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Frequently Asked Questions
What is workers’ compensation?
Although more than one type exists, workers’ compensation generally is collection of benefits (compensation) provided to people who are injured at work or “in the course” of work. This FAQ is intended to address questions specifically related to California workers’ compensation benefits only.
Who is eligible for workers’ compensation?
In order to be eligible for workers’ compensation, a person must be an employee that is performing services for another person (an employer) in exchange for some form of payment, and he/she must have either been injured on the job or in the course of performing his/her work.
What benefits are available under workers’ compensation?
Workers’ compensation generally consists of four benefits:
- Medical treatment
- Temporary disability
- Permanent disability
- Supplemental job displacement benefits
What medical care can be obtained?
Workers’ compensation provides medical care that is “reasonable and necessary” to cure or relieve from the effects of an on-the-job injury. This can include doctor’s visits, medication, therapy (including chiropractic care), medical mileage expenses and surgery.
Unfortunately, medical care under workers’ compensation is highly regulated, through Utilization Review and Independent Medical Review. (See below discussion.)
What are temporary disability benefits?
Temporary Disability (TD) pays an injured worker during a period of time that they are Totally Temporarily Disabled. This is, most often, a period of weeks or months immediately following an injury or a surgery. The weekly benefit rate is two-thirds of your average weekly wages. If you were paid a regular weekly salary, your benefit rate is two-thirds of that weekly salary. If your wage changes from week to week, then we calculate your average weekly wages made during the past year and you are paid two-thirds of that amount. The benefit, in most cases, is limited to 104 weeks.
Permanent Disability benefits (PD) can be paid to injured workers who have not fully recovered from their injury and have suffered “impairment” to the body that is not expected to go away.
How are permanent disability benefits determined?
Calculating an injured workers PD rating is done by considering various factors, including the medical information available, the earnings at the time of injury, and the worker’s age and occupation. The law requires that a doctor evaluating an injured worker to determine their level of PD by applying rules established known as the American Medical Association Guides. PD benefits are weekly benefits. The higher the percentage of disability, the more weeks of benefits are payable.
What are supplemental job displacement benefits?
Depending on the date of your injury, if you are so severely injured that you cannot return to your regular work and if your employer will not accommodate your work limitations, you may be eligible to receive a SUPPLEMENMTAL JOB DISPLACEMENT BENEFIT (SJDB). In most cases, this means that after your case has been concluded, you may receive a voucher (think gift certificate) that you may use to obtain job retraining or education expenses. For injuries on or after 1/1/13, the voucher equals $6,000.
If I am found to have a permanent disability, will I receive disability payments for the rest of my life?
Some workers who have received very severe injuries (such as spinal cord injuries resulting paralysis, brain injuries, blindness, multiple amputations) will be entitled to receive a Permanent Total Disability (100 percent PD benefit), which will pay them weekly for the remainder of their lives. The vast majority of injured workers, however, will not receive a lifelong weekly benefit. The term “permanent” does not describe the period of benefits, but rather, it describes the injured worker’s medical condition. For example, if a worker has a finger cut off, the worker is said to have a “permanent disability” (or impairment) because the finger will not grow back. A worker with an amputation may or may not be able to go back to work.
If I am permanently disabled, can I go back to work?
This depends on how severely you are injured and the nature of the work you do. The mere fact that a worker has a “permanent disability” does not mean that they cannot return to their work. Many workers who have a level of PD are able to resume their regular work. In some cases, they cannot perform their regular work, but may be able to return to the same employer performing modified or alternate work.
I’ve received a letter from an insurance company telling me how much they are going to pay me for my permanent disability. Is this an award of benefits?
No. In many cases a person who has not returned to work, but who is not expected to make a full recovery, may begin receiving PD benefit checks from an insurance company. This, however, is usually only an estimate of benefits to be paid. It is NOT a guarantee of further benefits or an award for further medical care.
Are permanent disability and Social Security or SSI benefits the same thing?
No. In fact, many people confuse PD payable under workers’ compensation law, with Social Security or SSI. If a person is injured or disabled for at least six months and is expected to be disabled for more than a year, they should consider applying for Social Security Disability income benefits or Supplemental Security Income (SSI) – or both. Continue reading to see the FAQ section regarding SSI.
Are there time limits to request workers’ compensation?
Yes! The time limits affecting workers’ compensation are very complex. Generally, one must file a claim no more than one year from the date of the injury. However, there are very short time limits that can have a critical effect on a worker’s benefits. SOME TIME LIMITS ARE AS SHORT AS 10 DAYS! Failure to act promptly can result in a partial or complete loss of benefits. It is recommended that you seek help with your workers’ compensation claim by contacting us.
What is utilization review?
When an insurance carrier receives a Request for Authorization for medical care, the insurance carrier can (and usually will) have a doctor they have chosen review your doctor’s requested care; this process is called Utilization Review or “UR.” If the insurance carrier approves or certifies the recommended care, then the care is usually authorized and provided.
However, if any or all of the care recommended by your doctor is denied or “not certified,” then an appeal must be filed within 30 days of the date of the denial. If an appeal is not filed in a timely manner, then a request for the same treatment cannot be made again for one year! While there are some exceptions to this rule, appealing a denial of medical care can be critical to getting full recovery and legal assistance should be sought.
How can I appeal a denial of medical treatment?
Although a person can file an Application for Independent Medical Review (IMR), it is generally best to consult with an attorney first to determine if the Utilization Review decision was proper. When Utilization Review is properly used to deny care, an Application for Independent Medical Review (IMR) must be filed within 30 days of the Utilization Review decision.
Why should I consult an attorney?
The laws relating to disability claims are very complex. An injured worker who does not have counsel, more often than not, will not receive the benefits that a represented worker will. Further, without careful assistance, resolution of a workers’ compensation case can significantly reduce other benefits, such as Social Security or Medicare. Our office provides no-charge phone or in-person consultations, so there is no good reason not to call.
Can I afford an attorney?
Our office handles both workers’ compensation and Social Security Disability and SSI claims on a contingency fee basis. This means that our fees are deducted from benefits that we successfully assist you in obtaining. Any fee we receive must be reviewed and approved by judge. If we are not successful in getting you benefits, then there is no fee – it is that simple.
If a person is injured due to the negligence or fault of another person or company, a personal injury or third-party liability claim may ordinarily be filed against the individual or company that caused the injury. This commonly occurs in motor vehicle accidents, product failures and construction site accidents, to name a few. Our firm works closely with a carefully selected group of personal injury experts to refer cases and to coordinate litigation. Coordination between these two specialties of law is critical to maximizing the injured worker’s recovery.
California State Disability Insurance (SDI) benefits are payable through the State of California Employment Development Department. Although our firm does not handle hearings before this agency, as a general rule, we routinely assist clients in applying for this benefit, integrating this benefit with other benefits. There are time limits to file for State Disability, and you are welcome to contact us to obtain some guidance in pursuing this benefit in connection with a workers’ compensation or Social Security matter. You should apply for SDI even if you are currently receiving workers’ compensation benefits!