All employers in California must provide workers' compensation benefits to their employees. The law requires all employers to purchase workers' compensation regardless of the number of employees that they have. This insurance compensates workers who fall ill due to the job conditions or workers who suffer accidents while on the job. The insurance company reimburses the workers for medical expenses, lost income, permanent or temporary disability, and job retraining. For the best guidance on workers' compensation in Los Angeles, CA, contact The Workers Compensation Lawyer Law Firm.

Typical Work-Related Injuries

What are some of the common injuries that workers suffer while on the job? Some of the common injuries that workers suffer at work include falls, vehicle accidents, injuries while lifting or moving objects. If the injury or an illness occurs while a worker is at work and is related to the job, the worker is entitled to the workers' compensation benefits. This insurance also covers injuries resulting from a one-time accident and cumulative injuries. Cumulative injuries result from making the same motion repeatedly. Sicknesses due to exposure, cumulative trauma injuries, and occupational disease are all covered by the workers' compensation insurance.

Most insurance companies deny compensation for psychiatric and stress-related injuries. Other injuries that might not qualify for payment include injuries resulting from horseplay and fighting. Injuries that occur when a worker is under the influence of alcohol or drugs or injuries that occur while committing a crime may not qualify for workers' compensation.

Filing a Workers' Compensation Claim

As soon as you suffer an injury or develop a worker-related illness, you should notify your employer. It's advisable to inform your employer before you seek medical treatment unless you have an emergency. Informing the employer is crucial because they will refer you to a doctor who is part of the medical provider network. You might lose your rights to compensation if you fail to inform your employer about the injury within 30 days.

After seeking treatment for your injuries, you should fill out the DWC form 1. DWC stands for Division of Workers Compensation. Within one year of your injury, you should file an application for claim adjudication to file your claim officially.

If you want to receive workers' compensation benefits after an injury, it's your responsibility to ensure that you file your claim on time. The process of filing a workers' compensation claim has three steps:

  • Reporting the injury
  • Filing the actual compensation claim with your employer
  • Submitting an application for adjudication of claim with the WCAB, WCAB stands for the Workers' Compensation Appeals Board.

For every step in filing a claim, there is a deadline. It is essential to ensure that you contact a workers' compensation lawyer soon after your injury. A lawyer will guide you through the claims process and ensure that you file all the claims within the set deadlines.

The clock starts ticking from the time of your injury. This date is precise if you are dealing with a work-related injury or accident. For instance, if you fall off the ladder in the workplace, you will be sure of the exact date of your injury. However, it might be challenging to identify the precise date when the trauma occurred if you are dealing with cumulative trauma. It might be hard to tell the specific date when you suffered a strain injury or repetitive stress. In such cases, the period for reporting the claim and seeking compensation will start when you first contacted a doctor or missed work because of the injury. The period will also depend on when you knew or should have known that the damage is work-related, usually after your doctor explains this to you.

Reporting Your Injury

You should seek immediate medical attention when you are injured in the workplace, especially if it's an emergency. If your employer or the insurance company has a medical provider network, you should ensure that you choose a doctor in that network. You should ensure that you inform your doctor or physician that your injury is work-related as you seek treatment.

Ensure that you inform your employer about the work-related injury or illness within 30 days after learning about it. Failing to inform your employer about the injury on time could make you lose your right to compensation. A delay might hold up your payment. However, there are some exceptions to the deadlines, including when you should inform the employer about the injury.

Filing Form DWC-1

Within one working day after reporting your injury, your employer should provide you with form DWC-1. This is a workers' compensation claim form. The employer must also inform you about your rights and your eligibility for compensation. The law also requires employers to educate their employees about what they should do to get the workers' compensation benefits and go about the claim process. What should you do if you don't get the DWC-1 form from the employer? You should visit the California workers' compensation website and download the form from the forms page.

Ensure that you follow all the instructions outlined in the form as you fill the employee's portion. Ensure that you capture all your injuries by mentioning every part of your body that was injured. After filing the DWC-1 form, you should hand the form to your employer in person. Alternatively, you could send the form through certified or first-class mail to ensure that your employer will receive it.  After receiving the filled form DWC-1, your employer will fill their section and submit the completed form to the insurance company. The employer will also give you a copy of the filled form.

Response from the Insurance Company

After submitting the claim form to the insurance company, the insurance company should authorize your medical treatment as it continues to investigate your claim and determine if the claim is valid. Before they even decide, the insurer must cover up to $10,000 of your medical bills. If the insurer does not deny the claim within 90 days of submitting it, it is considered approved.

If you can no longer continue working because of the injuries or the illness suffered in the workplace, the insurance company should begin paying for temporary disability benefits within 14 days after learning about your injury and the permanent disability. The insurer might have to pay a late penalty if they don't start paying the temporary disability benefits within the set 14 days after learning about your injury. The insurance company may also deny the claim or request the applicant to provide additional information. If a late penalty applies, the insurer will have to pay an extra 10% of the late temporary disability benefits.

Adjudication of Claim

You should not assume that all is well just because the insurance company has commenced the payment of your medical bills. You may only assume all is well if you had only suffered a minor injury and you recovered soon after treatment and resumed work. Your claim won't have complications if you don't have any disagreements with the insurer regarding the medical treatment and don't need to spend some time away from work. However, it's worth noting that your medical condition might change, and disagreements are common while seeking compensation. In case of any disputes, you won't resolve them even if you filed the claim accordingly with the employer. You need to open a case with WCAB by filing an Application for Adjudication of Claim.

The form WCAB-1 (Application for Adjudication of Claim) is available on the DWC website under the Court Forms. You should ensure that you fill this form within one year of:

  • The date of your injury or illness — Exceptions exist in the case of occupational diseases and cumulative trauma.
  • The last day when you received medical benefits from your employer
  • The day when you stopped receiving your temporary disability benefits

The above provisions are according to the California Labor Code Section 405. Courts have maintained that an injured employee might have longer to file for the adjudication of the claim. This applies as long as the insurer or the employer covers the workers' medical expenses while knowing that the treatment might be related to a potential workers' compensation claim. In this case, a worker will have up to five years from the injury date to file the application for adjudication of the claim. This is the same time that applies whenever there is a further or a new disability. An employee will have up to one year to file an application for adjudication of a claim if the insurer issues a notice that they deny the claim.

When Seeking Death Benefits

If an employee dies because of work-related injury or illness, the surviving dependents can claim to seek compensation for their loved ones' death. In this case, the dependent will have up to one year from the victim's death date to seek compensation.

While working with an experienced workers' compensation attorney, you will have an easy time filing all the necessary forms. However, if you don't have an attorney, the WCAB sends copies of your application to your employer and the insurance company.

When You Miss the Claim Benefits

What should you do if you miss the deadline for filing a workers' compensation claim? The first step should be to contact an experienced workers' compensation attorney. California's workers' compensation law is complicated, and you should not attempt to go it alone. Under certain circumstances, you might be excused for missing the deadlines. You might even get an extension of the deadline. An experienced workers' compensation lawyer will evaluate your situation and advise you on how the law works under such circumstances. A lawyer will also come in handy and represent you in the appeal process if the employer or the insurance company denies your claim.

Receiving Your Workers' Compensation Benefits

California workers' compensation insurance will cover all the medical expenses related to your work injury or illness. The medical expenses should be authorized, and it's advisable to go to a doctor within the network. If you have to stay out of work for some time due to your injuries, your workers' compensation lawyer can help you claim temporary disability benefits.

Typically, temporary disability payment covers 2/3 of your average weekly wage, up to a weekly maximum. You should start receiving temporary disability benefits within 14 days of filing a claim. You will be eligible for permanent disability benefits if your ability to work is permanently impaired, either fully or partially. The amount of compensation will depend on the percentage of the impairment that resulted from your injury or illness. The workers' compensation benefits are not taxable under California law.

Denial of a Workers' Compensation Claim

It is not automatic to have a workers' compensation claim approved. Filing a claim with the help of a workers' compensation lawyer increases the chances of having the claim approved. Some of the reasons why the insurance company might deny your workers' compensation claim are:

  • Lack of ample evidence to indicate that you suffered an injury at the workplace
  • Evidence that the injury you suffered is not work-related
  • You suffered the injury due to another job under a different employer.
  • You don't need medical treatment.
  • You can manage to resume work since the injury is minor and doesn't affect your ability to work.

Filing an Appeal After a Workers' Compensation Claim Denial

You should not give up if the insurance company or your employer denies your claim. With the help of your attorney, you can file a declaration of readiness to proceed. Your lawyer will help you file the declaration with the WCAB (Workers' Compensation Appeal Board). While filing an appeal, you must serve your employer and the insurance company with a copy of the appeal. 

While submitting an appeal, you also have to submit a proof of service form. The WCAB will hold a hearing and discuss your claim. The hearing resembles an informal court trial. During the hearing, the judge will listen to both the applicant's and the insurance company's side of the story. The judge will then decide whether the insurance company should accept the workers' compensation claim and compensate the victim. If you are still not comfortable with the help you receive from the WCAB, you can appeal a WCAB decision.

Even if most insurance companies have valid reasons for denying a workers' compensation claim, some companies are in the routine of denying claims without the right reasons. Some insurance companies deny claims hoping that an employee will drop the case instead of filing an appeal with the WCAB.

To get started with the appeal process, you or your lawyer will have to file a Declaration of Readiness to proceed with the WCAB. It's important to note that for you to file the DOR, you must have filed an AAC (Application for Adjudication of Claim). Filing an AAC is a crucial step in your claim process because it will enable you to get a workers' compensation number.

Priority Conference to Discuss AOE/COE Issues

AOE issues arise if the insurance company denies your claim on the basis that it doesn't believe the claim "arose out of employment." AOE issues imply that your injury probably resulted from other activities that are not related to your work. COE issues arise if the insurance company is not convinced that you suffered injuries or illness in the "course of employment." The WCAB will plan a meeting or hearing to resolve AOE the COE issues and determine whether to accept or deny your compensation. If you learn that the insurance company denied your claim based on AOE and COE issues, you should check the boxes indicating AOE or COE and priority conference on the Declaration of Readiness to proceed from.

Scheduling a Pretrial Conference

In most cases, the pretrial conference is scheduled if other issues rather than AOE and COE issues led to the denial of your workers' compensation claim. For instance, this conference might be scheduled if the insurer denies your claim because they don't believe you need medical treatment or that you deserve compensation for temporary or permanent disability.  You will receive a notice informing you about the hearing, including where the hearing will be held, the date, and the time. A workers' compensation judge will preside over the conference and help you solve the issue you have with the insurance company. The judge will then decide whether the insurance company should accept or deny your claim. 

If the workers' compensation judge cannot solve the issue at the conference, they will set your case for trial. At times, the judge might feel that more information is necessary before your case goes to trial. In this case, the judge sets a discovery plan. The discovery plan's role is to collect more evidence to determine all the issues in your case. In some instances, the workers' compensation judge sets up a status conference. The objective of a status conference is to determine whether the evidence collected is sufficient. Most of the disputed workers' compensation claims are resolved during the pretrial conference. Eventually, most insurance companies accept claims that get to the pretrial conference. Therefore, it's rare for a workers' compensation claim to proceed to trial.

If the Insurance Company Rejects Your Claim on Medical Grounds

If the insurance company denies your claim on the grounds of medical issues, it's essential to have a doctor evaluate your illness or your injuries. You may request a medical-legal evaluation by another doctor if you aren't content with your doctor's medical evaluation. The insurance company may request a medical-legal assessment from another doctor. If you don't have a workers' compensation lawyer representing you, you have to choose a doctor from a panel of qualified medical evaluators, commonly abbreviated as QME. However, if you have a workers' compensation lawyer representing you, the insurance company and your lawyer will choose from an agreed-upon medical examiner (AME).

The Role of an Attorney

If the insurance company denies you compensation, yet you suffered a significant injury, you should immediately contact a workers' compensation lawyer. You should not risk losing on the compensability issue. It would mean that you will not receive workers' compensation benefits, including compensation for the time away from work, reimbursement of medical expenses, and compensation for temporary or permanent disability.

A workers' compensation lawyer's primary role is to represent the claimant or the injured person to seek benefits. Some of the functions of a lawyer include:

  • Gathering medical evidence and compiling medical records
  • Taking the dispositions of physicians, claimants, medical experts, and other parties involved.
  • Conducting legal research and discovery, litigating cases before judges
  • Drafting findings of facts, pleadings, opinions, motions, and other legal documents

Other additional duties that your workers' compensation lawyer will conduct include:

  • Answering all your questions and guiding you through the workers' compensation process
  • Contacting the relevant medical providers and completing all the appropriate paperwork related to your claim
  • Representing your interests during the hearings, dispositions, trials, mediations, oral arguments, and arbitrations
  • Assisting you with benefits, including guiding you on how to obtain medical care
  • Communicating with the employer and the insurer regarding your medical condition
  • Negotiating workers' compensation settlements on your behalf

How Long it Takes to Settle the Case

How long it takes to settle a workers' compensation case depends on the case's issues. The case can be settled before trial when the parties involved agree. The claim may take longer if a lengthy discovery is needed to determine all the case issues. If a workers' compensation case goes all the way to trial, it means that the carrier and the claimant can't agree on a settlement. Working with an experienced workers' compensation lawyer could make the process seamless and shorter.

Find a Workers Compensation Lawyer Near Me

If you suffer an injury in the workplace or develop an occupational illness, you should file a workers compensation claim. It's wise to hire a workers' compensation lawyer to ensure that you get it right the first time and increase your chances of securing compensation. An experienced lawyer will gather all the necessary evidence and paperwork and present them to your employer and the insurance company. The Workers Compensation Lawyer Law Firm will help you file a claim in Los Angeles, CA. Contact us at 424-501-9228 and talk to one of our lawyers.