1. HOW TO FILE A CLAIM
Question: If I am injured at work do I have to file a claim?
Answer: Yes. If you do not inform your employer and file a claim, you may be time barred from doing so in the future. If your employer knows that you have been injured at work, they should file a claim for you. However, they might simply give you a claim form and ask you to fill it out and return it to them.
Question: How do I report a work injury and file a claim?
Answer: You should inform your immediate supervisor. Generally, your supervisor will either file the claim for you or inform those higher up in the company to do so. If nothing happens, you should report your injury to your company's Human Resources Department or your manager.
Question: After I file a claim, do I have to go to my employer’s doctor?
Answer: Usually, yes. In some cases, you can pre-designate a treating doctor. Pre-designation must be done before you are injured. In most cases your employer controls your medical treatment for the first 30 days, which means you have to go to the doctor you are assigned for the first 30 days. After the first 30 days you can change doctors. However, in most cases, you must choose a doctor that is within your employer’s Medical Provider Network (“MPN”).
Question: What does my employer do after I file a claim?
Answer: Your employer contacts its insurance carrier and reports the claim to them. That insurance carrier will send you letters, including a medical release, and may contact you to take your statement. The medical release, if you sign it and send it back, allows the insurance carrier to obtain your medical records from your doctors. It is generally best to speak to an attorney before you sign a medical release or give a statement.
Question: Once I file a claim, how long before my employer provides me benefits?
Answer: That depends on many factors. First, your employer has 90 days to accept or deny your claim. Your employer does not have to pay you anything, including temporary disability, until it accepts your claim. However, during the first 90 days after you file a claim, until your employer denies your claim, it must pay for reasonable medical treatment for your injury, up to $10,000. If your employer denies your claim, it will not pay any benefits. You should always consult an attorney if your claim is denied.
Question: Can I be terminated from my job if I have filed a workers’ compensation claim?
Answer: Yes. However, the reason for your termination cannot be related to your injury or because you filed or requested to file a workers’ compensation claim. You can be laid off while you have a workers’ compensation claim, but you cannot be laid off because you are injured or have been injured, or because you are on modified duty or light work. If you are terminated after filing a claim, you should consult an attorney.
Question: How do I maximize the value of my claim?
Workers' compensation is a delicate practice area, and any mistakes or delays could affect the outcome of your case. A lawyer can guide you through which steps to take in order to maximize the value of your claim.
2. MEDICAL TREATMENT AND BENEFITS
MEDICAL
Question: After I file a claim, do I have to go to my employer’s doctor?
Answer: Usually, yes. In some cases, you can pre-designate a treating doctor. Pre-designation must be done before you are injured. In most cases your employer controls your medical treatment for the first 30 days, which means you have to go to the doctor you are assigned for the first 30 days. After the first 30 days you can change doctors. However, in most cases, you must choose a doctor that is within your employer’s Medical Provider Network (“MPN”).
Question: How long after I file a claim can I get medical treatment?
Answer: In most case you should see a doctor the same day. If your employer does not refer you to a doctor, you can go to one and bill your employer. However, if your employer does refer you to a doctor you cannot bill your employer for seeing your own doctor. If your claim is accepted, you have to go to the doctor that your employer sends you to for 30 days. After 30 days you can change doctors. However, in most cases, while you can choose your own doctor after 30 days, you have to choose a doctor that is within your employers Medical Provider Network (“MPN”). If your claim is neither accepted nor denied, you can get up to $10,000 in medical treatment, paid for by the employer. After 90 days, if your employer has not denied your claim, it is deemed accepted by law.
Question: How do I pick my own doctor within the MPN?
Answer: If you are represented by an attorney, your attorney can find a doctor for you. If you are not represented, you can contact your claims adjuster and ask him or her to send you a list of doctors that are in the MPN. You can then choose one of those doctors. However, not every doctor listed in the employer’s MPN will be seeing new patients or new workers’ compensation cases. You need to call the doctor and make sure that they will treat you before contacting the carrier again and informing them of the change of doctor.
Question: If I have an injury before 2004 and I have a doctor, but my employer is trying to force me to choose a new doctor in their MPN, do I have to?
Answer: No, not always. However, you must very closely review the notices sent to you to make sure they are right. You should consult an attorney. The rules regarding MPNs are very technical and, generally, you will need an attorney to fight this. In some cases, your doctor can write a letter to the employer, stating that you have a chronic condition. If accepted by your employer, you may be able to stay with your existing doctor for up to one year. Again, you should speak to a lawyer about trying to keep your doctor. Otherwise, your employer can force you to select a new doctor that is within their MPN.
Question: If I have an injury before 2004 and I have a doctor, but my employer is trying to force me to choose a new doctor in their MPN, do I have to?
Answer: No, not always. However, you must very closely review the notices sent to you to make sure they are right. You should consult an attorney. The rules regarding MPNs are very technical and, generally, you will need an attorney to fight this. In some cases, your doctor can write a letter to the employer, stating that you have a chronic condition. If accepted by your employer, you may be able to stay with your existing doctor for up to one year. Again, you should speak to a lawyer about trying to keep your doctor. Otherwise, your employer can force you to select a new doctor that is within their MPN.
Question: Can I get medical treatment for a work injury even if I have a prior injury to the same body part?
Question: Why can my doctor say I need treatment, but my employer will not authorize it?
Answer: In 2004, the California Legislature passed a law that allows your employer or its insurance carrier to deny medical treatment that it does not think is necessary. The system created is called “Utilization Review” or UR. This system allows your employer to deny treatment that your doctor recommends. Even if your employer sent you to a doctor, it can deny treatment recommended by that doctor.
Question: If my employer denies medical treatment that my doctor is recommending, how can I fight back?
Answer: If you are represented by an attorney, your attorney can object to the denial and request that you be examined by another doctor to determine if the treatment is reasonable. If you are not represented by an attorney, you can object to the denial and request a “panel QME.” Upon your request, your employer or its insurance carrier will obtain a panel QME list of three doctors. You can choose one of the three doctors to examine you and determine if your doctor’s treatment recommendations are reasonable.
TEMPORARY DISABILITY
Question: What is temporary disability?
Answer: There are two types of temporary disability. One is total temporary disability (“TTD”) and the other is total partial disability (“TPD”). TTD is paid when you are unable to work for a temporary period, due to your injury. TPD is paid when you can work part-time, but not full-time, due to your injury.
Question: If I am injured at work, how do I get TTD or TPD?
Answer: You must first report your injury to your employer and then see a doctor. If that doctor takes you off work, you are entitled to TTD if you cannot work at all or TPD if you can only work part-time. However, your claim must be accepted by your employer before you will get either TTD or TPD. Your employer may take up to 90 days to decide whether to accept or deny your claim. During this 90-day period, you will not receive either TTD or TPD. Your employer may accept your claim before the 90 days are up, at which time, you can get TTD or TPD as long as your doctor says that you should.
Question: When does temporary disability end?
Answer: Either when you are released to return to work or when you are found to have reached maximum medical improvement (“MMI”), which means you have healed up about as much as you are going to. At that point, you may be entitled to permanent disability if you are not 100% better after you have reached MMI.
PERMANENT DISABILITY
Question: What is permanent disability?
Answer: As with temporary disability, there are two types of permanent disability. One is permanent total disability (“PTD”). This is very rare and is paid to injured workers that can never compete for any job in the future. This person is determined to be totally unable to work. The other is permanent partial disability (“PPD”. This is paid to injured workers that can work, but still have some residual effects from their injury.
Question: How is permanent disability determined?
Answer: First, a doctor evaluates you and determines if you have completely healed from your injury. If you have not completely healed, your doctor will state what physical impairment you have and phrase that as a percentage, between 0 and 100% whole person impairment (“WPI”). Then, a schedule that is issued the State of California is used to determine a permanent disability rating. This rating is again, phrased as a percentage, between 0 and 100%. One the number is determined, another chart is used to tell you how much money you will receive for the residual effects of your injury.
Question: Can I work and receive permanent disability checks?
Answer: Yes. Permanent disability checks are very different from temporary disability checks. You can be working, full-time and still receive permanent disability checks. These checks are not to supplement lost pay. They are to pay you because of the residual effects of your work injury. Even if you return to work, doing the same job with the same employer, you may be entitled to receive permanent disability checks.
Question: How is permanent disability paid?
Answer: Generally, it is paid in checks sent to you every two weeks. If you are injured in 2005 and your permanent disability is 15%, you will receive approximately $11,110, paid out at a rate of $220 per week or $440 every two weeks, until your award of $11,110 is fully paid out. You can work full-time during this period and you will still get this money. If you completely settle your case, including your right to get medical treatment paid for by your employer to the injured body parts, you can have your permanent disability award paid to you in a lump sum.
3. GENERAL QUESTIONS
Question: If I file a claim for a work injury will I get fired?
Answer: No. It is very rare that an injured worker is fired because he or she filed a claim. If you are fired because you filed a claim, you can take action in the workers’ compensation court system to obtain back pay, benefits, and penalties against your employer. However, you must file a petition in the workers’ compensation court system within one year of your employer’s bad conduct, or your claim will be barred.
Question: Am I suing my employer when I file a workers’ compensation claim?
Answer: No. Filing a workers’ compensation claim is not a lawsuit. Your employer is insured against work injuries. The claim you are making is against that insurance. Even if your employer is a public entity or is self-insured, your claim is against the workers’ compensation insurance, not your employer.
