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Detailed Disclosure to Client of Information Regarding Workers’ Compensation Benefits, Obligation, and Acknowledgement by Client

There Are Two Factors to Be Determined in a Workers’ Compensation Claim

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1. THE ISSUE OF INJURY ARISING OUT OF EMPLOYMENT & COURSE OF EMPLOYMENT:
Once an Employee Claim Form is filed with the employer, the insurance carrier can either accept the claim, deny the claim or delay the claim for ninety (90) days while they investigate the claim.
If the insurance carrier delays the claim they will only have to provide medical treatment approved by Utilization Review. The carrier will not have to pay any Temporary Disability Benefits.
2. WORKERS’ COMPENSATION BENEFITS:
There are four benefits currently available to injured workers in California. The benefits are as follows:
  1. Medical Treatment and Possible Future Medical Treatment;
  2. Temporary Disability Benefits (If the claim is accepted and the doctor takes the injured worker off of work or the employer can not accommodate the work limitations imposed by the doctor);
  3. Permanent Disability or Permanent Impairment, this is the settlement money if an injured worker does not recover completely from a work injury (Based upon the final report of the treating doctor, Agreed Medical Examiner or State Appointed Qualified Medical Examiner;
  4. Educational Voucher if the employer does not take the injured worker back to work.

A. Medical Treatment and Possible Future Medical Treatment:

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).

C. 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:
  1. Treating Doctor;
  2. Agreed Medical Examiner;
  3. State Panel Qualified Medical Examiner.

D. Educational Voucher:

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.

What Other Benefits May I Be Entitled to in Addition to Workers’ Compensation?

  1. Social Security: 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.
  2. State Disability Benefits: 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.
  3. Private or other Insurance: 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.
  4. Public Employees Retirement System: Please contact your union representative or personnel department to learn more about these benefits.

Recommendations and Important Considerations for the Client to Explore and Apply for After a Work Related Injury:

  1. APPLY AS SOON AS POSSIBLE FOR STATE DISABILITY BENEFITS THROUGH THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD);
  2. IT IS THE CLIENT’S RESPONSIBILITY TO KEEP YOUR EMPLOYER INFORMED OF YOUR WORK STATUS (IE. YOU NEED TO GIVE YOUR EMPLOYER you're OFF WORK OR MODIFIED WORK SLIPS AFTER YOUR APPOINTMENT WITH YOUR DOCTOR) FAILURE TO KEEP YOUR EMPLOYER INFORMED, MAY LEAD TO TERMINATION;
  3. IF THE WORK-RELATED INJURY WILL RESULT IN MORE THAN A COUPLE OF MONTHS OF DISABILITY, APPLY FOR SOCIAL SECURITY DISABILITY BENEFITS WITH THE SOCIAL SECURITY ADMINISTRATION;
  4. IF YOU ARE COVERED OR HAVE A SHORT TERM OR LONG DISABILITY POLICY (PRIVATE OR WITH YOUR EMPLOYER) YOU NEED TO APPLY FOR THE SHORT TERM OR LONG TERM BENEFITS IMMEDIATELY;
  5. UNDERSTAND THAT TEMPORARY DISABILITY BENEFITS PAID BY THE CARRIER WILL ONLY BE PAID FOR 2 YEARS (104 WEEKS) NO MATTER HOW SERIOUS THE WORK INJURY;

It is Important to Notify My Office if:

  1. You have returned to work or have changed job status or employment;
  2. You have been released by your doctor to return to work;
  3. You have a new injury or any re-injury regardless of the cause (Car accident, Accident at home or new injury because of your work injury) because this information is relevant to your pending work injury case.
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