of time--this is called a cumulative trauma injury. Psychological injuries can also be caused by your job under certain circumstances. Illnesses can also be work-related, such as certain cancers, hypertension, chemical exposures, hearing loss, vision loss, respiratory conditions, etc. 

 

 

 

 

 

 

 

 

2) How do I know if I am eligible for workers' compensation?

 

     If you are considered an employee in California, as opposed to an independent contractor, then you are eligible to receive workers' compensation benefits in the event of a work-related injury or illness. Under certain situations, even independent contractors, can be covered by workers' compensation. Also, you do not have to be a legal resident or citizen of the United States to be eligible for worker' compensation.

 

3) How do I file a claim?

 

     You should report your injury as soon as possible to avoid delays or problems in receiving benefits. After you report your injury, your employer is required to give you a claim form to fill out. You may also get a claim form from the California Division of Workers' Compensation. You should fill out the employee section of the form and return it to your employer right away and request medical care if needed. After you return your completed claim form, your employer is supposed to complete the employer section and give it to their insurance company or Human Resources Dept. for processing. An employer usually has 90 days to make a decision on your claim. During this initial waiting period, your employer is required to provide you with reasonable medical care up to $10,000. 

 

4) How do I receive medical care for my work injury?  

 

     Your employer is required to provide you with reasonable medical care to cure or relieve your work injury or illness, unless your claim is denied within 90 days of filing it. Many employers, through their workers' compensation insurance company, have either a Medical Provider Network (MPN) or a Health Care Organization (HCO). These are groups of doctors who provide medical care to injured workers. Your claims adjuster is required to give you a list of MPN doctors in your area, and you are allowed to select a Primary Treating Physician(PTP) from the MPN. If your employer does not have a MPN or HCO, you can select your own PTP after 30 days from filing your claim. Under California law, all medical treatment provided for a work injury must follow treatment guidelines called the Medical Treatment Utilization Schedule (MTUS). Also, your medical treatment is subject to review and approval under a program called Utilization Review (UR). Thus, your employer has control over your medical care either through the MPN/HCO or through UR, or both, in most cases.

 

5) What if I disagree with my treating doctor over my medical treatment? 

 

     In general, you have a right to challenge a treating doctor's medical report over things like the treatment you need, the cause of your injury and your work restrictions while you are recovering. For disputes over medical treatment only, if you are in a MPN you have the right to change treating doctors within the MPN. If this does not resolve the dispute, you can request a second and/or a third opinion from another doctor in the MPN. If you are in a HCO, and you disagree with the treatment prescribed by your doctor, you can change doctors within the HCO. If you  are not in a MPN or HCO, you can still change treating doctors. If this does not resolve the dispute, you will need to object to your treating doctor's report and seek an evaluation from another doctor.

 

6) What is Temporary Disability?

 

     If you are unable to work due to your work injury, you are entitled to receive Temporary Disability(TD) benefits if: your treating doctor certifies that you are unable to work or your employer does not offer you alternative work at your regular pay. Your actual benefit rate can be affected by situations, like having a second job, having a seasonal job, fluctuating weekly wages, bonuses and tips, housing and/or car allowances, or scheduled pay increases after your work injury. If you can only work part time or at a lower pay rate, you may be entitled to temporary partial disability (TPD) benefits. Your TD benefits typically end when your treating doctor says you can return to work or you actually do return to work at your regular wage or your medical condition is considered "permanent and stationary" by your treating doctor. In most cases, TD benefits are limited to a total of 104 weeks within 5 years from the date of injury. Certain injuries allow you to receive up to 240 weeks of TD benefits within 5 years from your date of injury. These can include acute and chronic illnesses such as Hepatitis B or C or HIV, pulmonary fibrosis or chronic lung disease, severe burns, amputations, and eye injuries resulting from chemical burns or high velocity trauma. 

 

7) What is Permanent Disability?

 

     If your treating doctor decides you will not fully recover from your work injury or illness or that you will have permanent work restrictions, you will have permanent disability (PD). Your PD level is determined mainly by medical evidence from your treating doctor or from an evaluating doctor such as an Agreed Medical Examiner (AME) or a Qualified Medical Examiner (QME). Your treating doctor will write a permanent and stationary(P&S) report describing your medical condition, your work restrictions, your future medical needs, your ability to return to your usual job, and an estimate of how much of your PD was caused by your work injury and how much was caused by other factors, including prior injuries or pre-existing conditions--this is called apportionment. If you disagree with your doctor's P&S report, you can object to it and request another medical opinion on your PD from a QME or AME, depending on whether you are represented by an attorney. Once all the reports are written, a rating of your PD will be needed to determine the amount of your PD benefits. There are different rating schedules that are used to calculate your percentage of PD, depending on the date of your injury. Most ratings of PD range from 0% to 99% which means you have permanent partial disability. A rating that is between 70% and less than 100% also entitles you to a supplemental benefit called a life pension.   

 

8) What if I cannot return to my job?

 

     A worker who was injured in 2004 or later may be entitled to receive a Supplemental Job Displacement Benefit (SJDB). This benefit is a voucher that you can use to receive training or education to help you get another job. This benefit only applies if you do not return to your old job or your employer does not offer you a suitable job and you have permanent partial disability. If you were injured between 2004 and 2012, your SJDB voucher ranges from $4,000 to $10,000, depending on the level of your permanent partial disability. For injuries from 2013 or later, the SJDB voucher is set at $6000. There is also an extra benefit available to workers injured in 2013 or later, whose PD benefits are disproportionately low in comparison to their earnings loss, called the Return-to-Work Supplement Program (RTWSP). This is a one-time benefit of $5,000 and must be filed online within one year of receiving your SJDB voucher.

 

9) How is my case resolved?

 

      One resolution is called a Stipulation with Request for Award (Stips). With Stips, you agree on the level of your PD, your PD benefit amount and whether you are entitled to medical care in the future. If your PD gets worse within 5 years from your date of injury, you can request an increase in your Stips Award. The second type of settlement is called a Compromise and Release (C&R) which is a lump sum payment that covers everything: PD benefits, future medical care, any additional claims such as penalties or unpaid TD benefits. Any settlement, Stips or C&R, must be approved by a Workers' Compensation Judge before it is finalized. The judge's role is to ensure the settlement is fair and adequate to you, the injured worker.

 

10) Do I need an attorney to represent me on my workers' compensation claim?

 

       This is an important decision, as it can affect the amount of benefits you receive now and in the long run. The role of an applicant's attorney is to protect your rights as an injured worker and to be your advocate when dealing with the insurance company handling your claim. The applicant's attorney's job is to gather all relevant and necessary evidence, medical or otherwise, to put a solid case together and to seek the maximum benefits available to you, the injured worker. There are many deadlines and procedures which must be followed and your attorney will keep track of everything to ensure compliance. Attorney's fees are on a contingency basis and paid out of any settlement reached with the insurance company. Any attorney fee must be approved by a Workers' Compensation Judge. In California, many applicant's attorneys charge a fee between 15% and 18% of a settlement, although this can vary depending on the complexity and duration of a case. Experience is always an important factor in selecting an attorney. You should always have confidence and trust in your legal counsel.       

       

          San Diego Worker's Compensation Attorney Helping You Maximize your Benefits 

 

To learn more about how the Acosta Law Office can help you, call for a free consultation at 619-391-9933.