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FAQ's      

Frequently asked questions for the Injured Worker.

 
     
     
     
     

Workers' Compensation - Frequently Asked Questions

Frequently asked questions about Workers' Compensation for the Injured Worker have been broken down into the following subject areas

1. General Questions

2. Medical Related Questions

3. Employer Responsibilities


Fundamental Questions

 

A. If you get hurt or sick because of your employment responsibilities, your employer is required by law to pay for Workers' Compensation benefits. Some examples of being injured on the job include:

  • hurting your back in a fall
  • getting burned by a chemical that splashes on your skin
  • getting hurt in a car accident while making deliveries
  • repeated exposures at work, such as hurting your wrist from doing the same motion over and over
  • losing your hearing because of constant loud noise
 

A. Workers' Compensation insurance provides six basic benefits

  1. Medical care: Paid for by your employer to help you recover from an injury or illness caused by work.
  2. Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering.
  3. Permanent disability benefits: Payments if you don't recover completely.
  4. Supplemental job displacement benefits (if your date of injury is in 2004 or later): Vouchers to help pay for retraining or skill enhancement if you don't recover completely and don't return to work for your employer.
  5. Vocational rehabilitation (if your date of injury is before 2004): Job placement counseling and possibly retraining if you are unable to return to your old job and your employer doesn't offer other work.
  6. Death benefits: Payments to your spouse, children or other dependents if you die from a job injury or illness.
 

A. First, report the injury to your employer by telling your supervisor right away. If your injury or illness developed over time, report it as soon as you learn or believe it was caused by your job.

Reporting promptly helps prevent problems and delays in receiving benefits, including medical care you may need. If your employer does not learn about your injury within 30 days and this prevents your employer from fully investigating the injury and how you were injured, you could lose your right to receive Workers' Compensation benefits.

Next, get emergency treatment if you need it. Your employer may tell you where to go for treatment. Tell the health care provider who treats you that your injury or illness is job-related.

Then, fill out a claim form, called a DWC form 1, and give it to your employer. Your employer must give or mail you a claim form within one working day after learning about your injury or illness. If your employer doesn't give you the claim form you can download it from the forms page of the DWC Web site.

Medical Related Questions

 

A.  The state Division of Workers' Compensation (DWC) is adopting medical treatment guidelines regarding the kinds and amount of treatment needed for different job injuries. State law requires the guidelines to be "scientifically based, nationally recognized, and peer-reviewed." They will be considered correct in most cases. In the meantime, guidelines published by the American College of Occupational and Environmental Medicine (ACOEM), called "Occupational Medicine Practice Guidelines," are considered correct in most cases. If your injury is not covered by the ACOEM guidelines, treatment may follow other guidelines that are scientifically based and nationally recognized.

 

A.  They may. Treatment guidelines are considered correct even in cases that settled before the guidelines were added to Workers' Compensation law in 2003. Your claims administrator may continue to pay for medical care you're accustomed to for your injury. If you have a question about whether you should still be receiving a certain kind of medical treatment and you cannot work it out with your claims administrator, call your local information & assistance officer for guidance.

If your medical treatment has been denied you can request an expedited hearing before a Workers' Compensation administrative law judge to get the situation resolved. Contact the information & assistance officer at your local DWC office for help.

 

A.  The claims administrator is required to authorize medical treatment within one working day after you file a claim form with your employer, even while your claim is being investigated. This treatment is limited to $10,000. If the claims administrator does not authorize treatment right away, speak with your supervisor, someone else in management or the claims administrator about the law requiring immediate medical treatment. Ask for treatment to be authorized now, while waiting for a decision on your claim.

 

A.  Yes. If your date of injury is in 2004 or later, you are limited to a total of 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits, unless the claims administrator authorizes additional visits.

 

A.  For as long as it's medically necessary. However, some treatments are limited by law and the medical treatment you receive must be evidence-based.

The state of California is currently using the "American College of Occupational and Environmental Medicine's (ACOEM) Practice Guidelines, Second Edition" as the standard or evidence-based medicine. The guidelines lay out treatments scientifically proven to cure or relieve work-related injuries and illnesses. They also deal with how often the treatment is given and for how long, among other things.

If the treatment your doctor wants to provide goes beyond what is recommended by the ACOEM guidelines, your doctor must use other evidence to show the treatment is necessary and will be effective.

Additionally, your doctor's treatment plan may be reviewed by a third party hired by the claims administrator. This process is called utilization review (UR). All claims administrators are required by law to have a UR program. They use UR to decide whether or not to approve treatment recommended by your doctor.

 

A.  Most likely, no. This is a problem your doctor and the claims administrator need to work out.

 

A.  A medical provider network (MPN) is a group of health care providers set up by your employer's insurance company and approved by DWC's administrative director to treat workers injured on the job. Each MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. If your employer is in an MPN your Workers' Compensation medical needs will be taken care of by doctors in the network unless you were eligible to pre-designate your personal doctor and did so before your injury happened.

 

A. That's a question you have to answer for yourself. You're not required to have an attorney, even if you have a disagreement with the claims administrator. However, if your case is complex you may benefit from having one. If you decide not to get an attorney, the information & assistance (I&A) officer at your local DWC office can help you with your claim. Even if you decide to hire an attorney you should educate yourself about your rights and responsibilities, stay in communication with your employer and claims administrator and don't be afraid to ask them questions. The vast majority of Workers' Compensation claims are resolved between injured workers and claims administrators with no problems.

 

A.  Your treating doctor is responsible for explaining in a medical report:

  • The kind of work you can and can't do while recovering
  • The changes needed in your work schedule or assignments

You, your treating doctor, your employer and your attorney (if you have one) should review your job description and discuss the changes needed in your job. For example, your employer might give you a reduced work schedule or have you spend less time on certain tasks.

If you disagree with your treating doctor, you must promptly write to the claims administrator about the disagreement or you may lose important rights.

 

A.  Your treating doctor may determine that you will never be able to return to the same job and working conditions you had before you were injured. The doctor should report this in writing. The report should include permanent work restrictions to protect you from further injury.

If you were injured before Jan. 1, 2004, you and the claims administrator first fill out a "description of employee's job duties" on form RU-91. This form is required if you have been off work 90 days. The doctor then reviews what you wrote on the form to determine whether you will be able to go back to your old job and working conditions.

If you were injured on or after Jan. 1, 2004, the doctor will report to your claims administrator about your ability to return to work. You will receive an offer to return to regular, alternative or modified work - or not - from your employer, depending on what the doctor's report says. You have a right to review the doctor's report.

Employer Responsibilities

 

A.  Before an injury or illness occurs, your employer must:

  • Obtain Workers' Compensation insurance or qualify to become self-insured
  • When hiring a new employee, provide a Workers' Compensation pamphlet explaining the employee's rights and responsibilities
  • Post the Workers' Compensation poster in a place where all employees can see it.

After an injury or illness occurs, your employer must:

  • Provide a Workers' Compensation claim form to you within 24 hours a work-related injury or illness is reported
  • Return a completed copy of the claim form to you within 24 hours of receipt
  • Forward the claim form, along with the employer's report of occupational injury or illness, to the claims administrator within 24 hours of receipt
  • Within one day of receiving your claim, authorize up to $10,000 in appropriate medical treatment
  • Provide transitional work (light duty) whenever appropriate
  • If you are the victim of a crime that happened at work, the employer must give notice of Workers' Compensation eligibility.
 

A.  Failing to have Workers' Compensation coverage is a criminal offense. Section 3700.5 of the California Labor Code makes it a misdemeanor punishable by either a fine of up to $10,000 or imprisonment in the county jail for up to one year, or both. Additionally, the state issues penalties of up to $100,000 against illegally uninsured employers.

If you get hurt or sick because of work and your employer is not insured, your employer is responsible for paying all bills related to your injury or illness. Contact the information & assistance officer at your local DWC office for further information. Workers' compensation benefits are only the exclusive remedy for injuries suffered on the job when your employer is properly insured. If your employer is illegally uninsured and you get sick or hurt because of work, you can file a civil action against your employer in addition to filing a Workers' Compensation claim.

You may also file a claim for benefits with the state's Uninsured Employers' Benefit Trust Fund (UEF). See DWC fact sheet F and guides 16, 16A and 16B for more information on filing a claim with the UEF.

DISCLAIMER: The following questions and answers are provided for the convenience of the user. We strive to make this information as timely and complete as possible, however, no representation or warranty is made that the information contained in this Web site is current or accurate. Also, unless otherwise stated, the user may not rely on the answers in this Web site as definitive, but should consult the actual text of the law or regulation. Statutes for the California Department of Industrial Relations are largely contained in the California Labor Code, searchable at http://www.leginfo.ca.gov/calaw.html. Regulations for the department are contained in the California Code of Regulations, Title 8, at http://ccr.oal.ca.gov.

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