California Worker's Compensation Insurance
If you are injured at work, you are protected by state and Federal law. Most jobs are covered by State law except post office longshore, railroad and certain federal jobs. You need to know which system applies to you. You need to know your rights and how to protect them. These laws are alternately referred to as "workers' comp", "worker's comp", "work compensation", "workers' compensation", or "worker's compensation".
You are entitled to get the medical care you need to cure your injury. If you cannot be cured, you are entitled to get treatment to relieve the problems caused by the injury. You will be paid while off work (called the “total temporary disability” benefit). This may be less than your usual salary. You will get a settlement if you have permanent problems. These are called “impairments.” Finally, if you cannot go back to your regular job, you can get retraining (“vocational rehabilitation”). You can also get help finding a new job.
You can get information from your insurance adjustor, from the state “information and assistance officers,” and from worker’s advocacy sites on the Internet. If you don’t think that you are getting the care you need, or if you are treated unfairly, you can see an attorney at no cost. Some lawyers specialize in worker’s compensation law. Their fees are set by the state and paid for by the insurance company. Injured workers are not allowed to pay for medical care or for legal help needed because of a work injury.
Worker’s compensation insurance is different from most other types of insurance. Most treatments must be approved in advance and there is a good deal of paperwork. Care can be denied for a variety of reasons. Some procedures covered by standard insurance are not covered by worker’s compensation policies and some care which is covered by worker’s compensation insurance are not covered by medical insurance plans. For a variety of reasons many doctors will not treat injured workers.
Worker’s compensation systems are always changing. In many states there has been a decrease in some of the benefits paid to injured workers. Access to certain care, such as chiropractic care and physical therapy, are now limited. For example, in California a patient may obtain no more than 24 chiropractic treatments or physical therapy sessions. The insurance companies also have greater control over how and where a worker may obtain care.
Changes will continue to occur over time as new laws are clarified by the courts. The information in this section may be slightly out of date as the system continues to change. If you do not like the new laws you can influence the legislature by personally visiting your representative. His or her name can be found in the phone book.
At the end of this document is a glossary of terms, a list of web sites, and a list of phone numbers which will help you get more information.
If you have a serious injury, get treatment first. You should go directly to the emergency room if needed. You should report your injury to your supervisor as soon as reasonably possible. For problems which do not need emergency room care, your employer may direct you to see their own doctors or clinics.
Both California and Federal law guarantee certain benefits to employees who are injured on the job.
"Worker’s compensation" is a system of laws to provide injured workers with specific benefits, and a system where disputes can be resolved. A worker’s compensation claim is generally not a lawsuit against your employer, but it is a request, or claim, for insurance benefits. Worker’s compensation insurance protects you if you are injured on the job. It will pay for needed medical treatment and time lost from work. It may provide retraining and compensate you if you have a permanent disability. This insurance is provided by your employer.
Worker’s compensation is a "no-fault system." In most cases, you are covered, no matter what or who caused the injury. Any injury or illness that is caused (or worsened) by your job is covered by workers compensation insurance. This includes specific injuries (falls, cuts, etc.) as well as illnesses or other problems related to cumulative trauma (carpal tunnels, etc.). Some injuries from voluntary, off-duty, recreational, social, or athletic activities (for example, a company bowling team) may not be covered.
If you are injured at work, you need to inform your employer. Some jobs are covered by Federal worker’s compensation programs (including Post Office jobs, longshore jobs, and railroad jobs), but most jobs are covered by the State laws.
Generally, your supervisor will refer you to an occupational medicine specialist for your care. That doctor may also refer you to other specialists. You may also be assigned to an insurance claims administrator who will handle your insurance benefits.
In most cases you will receive good care from the employer's doctor, and your insurance claim will be handled smoothly. Generally, the doctor will communicate with your claims administrator who will authorize your care. In most cases you will not need to worry about authorizations and will never see a bill.
When your work status (or your legal status) changes, your doctor will tell you and your claims administrator. Again, you will usually not need to worry. When your case is ready to settle, your doctor will report to your insurance company. Either the doctor will provide the information to your claims adjuster, or you will be sent to another doctor for a special report called a "QME."
There are four basic benefits.
All medical treatment is covered without a deductible or dollar limit. Doctors visits, chiropractic care, acupuncture, psychological counseling, hospitalization, x-ray and lab, durable medical items (splints, braces, etc.), some furniture and any other item needed to "cure or relieve" you from the effects of your injury are covered. Costs are paid directly by the insurance company. Certain non-medical costs, such as charges for some forms, are not covered.
Payment for Lost Wages
If you are temporarily disabled by a job injury, you will receive tax-free income until your doctor says you are able to return to work. Under the California system, payments are set at two-thirds of your average weekly pay, up to a maximum set by state law. Under the California system, payments start after you are off for three days unless you are hospitalized or off for over fourteen days. The rules are different for injuries in the Federal system.
If the injury or illness prevents you from returning to your usual job, and your employer cannot offer modified work, you may qualify for job placement assistance or retraining. You receive payment for time spent retraining. The amount is less than that paid while you are totally temporarily disabled.
Permanent Disability Settlement
If you don't completely recover from your injury, you may be entitled to a monetary award. In California, this is called a "permanent disability." In the Federal system it is called “impairment." For California injuries, you are compensated based upon your loss of ability to "compete in the open labor market" or find a new job. This is estimated based upon how your injury limits your activities, your age, and your occupation. Most Federal plans compensate you for your loss of earning capacity. It depends upon your earnings at the time of the injury and the amount you will be able to earn after the injury.
How does worker’s compensation affect my own health insurance?
Worker’s compensation is separate from your regular health insurance. Your regular medical insurance usually will not pay for treatment for work injuries.
How do I file a claim?
As soon as possible, after your injury, tell your supervisor. Under the California state system, except for injuries that require only first aid, your supervisor will provide you a claim form (a DWC-1 form). Simply fill it out, keep a copy, and return it to your supervisor. If your employer does not give you a form, write your employer a letter describing your injury and keep a copy. You will be assigned an insurance company, "claims representative," or "adjustor" who will contact you.
Can a worker’s compensation claim be filed for an injury that occurred outside of work?
No, you cannot (with some exceptions). Also, it is a felony to file a false claim.
What happens if my employer does not have worker’s compensation insurance?
All employers are required to have worker’s compensation insurance. If your employer does not have insurance, you still may be covered. There is a State managed fund that covers those who work for uninsured employers. The above applies only to the California state system.
Can my employer tell me not to file a claim?
Rarely an employer will ask you not to file a claim. They may offer to "take care of you on the side." If you do not file a claim, you may be giving up benefits to which you are entitled.
What are my benefits?
If your claim is accepted, all required medical, hospital, and medical transportation costs will be paid. A portion of any wages, which you have lost, will be covered. If you have a permanent disability, you will also be compensated. You may be entitled to retraining if you cannot go back to your job. The above applies only to the California state system.
Where do I go for treatment?
Unless you have selected a personal physician before the injury, your employer (or their insurance carrier) is responsible for arranging your treatment for the first thirty days. You will usually be directed to an occupational medicine doctor. Under the California state system, if you have pre-selected a doctor, you may see that physician immediately after the injury.
What happens if I become dissatisfied with my treatment?
If you are unhappy with your care, you may:
The above applies only to the California state system.
Can I have more than one doctor?
Yes. You can have as many doctors as you need. Only one of your doctors can be your primary treating doctor. Under the California state system, you may choose your primary doctor (after thirty days) by sending a written note to your insurance adjustor.
Can I lose my job because of a worker’s compensation injury?
The law prohibits your employer from discharging or discriminating against you because of work injury. Unfortunately, many employers routinely terminate injured workers, and the employees unfortunately have little or no recourse.
How is temporary disability calculated?
The amount of pay, for time off work, is set by law. It depends on your usual pay and the date when your injury occurred. For injuries occurring after July 1, 1996, the weekly amount is two-thirds of your average pay, with a minimum of $126 and a maximum of $490 per week. The above applies only to the California state system.
When do temporary disability payments start and stop?
Generally, payments start after you are off work for three days. They start immediately if you are off for fourteen days total, or are hospitalized. They stop when you return to work or become "permanent and stationary." Checks are sent every two weeks. The above applies only to the California state system.
How is permanent disability calculated and paid?
When you become "permanent and stationary," your "primary treating doctor" will complete a report which describes your pain, examination findings, and ability to perform work. Depending on the date when you became permanent and stationary, the doctor may also assign an impairment rating. The report is then sent to a "rater" who will assign you a "disability rating." This reflects your loss of ability to compete for a new job. The rating is expressed as a percentage, from 1% to 100%. There is a table that allows your insurance company to calculate of the amount of money which you will be paid. The money is paid over a number of weeks or months. The above applies only to the California state system.
When do permanent disability payments start and stop?
Payments begin about two weeks after you become "permanent and stationary" assuming that your claim is not disputed. You receive from $140 to $230 every two weeks until the whole amount is paid (under the California state system).
What do I do if I have not received benefits I think I am entitled to receive?
Ask your claims representative. If you are still not satisfied, you may request the help of an Assistance Officer who works for the State. See the contact numbers below. You may also contact an attorney for help. You can find a lawyer in the phone book or by contacting the California Applicant Attorney's Association. See the contact numbers below. For your convenience, we have listed a number of law firms that practice workers compensation claims.
Do I need to hire a lawyer?
A lawyer can help you if you feel you have not received fair treatment. An attorney may be of help if you do not understand the system. In California worker’s compensation cases, the lawyer's fee is subtracted from your permanent disability settlement. You can find a lawyer in the phone book, by calling the California Applicant Attorney's Association, or by asking your union representative. In Federal worker’s compensation cases, your lawyer's fee is covered depending on your case.
Is worker’s compensation the same as State Disability?
No. Worker’s compensation is for injuries that result from work. State Disability is a type of insurance for other, non-work injuries. State Disability is handled by the California Employment Development Department.
Worker’s Compensation Glossary (see also the main glossary)
Adjustor - an insurance company employee who oversees insurance benefits; a claims examiner.
Agreed Medical-Legal Examination (AME) - a medical-legal examination, performed by a physician who is hired jointly by the applicant's lawyer and the insurance company to write a report which is then usually used to settle a worker’s compensation case; applies only to the California state system.
AOE/COE - "arising out of employment" or
occurring in the "course of employment;" an injury determined to be work
related; applies only to the California state system.
Apportionment - a legal determination that employment did not cause all of the problems related to an illness or injury (a finding that some other event contributed to the disability).
Causation - the legal determination that employment resulted in (or "caused") an illness or injury.
Claims Examiner - an insurance company employee who oversees insurance benefits; an adjustor.
Congenial - referring to a job which is consistent with a worker's disability restrictions.
Constant - under California law describes the frequency of a pain as occurring from 95% to 100% of the time; of "occasional," "intermittent," "frequent," and "constant."
Defense - the insurance company and/or employer who dispute a claim.
DEU 100 form - One of two forms needed with every QME report (click here for the form).
DEU 101 form - The other of the two forms needed with every QME report (click here for the form).
Disability – a numeric percentage (from 1% to 100%) that reflects an injured workers loss of ability to compete in the open labor market. This was replaced by “impairment” on 1/1/05.
Disability Evaluation Unit (DEU) - a California state office which calculates disability ratings based upon medical reports.
Disability Rating - a numeric percentage (from 1% to 100%) that reflects an injured worker's loss of ability to compete in the labor market; the percent of jobs he/she can no longer do; applies only to the California state system.
Dispute - any disagreement between the insurance company and the injured worker in a worker’s compensation case.
Doctor's First Report of Injury - a form completed by a doctor after your first visit; describes the cause of injury, treatment advice, etc. (click here for the form).
DWC-1 - a form completed by a patient to
report an injury to an employer (click
here for the form).
Frequent - under California law describes the frequency of a pain as occurring 75% of the time; of "occasional," "intermittent," "frequent," and "constant."
IME (Independent Medical-Legal Examination) - a medical-legal examination, performed by a physician, who is hired by a lawyer or insurance company and who creates a report which can be used to settle a lawsuit or a worker’s compensation case.
Impairment - a numeric percentage (from 1% to
100%) that reflects an injured worker's capacity; applies to the Federal system
and many state systems, including injuries in California where the patient is
declared permanent and stationary after 1/1/05.
Intermittent - under California law describes the frequency of a pain as occurring 50% of the time; of "occasional," "intermittent," "frequent," and "constant."
LC §4600 - The section of California law that regulates worker’s compensation claims and settlements.
Liability - responsibility to pay for an injury.
Litigation - a law suit.
Long Term Disability (LTD) - a private disability insurance policy that pays when people are unable to work for a "long" period (usually more than three to six months).
Loss of Capacity - decreased ability to perform work tasks, one component of the disability (not impairment) rating.
Maximum Medical Improvement - under Federal and some state systems (not California), when improvement stops and impairment can be calculated.
Medical-Legal Examination - an examination, performed by a physician, to determine legal issues such as disability.
Minimal - under California law describes the severity of a pain as an annoyance; of "minimal," "slight," "moderate," and "severe."
Moderate - under California law, describes the severity of a pain as causing a marked hindrance in performing an activity; of "minimal," "slight," "moderate," and "severe."
Negligence - responsibility; having caused an injury.
Nurse Case Manager - a registered nurse (R.N.) assigned by the lawyer or insurance adjustor to monitor medical treatments.
Nurse Practitioner - a registered nurse who provides care to patients; usually works with a physician to give care.
Objectives - physical examination abnormalities found by the doctor, one component of the disability rating.
Occasional - under California law describes the frequency of a pain as occurring 25% of the time; of "occasional," "intermittent," "frequent," and "constant."
Panel QME - a medical legal examination by a physician selected by the California WCAB computers.
Penalties - monetary fines imposed when a party violates the law; applies only to the California state system.
Periodic Report - a report submitted to the insurance company by the doctor after some visits; required by law; describes the current complaints, examination findings, treatment advice, etc.; applies only to the California state system.
Permanent and Stationary (P&S) - a point in time when problems related to an injury are relatively stable and most treatment has been completed; the time when temporary disability payments stop and permanent disability payments start; the time when the disability rating can be assessed; applies only to the California state system.
Permanent Disability (PD) - a numeric percentage rating (from 1% to 100%) that reflects an injured worker's loss of ability to compete in the labor market; the percent of jobs he/she can no longer do; applies only to the California state system.
Physician - under California worker’s compensation law this includes medical doctors, osteopaths, chiropractors, and acupuncturists.
Plaintiff - a person claiming injury in a lawsuit, not worker’s compensation.
PR-2 - a form completed by a doctor after each visit; describes the current complaints, examination findings, treatment advice, etc. (click here for the form)
PR-3 - a form completed by a doctor after a patient is "permanent and stationary;" describes the "subjectives," "objectives," "loss of capacity," and other disability issues. This form is for injuries that became permanent and stationary before 1/1/05 (click here for the form).
PR-4 – a form completed by a doctor after a patient is “permanent and stationary,” this describes the impairment related to the new impairment system in place since 1/1/05 (click here for the form).
Primary Treating Physician (PTP) - the one doctor, usually selected by the injured worker, who is primarily responsible for giving care and reporting to the insurance company; applies only to the California state system.
Qualified Medical-Legal Examination (QME) - a medical-legal examination, performed by a State "qualified" physician (who has passed a qualification exam), and who is hired by a lawyer or insurance company, to write a report which can be used to settle a worker’s compensation case; the examination may be requested by either the applicant or defense.
Qualified Injured Worker (QIW) - a person injured on the job who cannot go back to their usual work and must either be given either modified work or retrained for a new job; applies only to the California state system.
Sanctions - monetary fines imposed when a party violates the law; applies only to the California state system.
Second opinion – there are several types of second opinions. An employee may ask for a second opinion if he or she has questions regarding care. A doctor may ask for a second opinion. The insurance company can ask for second opinions at any time. For spine problems, a special second opinion system has been set up. A state assigned doctor may be required to authorize certain spine operations before they can be scheduled.
Serious and Willful - applies to an injury caused by an employer’s failure to follow the law; applies only to the California state system.
Severe - under California law, describes the severity of a pain as causing an inability to perform an activity; of "minimal," "slight," "moderate," and "severe."
Slight - under California law describes the severity of a pain as causing some hindrance in performing an activity; of "minimal," "slight," "moderate," and "severe."
Social Security - a Federal safety-net system which provides disability payments in addition to retirement benefits.
Special Report - a report submitted to the insurance company by the doctor when requested by the insurance company or required by law; describes the current complaints, examination findings, treatment advice, etc., or answers specific questions; applies only to the California state system.
State Compensation - a California state program which provides coverage for individuals disabled from work due to problems other than work injuries.
Subjectives - complaints or problems reported by the patient, one component of the disability rating; applies only to the California state system.
Total, Temporary Disability (TTD) - the time period when an injured worker must remain off work and also the money paid for the time off; applies only to the California state system.
Usual and Customary - referring to a job; one's ordinary work.
Vocational Counselor - an expert in retraining who helps an injured worker retrain and find a new job.
Vocational Rehabilitation (VR) - the process of retraining an injured worker and helping them find a new job.
Words-of-art - specially defined legal terms.
Work Restrictions - limitations of work activities which are imposed by your doctor.
Worker’s Compensation - an insurance system which provides benefits to workers injured on the job.
Worker’s Compensation Appeals Board (WCAB) - a group of judges, appointed by the State of California, who review cases and interpret the law.
Worker’s Compensation Judge (WCJ) - a California judge who presides over California state worker’s compensation cases, including those settled without a trial.
Every attempt has been made to insure that this information is a reasonable summary of the several common worker’s compensation systems in California. It does not apply to other states and may not apply to all workers in California. The law changes periodically, there may be special rules that apply to your case, and there are many situations not covered here. This is only a summary. It is neither legal nor medical advice. You should consult your employer, your insurance company, your union representative, the State or Federal representatives, or an attorney specializing in work injuries.
I am required by law to place the following statement on my web site:
"Making a false or fraudulent workers compensation claim is a felony subject to up to five years in prison or a fine of up to $50,000.00, or double the value of the fraud, or whichever is greater, or both, imprisonment and fine."