Frequently Asked Questions |
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What is workers’ compensation? 2) What is a workers’ compensation injury or illness? 3) Is workers’ compensation the same as State Disability Insurance? 4) How does this coverage affect my own health insurance? 5) How do I file a claim? 6) How do I get emergency medical treatment? 7) What are my benefits? 8) When does temporary disability start and stop? 9) How is permanent disability calculated and paid? 10) What is the role and function of the primary treating physician? 11) Can I choose the doctor who will treat me for my job injury? 12) What if I become dissatisfied with my treatment? 13) May I file a workers’ compensation claim if an injury occurs outside of work? 14) What if I have a recurrence and require further medical care? 15) What if I have to change my line of work because of a workers’ compensation injury? 16) What if I have not received the benefits I think I should have? 17) Are there time limits for filing a claim? DIVISION OF WORKERS’ COMPENSATION INFORMATION AND ASSISTANCE OFFICERS Free help and information is available by contacting a Division of Workers’ Compensation Information and Assistance Officer. For a listing of local offices you may call 800 736-7401 (recorded information only). Additional information may be obtained by going to the Division of Workers’ Compensation web site at http:www.dir.ca.gov. WARNING: Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony and may be fined and imprisoned. 1) What is workers’ compensation? At no cost to you, it is insurance that the law requires your employer to carry to help you if you are injured on the job or if you become ill due to your job. 2) What is a workers’ compensation injury or illness? An injury or illness that occurs due to employment is considered a workers’ compensation injury or illness. Under workers’ compensation law, you will receive help if you are injured, no matter who was at fault. 3) Is workers’ compensation the same as State Disability Insurance? No. Workers’ compensation is only for injuries or illnesses that occur due to employment. State Disability Insurance (SDI) is for injuries or illnesses that are not work-related, and it is a benefit that the Employment Development Department provides. 4) How does this coverage affect my own health insurance? Workers’ compensation is separate from personal health care insurance. Workers’ Compensation insurance covers work-related injuries and illnesses only. There is no deductible - the insurance carrier pays all approved medical bills. It is important to let the treating doctor know if your injury is work-related. 5) How do I file a claim? If you are injured on the job, as soon as you can, tell your supervisor and set medicthat you have been hurt. Your employer will provide you with a claim form within one working day after learning about your injury and to authorize medical treatment within one day of receiving the claim form, on which you can describe your injury, as well as how, when, and where it occurred. Return the completed form to your employer, who will send the form to the insurance carrier. The claims administrator will then get in touch with you to explain the benefits to which you may be entitled. 6) How do I get emergency medical treatment? If it’s a medical emergency, call 911, get immediate help and the best available treatments until emergency personnel arrives, or go to an emergency room right away. Your employer may advise you where to go for treatment. Tell the health care provider who treats you that your injury or illness is job-related, and, if possible, give your employer’s workers’ compensation carrier information. 7) What are my benefits? Your claims administrator will pay all approved medical, hospital, and reasonable medical transportation expenses. If you cannot work due to the injury, a portion of your lost wages will be paid. This benefit is called temporary disability. If your injury or illness results in a permanent impairment that decreases your ability to compete in the open labor market, you may receive permanent disability benefits or for injuries on or after 1/1/04, you may be eligible for supplemental job displacement benefit. For injuries prior to 1/1/04, you may qualify for vocational rehabilitation. In the event of a work-related death, death benefit payments may be made to your qualified surviving dependents. 8) When does temporary disability start and stop? The weekly temporary disability rate is two-thirds of your average weekly earnings, subject to minimum and maximum amounts set by the state legislature. If you are unable to work for more than 3 calendar days, the claims administrator will pay you temporary disability. This 3-day “waiting period” will qualify for payment, however, if you are unable to work for more than 14 calendar days, or if you are hospitalized as an inpatient. You will receive temporary disability payments every two weeks during the time you qualify for this benefit. Generally, temporary disability stops when you return to work, or when the treating physician releases you for work or says that your injury has reached a point of maximum improvement. There is a 104 week limit on temporary disability for most injuries. 9) How is permanent disability calculated and paid? Your examining physician will report on any permanent impairment that may be considered a permanent disability. Under workers’ compensation law, a permanent disability rating involves the use of a specialized formula. This formula considers your age and occupation at the time of your injury or illness, consideration being given to an employee’s diminished future earning capacity. The permanent disability rating yields a specific dollar amount. The exact amount depends on the date of injury, the percentage of disability, and your average weekly earnings at the time of injury. Once permanent disability payments begin, you receive payments every two weeks at your permanent disability rate. This rate is equal to two-thirds of your average weekly wages at the time of injury, subject to the established minimum and maximum rates. 10) What is the role and function of the primary treating physician? Your treating doctor will decide what type of medical care you’ll get for your injury or illness, determine when you can return to work, help identify the kinds of work you can do safely while recovering, refer you to specialists, if necessary, and write medical reports that will affect the benefits you receive. 11) Can I choose the doctor who will treat me for my job injury? You may be able to choose the doctor who will treat you during the first 30 days after a job related injury or illness if your employer provides group health coverage, or if you have medical benefits through a union. You must pre-designate your treating physician prior to an injury, and give your employer written notice of the name and address of your personal physician or personal chiropractor who maintains your records of prior care, and your doctor has agreed in advance to treat you for any work injuries or illnesses, then you may go to this doctor for treatment immediately after your injury. 12) What if I become dissatisfied with my treatment? If you dispute the diagnosis or treatment prescribed by your treating physician, you may request two additional opinions from other MPN Physicians. To file a dispute, you must submit the objection in writing to the insurance carrier with in 20 days of receipt of the decision in dispute. Your claims handler will set up a medical evaluation with a mutually acceptable MPN physician. If you dispute the third physician’s opinion, you may contact the California Department of Workers’ Compensation at (415) 703-4600 for an independent medical review. 13) May I file a workers’ compensation claim if an injury occurs outside of work? Your employer or their insurance carrier may not be liable for the payment of workers’ compensation benefits for an injury resulting from your voluntary participation in any off-duty recreational, social, or athletic activity which is not part of your work-related duties. NOTE: Workers’ compensation fraud laws make it a felony for anyone to file a false or fraudulent statement or to submit a false report or any other document for the purpose of obtaining workers’ compensation benefits. Anyone caught performing these illegal acts will be prosecuted. If convicted, the person can face up to 5 years in prison and/or up to a $150,000 fine, or twice the amount of the fraud. 14) What if I have a recurrence and require further medical care? If you need more medical care for your injury after your original treatment has ended, you have one full year after your last treatment to notify us of your request for more medical care. For injuries occurring on and after 1/1/04, an employee is limited to 24 chiropractic, 24 occupational therapy AND 24 physical therapy visits. 15) What if I have to change my line of work because of a workers’ compensation injury? A Supplemental Job Displacement Benefit (SJDB) provides that employees who do not return to work for their employer within 60 days of the end of TD period will receive a voucher of $4,000 for permanent partial disability of less than 15%; $6,000 for permanent partial disability between 15% and 25%; $8,000 for permanent partial disability between 26% and 49%; and $10,000 for permanent partial disability between 50% and 99%. The voucher must be used at state-approved or accredited schools for education-related retraining or skill enhancement, or both. This shall apply to injuries occurring on or after January 1, 2004. 16) What if I have not received the benefits I think I should have? If you have not received the benefits you think you should have, ask for an explanation from your claims administrators. Misunderstanding and errors sometimes do occur, but you can resolve most of them by talking with your claims administrator. If you are not satisfied with your claims administrator’s answers, you have several options. You have the right to consult with and be represented by an attorney. You can consult with an Information and Assistant Officer of the Division of Workers’ Compensation. You can also file an Application for Adjudication of Claim with the Workers’ Compensation Appeals Board (WCAB) to resolve your claim formally. The Information and Assistance Officer can help you file the Application for Adjudication of Claim. 17) Are there time limits for filing a claim? Yes. Generally, the law requires you to provide your employer with notice of your injury within 30 days of the date of injury. In addition, should you disagree with any of our actions, in order to protect your rights you must commence proceedings before the Workers’ Compensation Appeals Board by filing Application for Adjudication of Claim within one year of the date of injury, or one year from the last furnishing of indemnity or medical treatment benefits by your employer. It is very important that you act promptly so as not to risk losing your benefits because you waited too long. DIVISION OF WORKERS’ COMPENSATION INFORMATION AND ASSISTANCE OFFICERS Free help and information is available by contacting a Division of Workers’ Compensation Information and Assistance Officer. For a listing of local offices you may call 800 736-7401 (recorded information only). Additional information may be obtained by going to the Division of Workers’ Compensation web site at http:www.dir.ca.gov. WARNING: Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony and may be fined and imprisoned. |