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The standard by which you may be entitled to certain benefits is whether you were injured in the course and scope of your employment. For instance, if during your work you slipped and fell on a tool left behind by another worker, fell off a high wall, injured your back lifting a heavy object, or inhaled toxic fumes over time that led to a respiratory or cardiovascular condition, then you can make a claim for benefits. Repetitive type injuries such as carpal tunnel injuries are included.

Notifying Your Employer

If you sustained a work-related injury, you have 30-days from the date of the injury to report it to your employer or it will likely be denied. It is highly recommended you inform a supervisor or HR department of your injury as soon as possible to prevent delays and for a complete investigation of your injury.

After reporting your injury, your employer has one working day to mail or provide you with a claim form. If your employer or insurer does not accept or deny your claim within 90-days of receipt of your completed claim form, there is a presumption that you were injured while on the job.

If you feel that you are having difficulty communicating with the insurer or employer or that your claim is being unreasonably delayed, contact an experienced workers compensation lawyer. Having an attorney at the early stages of your claim can move your claim along more smoothly, avoid delays, and result in your receiving all your benefits.

Workers Compensation Benefits

There are a number of benefits to which you are entitled if injured:

Medical care

You are entitled to medical payments one day after reporting your injury and while your claim is being investigated for up to $10,000 in such payments. Once approved, your medical care includes surgical procedures but is limited to 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits. These may be extended by your claims administrator or if you receive subsequent surgery and require additional post-surgery visits. Oftentimes, more visits are requested by your doctor but you may need your labor lawyer to make the request to the claims administrator along with the medical evidence or opinion to support it.

The length of your treatment may be governed by the MTUS (medical treatment utilization system) whereby a particular condition or illness has been medically shown or proven to cure or relieve work-related injuries and illnesses within a certain time frame or number of visits within that specialty. Also, your care and treatment is reviewed by a UR (utilization review) procedure to see if it considered medically necessary and effective. A UR review can sometimes be flawed. If so, your labor lawyer can file a complaint with the DWC.

Temporary Disability Benefits

You are entitled to payments while you are injured and unable to work. If you are unable to completely return to work for a time, you may receive temporary total disability (TTD). If you are only partially able to work, then you may receive temporary partial disability (TPD). This pays two-thirds of your gross pay but not more than the maximum weekly amount. Your income can include bonuses, commissions, and tips. Payments are made every two weeks and end when your doctor returns you to work. TD payments last up to 104 weeks for up to 5 years of the date of your injury, if injured after January 1, 2008. If your injury was chronic and severe, they can last for 240 weeks within a 5-year period.

As of 2017, the maximum TTD rate is $1,172.57 per week. On January 1, 2018, it will increase to $1,215.27 per week.

Permanent Disability Benefits

Injured workers who are unable to return to their usual employment at all or who have permanent impairments that result in decreased earning capacity are are also entitled to payments. You are given a PD or permanent disability rating once your treating doctor has determined you have reached MMI or maximum medical improvement. In other words, when your condition has stabilized and you will not improve.

In some cases, a doctor may give an opinion that part of your disability or impairment was caused by a non-work related condition and apportion it. An impairment is how your injury limits your daily living activities. A disability is how your injury affects your ability to work. An impairment number is put into a formula that determines your disability percentage. Your percentage is equal to a dollar amount that is dependent on your date of injury and your average weekly wages at the time of your injury.

Your condition was likely determined by a QME, or qualified medical examiner, who may be your treating physician. A rater from the DEU (Disability Evaluation Unit) will determine your rating or your lawyer can also have it done by a private rater.

If your doctor is not a QME and you do not agree with your doctor’s findings, your labor lawyer can request that a QME, paid for by the insurer, review your records.

Claims can be resolved by a lump sum that must be approved by the workers compensation judge overseeing your case. If you receive this, the insurer is no longer obligated to provide future benefits including medical care. An alternative is a stipulation for a sum of money and continued medical payments. An experienced workers compensation lawyer can negotiate a settlement that fits your goals, is reasonable, and protects your rights.

Supplemental Job Displacement Benefits

These are vouchers for retraining or enhancing your skills because you are unable to return to your usual employment because of a disability and restrictions.

Death Benefits

If you are killed on the job or from a job-related illness, then the insurer will make payments to your spouse or dependents. For one dependent, they get $250,000. $290,000 for 2 dependents, and $320,000 for 3 or more. Burial expenses are up to $10,000.

Reasons for Retaining a Workers Compensation Lawyer

Retaining a workers’ compensation lawyer is often necessary for a variety of reasons. Even if your claim has been accepted and you are receiving benefits, issues commonly arise where you will need a workers compensation lawyer to ensure all your benefits are being paid according to what you are entitled. In a large number of cases, a claim is denied because of insufficient medical evidence that your lawyer can review and remedy.

A workers compensation lawyer is paid on a percentage basis. In California, your labor lawyer is paid 10%, 12% or 15% of your benefits as approved by the workers compensation judge and is dependent on the amount of time your lawyer spent on your case. The fee does not include your medical payments or temporary disability payments. The simplest cases may result in the attorney receiving less than 10%.

Common issues for which an attorney is recommended include:

• Your injury was denied as non work-related
• You are considered an independent contractor and not an employee
• Your doctor gave you a permanency rating that the insurer is disputing
• You were terminated or laid off after your injury
• You have not received TTD benefits
• You have permanent restrictions but are denied occupational rehabilitation
• Your employer has given you a different job at a lower wage
• You are reported as permanently disabled and unable to return to any kind of work
• You are not receiving the correct benefits or other benefits to which you are entitled
• Medical benefits have been denied

Retain an experienced lawyer promptly if you are experiencing any issue or obstacles with your workers compensation claim.