Workers Compensation Basics

An injury can be classified as a work-related injury if an exposure or event at the workplace contributed to or caused the resulting condition. Work-related injuries may lead to restricted work activity, need for medical treatment, loss of consciousness or even death. The percentage of loss of function your body part suffers helps rate your level of impairment.

What are Workers’ Compensation Injuries?

Workers’ compensation injuries refer to the work-related (occupational) injuries that qualify for compensation under Section 4 of Article XIV of the California Constitution, which mandates employers in California to have workers' compensation insurance. Employers who fail to get the insurance policy risk facing criminal and civil penalties.

Under Labor Code 3208.1 work-related injuries can either be categorized as specific or cumulative. Specific injuries usually arise from an incident or exposure that increases your need to seek medical treatment or risks of being disabled. Cumulative injuries, on the other hand, are in the form of repetitive physically or mentally traumatic activities. They tend to extend over a specified period increasing the need to seek medical treatment or disability risks.

Examples of Specific Injuries

Specific injuries that deserve compensation include fractures, inflammation, contusions, cuts/punctures, and strains and sprains. You may also seek compensation for specific injuries such as back, knee and shoulder injuries and loss of grasping power. Others include hand/wrist injuries, elbow injuries, heart injuries, hernia injuries (affecting the internal organs) gastrointestinal injuries, and psychiatric injuries.

Examples of Cumulative Injuries

Also known as cumulative trauma, these injuries occur over a long period as a result of multiple incidents or exposures. You may not know about your cumulative trauma unless a medical doctor diagnoses you. Examples of cumulative injuries affecting your body's musculoskeletal system include neck and back disc herniation, cubital elbow tunnel and wrist carpal tunnel. Heart disease (caused by continued stress) and breathing issues (due to the exposure to chemicals/dust) may qualify as cumulative internal injuries.

A workers' compensation policy helps provide you benefits after suffering injuries at your workplace. The policy only applies to injuries that may arise out of your employment or those that occur at the course of your job. Since the benefits are limited, your primary task is to prove that you suffered the injuries while working. As the injured employee, the California Constitution entitles you to seek compensation.

You may have your claim rejected if you were working while intoxicated or you intentionally harmed yourself. Injuries caused by deliberately starting a fight, committing a felony or engaging in a voluntary work activity may disqualify you from the compensation. You won't also make a claim if you suffered the injuries while on your lunch break or while commuting from work or home.

Are Independent Contractors Eligible for Workers' Compensation Benefits?

The California workers’ compensation system disqualifies independent contractors from receiving damages for their work-related injuries. In California, an independent contractor is an individual working for a particular fee to achieve a particular result while an employee is an individual that’s in service (with a written or an oral contract) of an employer. Unlike employees, independent contractors must control their own workplace safety and choose the benefits/burdens of being self-employed.

If you're categorized as an employee, the California Labor Code mandates your employer to get workers' compensation insurance on your behalf. This law also requires your employer to pay part of your Medicare and Social Security taxes. Your employer may categorize you as an independent contractor to avoid settling the workers' compensation benefits. Through your lawyer, you can file a lawsuit against the company for misclassifying you and refusing to give you benefits for your work-related injuries.

If the insurer denies your claim by wrongly referring to your employment status as an independent contractor, your lawyer should file certain motions for this inaccuracy. The motions include the Declaration of Readiness to Proceed and Application for Adjudication of Claim. Once a California judge rules in your favor, you’ll automatically be eligible for the workers’ compensation. If the verdict isn’t in your favor, you still have the right to appeal.

Are There Any Special Benefits for a Public Employee?

In California, the phrase "public employees" can refer to individuals working in firefighting or law enforcement sectors. Public employees usually receive regular benefits together with other special benefits and advantages as explained in Labor Codes 4850 to 4856. For injuries that result in temporary leave, firefighters and law enforcement officers get their full salaries for one year. Public employees also receive special retirement benefits for work-related injuries that led to their retirement.

Public employees including firefighters or law enforcement officers can get the benefits without proving that their jobs resulted in them suffering cancer, pneumonia, heart disease or hernia. The spouse or children (under the age of 22) of a firefighter or a police officer that died on duty should receive a portion of the salary of the deceased. They are also entitled to government health insurance benefits.

What if You’re Undocumented?

The California Labor Code covers injured undocumented workers. However, your employer may be charged for allowing you to resume work with knowledge of your illegal citizenship status in the country. As an undocumented employee, you can receive permanent disability benefits or medical treatment for your occupational injuries.

Though it’s illegal to file false employment documents as an undocumented employee, such an offense won’t be regarded as workers’ compensation fraud. Note that a conviction for workers’ compensation fraud may deem you ineligible for workers’ compensation. As an injured undocumented worker, you can have your lawyer argue your eligibility for temporary disability benefits in court.

What If You Were Fired Before Filing the Claim?

For this case, you'll have to give medical records showing evidence of injury before your employment status was terminated. You'll also have to show that you notified your employer about the injury before being fired or that you suffered a cumulative injury. You can still file the claim if you got injured at your workplace days after getting notified about the job layoff or termination.

If your injury is justified, you are entitled to receive medical treatment, temporary disability benefits, permanent disability benefits, and supplemental job displacement benefits. Your immediate spouse or children (over the age of 22) are also entitled to receive death benefits in case of your demise. The various types of workers’ compensation benefits are discussed below:

1. Medical Treatment

Medical treatment, in this context, includes hospital, medical, dental, acupuncture or surgical treatment aimed at curing or relieving you from an injury. Though you’ll be required to choose a doctor (working in or out of California), only reasonable treatments are covered under your workers’ compensation benefits. You can still seek medical treatment on a lien basis when your claim is denied. In this case, the medical practitioner will offer you free treatment but collect the fees from the insurer.

Filing a Medical Mileage Expense Form with the required details can entitle you to reimbursement for commuting to and from your medical provider. The insurance company can pay for out-of-state treatment. For this case, you'll need to find a medical provider that's willing to transact with the insurer.

2. Temporary Disability Benefits

You may seek temporary disability benefits when you’re incapable of working. The benefits amount to up to two-thirds of your total weekly salary. The maximum time frame for receiving these benefits is 104 weeks under Labor Code 4656. The nature of your injury and your job status help determine the total amount and rates of temporary disability benefits to receive in California.

Unlike temporary disability benefits that are paid by the insurer, SDI (State Disability) benefits are issued when you experience an illness or injury that’s not work-related.  The EDD (Employment Development Department) facilitates this type of disability benefits. You can apply for SDI benefits if your workers’ compensation claim is denied. Once your injury is proved to be a work-related injury, the SDI benefits will be considered as the disability benefits you should’ve received for a work-related injury.

3. Permanent Disability Benefits

You’re entitled to receive a sum of money for a work-related injury that made your medical condition to be permanently changed. A doctor will calculate the permanent disability benefits after noticing that your medical condition is stable though there’s no room for further improvements. A Permanent Disability Rating Schedule helps calculate the permanent disability benefits. Factors such as age, job type, injury and changes (caused by the injury) in your future earning capacity are considered in the calculations.

4. Supplemental Benefits for Job Displacement

You're entitled to receiving these benefits if your injury makes you incapable of returning to a modified or regular job under Labor Code 4658.7. You should receive the compensation as a $6,000 voucher to be used to pay for job training classes. The money can help you sustain yourself when finding a new occupation.

5. Death Benefits

Death benefits apply to injuries that result in an employee’s death under Labor Code 4702. In case you succumb to a work-related injury, your family members are entitled to get up to $320,000 (to be split between them) as death benefits. Your family will also receive up to $10,000 to cover the burial expenses.

You can file a workers’ compensation claim if your injury requires medical treatment or makes you temporarily/permanently incapable of working. Your employer must have copies of certain workers’ compensation notices and forms (about your right to compensation) in both Spanish and English. You should also expect an insurance company (dealing with workers’ compensation benefits) to notify you about any events related to your benefits. The notices may inform you about your rights as a worker, requests for medical records, medical consultation and treatment, hearings and the available permanent job offers as explained below.

Notifying Your Immediate Employer of the Injury

Under Labor Code 5400, you’re mandated to notify your immediate employer of your injury in writing within 30 days of suffering the injury. Your employer can also be informed about your injury from another source as highlighted under Labor Code 5402. Failing to convey this information won’t prevent you from seeking the workers’ compensation benefits. Upon receipt of details regarding your injury, your employer must give you a Claim Form within one official working day.

You should fill the Claim Form with details such as the date/time of your injury, address/description of the injury location, type of injury, body parts affected and your social security number. You’re required to sign it after providing this information. There’s also a segment in the form mandating your employer to give their identifying information and other details on your injury. Submitting false information on the form for you to get the workers’ compensation payments may make you guilty of a California felony.

Receiving Notices from the Insurer

Your employer must send the Claim Form to their insurer once it's filled with the required details. Upon receiving this form, the insurer will send you notices stating certain rights, which include:

• Descriptions of the various kinds of workers’ compensation benefits
• Procedures involved in collecting the benefits
• What would transpire once your claim form is filed
• Whom you can contact for medical treatment on your injury
• Primary roles and functions of your treating physician
• Your rights to choose and change your treating physician as stipulated under Labor Codes 3550 and 4600
• How to seek medical treatment/care with your claim still pending
• Protections against discrimination as highlighted in Labor Code 132(a)
• Your rights to oppose decisions that affect your workers’ compensation claim

Is There Any Statute of Limitations for Filing a Workers’ Compensation Claim?

Insurance companies tend to use the statute of limitations when they want to refuse to settle your benefits. The timeline for receiving benefits is usually set once you file a claim notifying your immediate employer of your injury. The phrase "statute of limitations," in this context, refers to the particular period (which is one year) for receiving workers' compensation benefits. This one-year period starts at the date you suffered an injury, the last date you sought medical treatment and the last date you received disability benefits.

The statute of limitations might fail to apply to your case if your employer didn't inform you about your entitlement to filing a workers' compensation claim. The principle will also be invalid to your case if your employer doesn't present you a Claim Form. Employers have to inform new and existing workers about their entitlement to workers' compensation benefits.

How Do Insurance Companies Investigate Workers’ Compensation Claims?

Your employer’s insurer has 90 days to either accept or reject your claim once your employer files it under Labor Code 5402(b). Note that your injury claim will automatically be accepted if the insurance company fails to make this decision in the 90-day period. You should also expect the insurer to question you (in a deposition) about your injury under oath.

The insurance company may seek a subpoena to obtain your employment and medical treatment records through their lawyer. They can even have a doctor evaluate you before or after accepting or denying your claim. In the event your request is rejected, you'll receive a notice of claim denial from the insurer. Upon receiving such a notice, you'll only have one year to appeal for having your workers' compensation claim denied.

Though it’s rare, your employer may fire or threaten to fire you for filing a workers’ compensation claim. Under Labor Code 132(a), you’re entitled to an additional $10,000 if your employer tries to act this way. In case you were fired, your employer must give you back payments from the time the wrongful job termination was initiated.

What If You Have a Dispute With the Insurer?

Always expect the insurance company to have a doctor review the treatment plan proposed for your injury. While this procedure is conducted, you may find yourself disputing certain parts of your claim. The aspects may include your medical treatment, the injury itself or your permanent/temporary disability.

To have this dispute resolved, you must involve a California court by filing an Application for Adjudication of Claim. Your lawyer can file the claim from an Appeals Board in your area of residence to give your injury claim a valid case number. The next step involves filing a Declaration of Readiness to Proceed, which is a form used to request for a judicial hearing by stating the issue you’re disputing. Once this form is filed, you’ll get a Notice of Hearing informing you about your upcoming court appearance and the judge that will handle your case.

Penalties Available to You as the Injured Worker

You have the right of obtaining a penalty if you believe that the insurer is denying or delaying you the workers' compensation benefits unreasonably. In every workers' compensation case in California, insurance companies are required to pay injured workers when they fail to pay the benefits in time. The penalty for late payments ranges between 10 percent and 25 percent depending on the reason for the delay and type of benefits.

Labor Code 4650 imposes a 10 percent penalty for overdue payments of permanent disability benefits and temporary disability benefits. Labor Code 5814, on the other hand, imposes a 25 percent penalty for late permanent disability benefits, temporary disability benefits, settlement funds, mileage, and medical treatment. In both Labor Codes 4650 and 5814, the penalty is calculated as a percentage of the amount the insurance company failed to pay appropriately.

Settling a Workers’ Compensation Claim in California

As the injured employee, you have two options when it comes to settling your workers' compensation claim in California. The options include agreeing to have the insurer pay for your future medical expenses for life or taking a sum of money that's equal to the value of the proposed future medical care. The terms "compromise and release" and "stipulation and award" are used to refer to the alternative settlement agreements made in this context.

A compromise and release settlement is usually paid immediately as a single lump sum while a stipulation and award settlement is paid over a period of years or weeks. Receiving a compromise and release can help settle your entire case and end your relationship with the insurance company. A stipulation and award, on the other hand, calls for a continuing relationship between you and the insurer. The term "award," in this case, refers to the agreement on the injured body parts and future medical treatment the insurer will cover for a particular period.

If you happen to receive Medicare while you reach a Compromise and Release settlement, you'll need an additional agreement. The supplemental agreement (also known as Medicare Set Aside), will state that part of the money received from the Compromise and Release settlement is meant to cover future medical expenses incurred on your work-related injury. Your future medical expenses will be paid by the Medicare Set Aside.

Once you sustain a work-related injury that leaves you temporarily or permanently disabled, a lawyer is your best hope to recover the financial losses the injury caused. At The Workers Compensation Attorney Group in Long Beach, it's our priority to help you receive medical treatment or disability benefits for your injury. We earned a good reputation across Long Beach, California for helping clients with cases involving workers' compensation. Call us at 714-716-5933 to speak with a qualified attorney regarding your workers’ compensation case.