As a California employee, it is essential that you learn about your legal rights regarding work injuries. There are important deadlines that must be met at the outset of each workers’ compensation claim, including a deadline by which you must report your injury to your employer. Employees who are already familiar with their legal rights to workers’ compensation benefits in California will generally have an easier time initiating their claims.

What Are My Rights Immediately Following a Work Injury?

Your employer is required to acquire and maintain workers’ compensation insurance, which provides workers’ compensation benefits to its employees if they get injured on the job. As an alternative, some employers may qualify to self-insure for workers’ compensation benefits. Whether your employer is self-insured or maintains outside workers’ compensation insurance coverage should not impact on your benefits.

Once you have reported your work injury to your employer, your employer must provide you with a workers’ compensation claim form. You will be responsible for filling out the employee portion, and then you must return it to your employer, who will then fill out the remainder of the form and forward it to the claims administrator. Your employer must submit it to the claims administrator within one working day of receiving it and must also provide you with a copy of the completed form.

Your Right to Medical Treatment

Within one day of receiving your injury claim form, your employer is required to authorize up to $10,000 in reasonable and appropriate medical treatment related to your work injury or illness. This is true even if your claim is in the process of being investigated.

If the claims administrator does not authorize your medical treatment right away, you should speak with an experienced workers’ compensation attorney who can help get your case back on the right track. You should be able to get necessary medical care now, even before the investigation of your workers’ compensation claim has been completed.

What Workers’ Compensation Benefits Am I Eligible For?

There are five different types of workers’ compensation benefits that you could be eligible for, depending on the nature and extent of your injury.

  1. Medical Treatment: Medical bills for reasonable and necessary treatment related to your work injury or illness will be paid for by your employer for any accepted claim (unless such treatment is disputed, in which case it is helpful to get a workers’ compensation attorney involved).
  2. Temporary Disability Benefits: Regularly paid benefits, usually by check or direct deposit, designed to compensate you for lost wages due to time taken off work to recover from your work-related injury.
  3. Permanent Disability Benefits: You are eligible for this benefit if you do not fully recover from your work injury and retain some level of permanent disability as determined by a physician.
  4. Supplemental Job Displacement Benefits: Injured workers with an injury date of 2004 or later may be eligible for supplemental job displacement benefits. This benefit includes a voucher to help pay for enhancing skills or for job retraining in the event that they do not fully recover from the work injury and are unable to return to work for their former employer.
  5. Death Benefits: Death benefits are available in cases in which an injured worker dies as a result of their work injury or illness. This benefit is payable to the deceased worker’s spouse, children, or other dependents. The disbursement of this benefit is based on how much the dependent financially depended on the deceased worker prior to their death.

What Are My Rights If My Medical Treatment Is Not Authorized?

Although your claim may be accepted, the claims administrator can challenge certain types of treatment as medically unnecessary or even unrelated to your work injury. Since the claims administrator is not a doctor and cannot give a medical opinion on their own, they typically hire a third party to review your doctor’s treatment plan. This process is called a utilization review (UR).

Under California law, all claims administrators must have a UR program in place. Based on the findings of the UR, the claims administrator may decide not to approve your doctor’s treatment plan.

If you find yourself facing this setback, it is a great time to seek out legal representation, if you still need to do so. An experienced workers’ compensation attorney will be knowledgeable about these types of disputes and will work to challenge the dispute.

Do I Have the Right to Challenge a Negative Utilization Review?

Yes, you have the right to challenge an unfavorable utilization review. However, it is important to note that there are specific deadlines that must be met in order to successfully complete this process and maintain your rights. Medical disputes for all dates of injury are resolved through the process of an independent medical review (IMR). So, if your treatment plan is unauthorized based on a UR, or modified to an extent that your doctor does not agree with based on a UR finding that the original treatment plan is not medically necessary, you can request a review of the UR decision through an IMR.

If your treatment plan was denied or modified by a UR, you will receive a written determination letter containing the details of the decision. With that letter, you will also receive a completed (but unsigned) IMR form, along with a pre-addressed envelope. To challenge the UR decision, you need to sign and send in the form to initiate the IMR process. If you are represented by an attorney, your attorney should receive the letter and will discuss your options with you.

Do I Have Any Right to Challenge My Doctor’s Report If I Disagree with It?

If you receive a medical report from your treating physician and you disagree with what your physician says about your injury, work restrictions, or your temporary disability status, you should discuss this with your attorney, if you have one. However, if you do not have an attorney, you do have some options you can pursue on your own.

You can request a medical evaluation with a physician called a qualified medical evaluator (QME) if your claim is denied and you need a medical evaluation, or if you need to find out if you are permanently disabled or will need future medical treatment.

Once you request a QME, the DWC Medical Unit will send you a panel of three QMEs, which are randomly selected. You have ten days from the date that the panel of QMEs is mailed out to select one from the list, make an appointment, and advise the claims administrator of the name of the doctor you have chosen and the date of your appointment. If you do not do this within ten days, the claims administrator can choose the doctor.

What Are My Rights If I Disagree with My Permanent Disability Rating by the State Disability Rater?

You do have options if you do not agree with the permanent disability rating issued in your case by the state disability rater. If you do not have an attorney, you can request that the state DWC review the rating. This process is called reconsideration of your rating.

This reconsideration review will allow the DWC to assess the medical evaluation and rating process to determine if mistakes were made. Additionally, you can also take your case before a workers’ compensation administrative law judge.

Alternatively, you cannot request reconsideration if you have an attorney. However, this does not mean that you are out of options regarding a challenge to your rating. Your attorney can also present your case to an administrative law judge and argue that your rating should be different for any number of reasons, depending on the circumstances involved in your case.

Do I Have a Right to Permanent Disability Benefits?

While most injured workers recover from their work injuries, many continue to have medical issues to some extent due to their work injuries. Permanent disability is considered any lasting disability resulting in a reduced earning capacity after you have reached maximum medical improvement. You can receive permanent disability benefits even if you are able to return to work. If you are eligible for these benefits due to the permanent nature of your injuries, you do have a right to receive them.

Should I Hire a California Workers’ Compensation Attorney to Protect My Legal Rights?

You can file your own claim for workers’ compensation benefits in California after suffering a work-related injury or illness, but it is often more beneficial to hire an experienced attorney. An attorney can help you navigate the complex legal issues that often arise throughout workers’ compensation claims.

At Kneisler & Schondel, our legal team has decades of experience helping injured workers fight for the benefits that they deserve. We take pride in our dedication to obtaining justice for our clients and do not hesitate to take tough cases to trial if necessary. If you have recently been injured at work and are wondering how to move forward with a claim for workers’ compensation benefits, contact our office today for a free consultation.