Most California workers compensation cases resolve quickly but complex claims may take longer

Could It Really Take Three Years to Get Paid for Workers Compensation?California’s system of workers compensation is meant to provide injured workers with a prompt resolution of their claims for benefits. Some decisions are more prompt than others. When cases are complex or contested, a delay in paying benefits is more likely. Fortunately, the law provides injured workers with protections that discourage workers compensation insurance companies from deliberately delaying the payment of benefits.

Timeline to Collect Benefits

Some workers compensation benefits are paid right away. In most cases, medical treatment is provided immediately. Injured workers are also entitled to temporary disability benefits after they miss three or more days of work due to a work-related injury. Those benefits usually start being paid about two weeks after the injury is reported.

When employers contest whether an injury occurred or contend that it is not work-related, the employer might not pay for medical treatment or temporary disability benefits. However, a workers’ compensation lawyer can generally assist injured workers in obtaining the benefits to which they are entitled.

If an injured worker has paid for medical treatment out of his or her own pocket, he is entitled to reimbursement of those costs after establishing that benefits should be paid. In addition, if the employer’s failure to provide treatment was unreasonable, the injured worker may be able to collect a penalty of up to 25% of the medical treatment costs which the employer should have paid.

The same “delayed payment” penalty applies to temporary disability benefits when the employer unreasonably delays or refuses to pay that benefit. The availability of that penalty creates an incentive for employers to start paying temporary disability benefits promptly.

Permanent Disability Benefits

How long it takes to collect permanent disability benefits depends on several factors. First, permanent disability benefits do not begin until temporary disability benefits end. As long as an injured worker remains unable to work and the injury is getting better, the injured worker has not reached the stage of “maximum medical improvement” which triggers eligibility for permanent disability benefits.

With certain rare exceptions injured workers cannot receive temporary disability benefits for more than 104 weeks (2 years). Most often, injured workers either return to work or transition from temporary disability benefits to permanent disability benefits well before reaching that 104 week limit.

Keep in mind, however, that healing times vary. Even when two people have similar injuries, one might reach maximum medical improvement more quickly than the other. The longer it takes to reach the point at which healing stops, the greater will be the delay in receiving permanent disability benefits.

In addition, it may take some time before the amount of the permanent disability benefit that should be paid is known. The most common disputes in California workers’ compensation cases involve the nature and extent of permanent disability. Either the injured worker or the employer may disagree with how the treating physician assessed the injured worker’s impairment. When that happens, it is be necessary to obtain the opinion of an independent doctor, called a Qualified Medical Examiner (QME).

Generally, the injured worker’s lawyer can negotiate a workers compensation favorable settlement after a QME provides an independent opinion about the nature and extent of the permanent disability. In some cases, however, the dispute may need to be resolved by a judge at a hearing. Hearings add further delay to the process.

An unreasonable refusal by a claims administrator to pay permanent disability benefits can trigger a penalty. When employers agree that a permanent disability exists and is work-related, they must generally pay permanent disability benefits up to the reasonable value of the disability that they believe exists, even if a determination of the full benefit must await the outcome of a hearing.

Workers’ Filing Deadlines

Before an injured worker can obtain a hearing on disputed benefits, he/she must first file an Application for Adjudication of Claim with the Workers’ Compensation Appeals Board. The Application generally must be filed within one year of:

  • the date of injury,
  • the date medical treatment ended, or
  • the last date on which benefits were paid.

An Application for Adjudication of claim is the first step in moving a workers’ compensation claim towards resolution. Any time thereafter, an injured worker can request a hearing before a judge in order to have disputed issues resolved.

However, the parties will usually need to engage in discovery, including questioning witnesses to uncover all the relevant facts prior to a hearing. In some cases, it might take more than a year to complete the discovery process.

In order to set a case for a hearing before a judge, one must file a Declaration of readiness to Proceed (DOR) to hearing. The Workers’ Compensation Appeals Board (WCAB) will schedule the case for a Mandatory Settlement Conference (MSC) before setting it for trial. The judge will then require the parties to make one last effort to resolve the disputed issues informally. If that is unsuccessful, the judge will set the matter for trial. During that process the judge will try to narrow the contested issues by encouraging the parties to agree on the facts and those issues in dispute.

Settlement conferences prior to trials are used to encourage the parties to settle. When a settlement can be negotiated, both parties can put the case behind them rather than facing further delay and an uncertain outcome.

If the case does proceed to a trial, it may or may not finish in one day, depending on the number of disputed issues and the amount of evidence that will need to be presented. If the case does not finish, the hearing might not resume for several months because of crowded court calendars.

Ninety days after the trial ends, the workers’ compensation judge will issue a written decision. If either party disputes the findings of the judge, that party can appeal the decision to the seven member commission of the Workers’ Compensation Appeals Board in San Francisco. That appeal can add another year or more to the final resolution of the case.

Making Cases Move Quickly

The cases that take longer to resolve generally involve serious injuries, or serious disputes of fact. An experienced workers’ compensation lawyer can help injured workers take important steps which will maximize their ability to obtain a full and fast settlement of their cases.

To learn what you can do to speed your workers’ compensation claim to a fair resolution, contact the workers’ compensation team at Santa Rosa’s Kneisler & Schondel. Call us at (707) 542-5132 or ask us a question using our online contact form.