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Frequently Asked Questions

 

I was hurt at work, who pays for my medical treatment?

You are entitled to medical treatment coverage through a physician within the Medical Provider Network for the insurance carrier. Medical treatment is to be 100% coverage of any treatment which is reasonable and necessary to cure or relieve from the effects of the industrial injury. Any treatment recommendations by your doctor must be submitted by way of a Request for Authorization Form (RFA) which accompanies a physician’s report. All RFA’s are subject to Utilization Review (UR) which is a process by which treatment requests are analyzed in the context of the California Medical Treatment Utilization Schedule (MTUS). UR decisions are supposed to be made within 5 working days of the RFA being submitted.

 

My doctor has requested medical treatment but the insurance company has denied it, what now?

If a UR request is denied, an appeal must be filed within 30 days. The only appeal of medical treatment which can be made is through a request for Independent Medical Review (IMR).

 

My doctor has taken me off work, how do I get disability benefits?

Temporary Disability (TD) benefits are paid to an injured worker when their injury prevents them from doing their normal and customary job and puts them in a “Total Temporary Disability Status”. There must be medical support (a doctor’s report/note) for any period off work.

TD benefits are supposed to represent 2/3 of an injured worker’s average weekly earnings on the date of the injury. There are minimum and maximum rates which apply, which vary depending on the date of injury. There are also special rules in situations of seasonal employment.

Benefits can continue for a maximum of 104 weeks of temporary disability benefits paid within five years of the date of injury.

Whether or not your claim has been accepted if you have contributed to State Disability Insurance from your paycheck, application should be made for State Disability Insurance (SDI) benefits through the Employment Development Department. Credit will be allowed for benefits you are receiving from other sources, but if your SDI rate is higher, or if you reach the end of TD eligibility, you may receive additional benefits.

 

If I hire an attorney, how are the fees paid?

Attorney’s Fees in Workers’ Compensation Representation are contingent fees based on an award of benefits, permanent disability award, or full negotiated settlement. Attorney’s fees range from 9% to 15%, and are subject to approval by the Workers’ Compensation Appeals Board. There is no situation in workers’ compensation representation where you are required to pay for an attorney’s services out of your pocket.

 

Will a workers’ compensation injury result in a monetary settlement?

If your injury results in permanent physical impairment, you will be entitled to an appropriate award of Permanent Disability (PD) benefits. A claim can be settled by way of a Stipulated Award, whereby PD benefits are paid out over time, and there is a right to continuing medical treatment coverage by the insurance carrier. It can also be paid by way of a Compromise and Release, which

 

I was injured several years ago and filed a claim but never followed up, is it too late to do something about it now?

Generally a workers’ compensation claim must be filed within one year of the date of injury. If it has been appropriately filed but never pursued, it can be still be pursued by filing an application with the Workers’ Compensation Appeals Board within five years of the date of injury. Special rules apply to injuries which are cumulative in nature, or are in the form of a disease process which may take a number of years to manifest.

 

A family member died as a result of work activities, are his dependents entitled to any compensation?

In the event of a death which results from an industrial injury or accident, a spouse or other partial or total dependent may be entitled to an award of compensation, including an allowance for burial expenses. When there is a minor dependent, benefits can continue until the age of 18 is achieved.

 

I am a firefighter/police officer and I had a heart attack – I have heard that some injuries are presumptive, is that true?

For certain public safety employees there are specific provisions of the California Labor Code which can cause heart injury, cancer, low back injuries, pneumonia, and hernias to be presumed industrial in origin. There are often highly contested claims which benefit from legal assistance.

 

My injury has forced me out of my job, can I get retrained into another type of work?

For dates of injury before January 1, 2013 if an injury prevents a return to work, there is provision of a $4,000 – $10,000 retraining voucher which can be used towards vocational rehabilitation.

For dates of injury after January 1, 2013 if an injury prevents a return to work there is provision of a $6,000 retraining voucher which can be used towards vocational rehabilitation.

 

I told my employer that I got hurt on the job and they fired me, can they do that?

There are provisions of the California Labor Code which prohibit an employer from discriminating against an employee because they have filed or made known their intention to file a workers’ compensation claim. If found to have been violated, the Workers’ Compensation Appeals Board can impose penalties and order restitution and reinstatement of a job.