Workers' Compensation in California



Employees who have been injured on the job in the State of California are frequently confused by the vast array of laws and procedures involved in:
    (1.) Determining whether or not they have a "case" and
    (2.) How to pursue a claim for workers' compensation benefits.

The information contained in this article is intended to be a general summary of the various benefits that  MAY BE available to an injured worker pursuant to  the workers' compensation laws in the State of California.

While each case is different, the following is an outline of how a case normally proceeds through the system. In general, there is a big difference between a "denied" case and an "admitted" case. The outline below deals primarily with cases where the insurance company has admitted that an injury has occurred. However, there may be disputes regarding other important issues such as the nature and extent of the injury, the need for medical treatment and the need for vocational rehabilitation. When the insurance company "denies" that an injury occurred, many of the issues will have to be litigated or the injured worker will have to agree to take something less then the maximum allowable benefits that the law provides.
Temporary Disability  Permanent Disability Medical Consultations Agreed Medical Examinations
Settlement Rehabilitation How the system works Workers' Compensation Medical Liens(Under Construction)
The Uninsured Employer
 

Temporary disability is paid at a weekly rate during the time the doctor says the injured worker is unable to work due to the injury and there is still a chance of improving the condition with medical treatment. The compensation rate is two-thirds (66%) of the employees gross earnings, up to the maximum amounts set by law. The current maximum rate is $490.00 per week(if the injury occurred on or after 1/1/96). Depending on the date of injury, there is a short waiting period for your first check. It usually takes about 2 weeks before the first payment is made.

If for some reason the insurance company will not pay temporary disability, it is often possible to receive disability payments from the Employment Development Department. These are called SDI (State Disability Insurance) benefits. An injured worker cannot receive benefits from both the workers' compensation carrier and from the Employment Development Department.

PERMANENT DISABILITY (PD)

An injured worker may be entitled to receive a permanent disability award if the injury leaves her or him with any residual disability. This is not payable until the medical condition becomes permanent and stationary, which means the doctor has stated the condition has leveled off and will stay substantially the same in the future. It does not necessarily mean that the person has totally recovered from the injury. In fact, if the doctor says there has been a total recovery, there would be no permanent disability award.

MEDICAL CONSULTATION

As soon as the treating doctor indicates that the person's medical condition may be permanent and stationary or that the person can return to work, arrangements should be made for you to be examined by a medical specialist who deals with the type of injuries sustained. If the injured worker is not represented by an attorney, the insurance company will send the injured party a list of doctors to choose from. If the person is represented by an attorney, the attorney will choose the evaluating doctor or make an agreement with the insurance company to utilize an AME(see below). The insurance carrier may also have the injured worker evaluated by a physician of their choice.

AGREED MEDICAL EXAMINER(AME)

Sometimes the injured worker's attorney and the insurance company can agree to utilize one doctor to examine the injured worker once she or he is permanent and stationary. There are many benefits to using an AME. There are also risks. One benefit is that relying upon one doctor to address the issues eliminates the problem of trying to settle a case based upon two medical opinions that are often in major disagreement. Another good reason is that when using an AME, it is pretty much certain that the resolution of the case will be based upon the medical issues as opposed to legal technicalities. The risk involved is that both sides are bound to the doctor's opinion unless it can be shown the doctor in some way made a mistake in his or her opinion.

The consulting physician prepares a detailed narrative report setting forth his or her opinion as to the nature and extent of any disability, the need for further medical care and the ability to return to work. It usually takes the doctor about 4 to 6 weeks to prepare and mail out the report.

SETTLEMENT OF THE CASE

Generally, a case cannot be settled until all of the medical reports are prepared and mailed to all parties. The report will also be "rated" and a percentage of disability will be assigned to the doctors opinions in accordance with the rating guidelines of the State of California. These rating guidelines are pre-set and uniform throughout the state. The "rating" percentage is then converted to a monetary amount also in accordance with a pre-set schedule.

REHABILITATION

If the doctor indicates that because of the injury, the employee will not be able to return to their usual occupation or the job engaged in at the time of the injury, the injured worker may be entitled to rehabilitation benefits. A rehabilitation program includes services which are reasonably necessary to return you to suitable gainful employment. A rehabilitation counselor will be assigned and the counselor will assist in the preparation of the program, taking into consideration the injury, past working experience, transferable skills, motivation and labor market. While actively engaged in the rehabilitation program, the injured worker will continue to receive either temporary disability benefits or a rehabilitation maintenance allowance, depending on the date of injury.

HOW THE SYSTEM WORKS

1. COURTS AND LAWSUITS
The Workers' Compensation Appeals Board is the trial court for all industrial injuries involving your employer. This is an administrative law proceeding. There are no juries. A workers' compensation judge makes all of the decisions if the case goes to trial. If you are injured as a result of the fault of someone who is not employed by your employer, you may be able to sue that person in Civil Court, in addition to your action against your employer.
2. ATTORNEYS' FEES
Attorneys' fees are set by the Workers' Compensation Appeals Board and are usually 12% to 15% of your award or settlement. Attorneys are also entitled to a similar fee for assisting in arranging the rehabilitation program. When there is no recovery on a case, there is no attorneys' fee.
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