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Current Treatment:
The right to medical care and treatment are controlled by the workers’ compensation insurance carrier. The medical care and treatment benefits have been severely limited as a result of the Workers’ Compensation Reforms implemented by the Governor.
The insurance company controls the right to medical treatment and doctors will not provide medical treatment unless the treatment is authorized by the insurance carrier.
If the workers’ compensation insurance carrier or employer has established a Medical Provider Network, then the injured worker must treat with a doctor who is part of the Medical Provider Network. If the injured worker treats with a doctor outside of the Medical Provider Network, then the workers’ compensation insurance company will not recognize that the doctor’s opinions and benefits will not be provided.
If the employer does not have a Medical Provider Network, then the injured worker can designate their own doctor after thirty days from the date of injury.
The amount of physical therapy and chiropractic treatment is strictly limited to 24 physical therapy visits per injury, 24 chiropractic visits per injury and 24 Occupational Therapy visits per injury. The workers’ compensation insurance carrier can authorize more if they want to but most of the time the workers’ compensation carriers will not authorize more.
The right to medical treatment is determined by the workers’ compensation carrier through its utilization review company. Utilization review is the process by which the treating doctor’s recommendation for treatment is reviewed by a doctor or nurse to determine if the workers’ compensation carrier will authorize the treatment.
If the Utilization Review Company “Certifies” the treatment then the treatment will be authorized.
If the Utilization Review Company “Non Certifies” the treatment, then the workers’ compensation carrier will not provide the treatment and the treating doctor must appeal the “Non-Certification” by sending an appeal to the Utilization Review Company setting forth detailed medical information why the treatment should be provided.
If the treatment is denied again then the injured worker will have to see a State Appointed Qualified Medical Examiner or and an Agreed Medical Examiner (This process can take months).
Future Medical Treatment:
The right to future medical care when your case settles will be determined by either an Agreed Medical Examiner (Doctor that your attorney and the insurance company agree to use to resolve the issues or dispute) or by a State Appointed Qualified Medical Examiner.
B. Temporary Disability Benefits:
If the insurance company accepts (admits) the work injury claim and the treating doctors determines that the injured worker is unable to work (Temporary Totally Disabled), then the insurance company will pay Temporary Disability Benefits.
If the doctor takes you off of work, THEN IT IS YOUR RESPONSIBILITY TO KEEP YOUR EMPLOYER ADVISED OF YOUR OFF WORK STATUS BY SUBMITTING THE OFF WORK OR MODIFIED WORK SLIPS TO YOUR EMPLOYER.
Temporary Disability Benefits are paid at two thirds (2/3’s) of the injured workers’ average weekly wage (VERY IMPORTANT LIMITATIONS ON HOW LONG TEMPORARY DISABILITY BENEFITS ARE PAID). THE WORKERS’ COMPENSATION INSURANCE CARRIER ONLY HAS TO PAYOUT 104 WEEKS OF TEMPORARY DISABILITY BENEFITS.
TEMPORARY DISABILITY BENEFITS ARE PAYABLE FOR A MAXIMUM OF 2 YEARS OR 104 WEEKS THE DATE OF FIRST PAYMENT IF THE INJURY OCCURRED BETWEEN APRIL 17, 2004 THROUGH DECEMBER 31, 2007.
If your doctor puts on your disability slip that you are released to modified duty, then it is your responsibility to notify your employer by giving the employer the modified work slip to see if the employer is willing to provide modified work. If the employer is willing to provide modified work and you choose not to return to work then you will not receive Temporary Disability Benefits and the employer may terminate you.
THE INJURED WORKER SHOULD ALWAYS TRY TO OPEN UP A CLAIM FOR STATE DISABILITY BENEFITS WHEN THE WORK INJURY OCCURS.
State Disability Benefits are paid by the Employment Development Department of the State of California. The benefits are applied for by filling out a State Disability Application (Two parts, One by the injured worker and one by the doctor).
If you do not immediately apply after the injury for the State Disability Benefits then you will be precluded (Must apply within 47 days of the qualifying event, injury).
Permanent Disability or Permanent Impairment:
Permanent Disability or Permanent Impairment benefits are the settlement money paid when an injured worker does not recover completely from a work-related injury.
The Permanent Disability or Permanent Impairment is determined by the doctor when an injured worker is discharged from care. The analysis of the lasting consequences of an injury is determined by one or a combination of the following:
If the doctors indicate that the injured worker can not go back to work, then the injured worker may be entitled to the Educational Voucher.
If you are totally disabled and unable to work in any capacity for a full year, you may be entitled to Social Security Disability Benefits in addition to your Workers Compensation Benefits. Please consult your local Social Security Office any time after the fifth month of being disabled If you anticipate that you will be disabled for at least a year. If you want to file for Social Security Disability Benefits, you will need to complete their application (Information is available online) If you are turned down or denied after applying, let me know immediately so that I can refer you to an attorney that will assist in filing an appeal. Denials are often overturned on appeal.
If you are disabled and not getting Workers’ Compensation Temporary Disability Benefits or if you just filed the report of injury, you should apply the Employment Development Department for State Disability Benefits. You may be able to get State Disability payments while waiting for the workers’ compensation carrier to determine your entitlement to Workers’ Compensation Benefits (Temporary Disability Benefits). The application for State Disability Benefits need to be completed by you and your doctor and submitted to the Employment Development Department. Please note that you are not entitled to receive both Temporary Disability and State Disability (Unless your State Disability rate is higher, then you can receive the difference). I recommend that all of my client’s file for State Disability Benefits.
If you are disabled from working, you may be covered by other disability insurance such as short-term disability or long-term disability insurance, house, car, or credit card disability insurance. Consult your personnel department or if part of a union, consult the union benefits counselor for further information. In some cases, these benefits may be offset with your workers’ compensation benefits. It is a good idea to get a copy of your insurance policy from the insurance company.
Please contact your union representative or personnel department to learn more about these benefits.