Workplace injuries are common and can occur when you least expect them. The process of filing a workers' compensation claim is uniform irrespective of where you work. If you suffer workplace injuries in Los Angeles, California and you are not sure about the process of seeking compensation, The Workers Compensation Lawyer Law Firm can guide you through the claim process.

The Process Of Seeking Workers’ Compensation Benefits

After suffering injuries in your workplace, it is advisable to get started with the workers’ compensation process right away. These benefits could be the lifeline you require after sustaining injuries. The benefits could help you cover your medical bills and compensate for lost income when you spend time away from work. However, the process of seeking benefits isn’t always straightforward. Any error or delay in the claim process could jeopardize your legal rights. This is where a workers’ compensation lawyer comes in. A lawyer will be your advocate, fighting for you at every stage of the claim process. Experienced workers compensation lawyers know how to deal with employers, medical practitioners, insurance companies, and judges.

The following are the steps you should follow when filing a workers’ compensation claim:

Reporting The Workplace Injury To The Employer

The first step in seeking your workers' compensation benefits is ensuring that you report the injury to your employer. You inform your employer about the damage and file a DWC-1 claim within thirty days after suffering an injury. The California Labor Code Sec. 5400 requires an injured worker to inform their employer about an injury within thirty days of suffering the work injury. However, as outlined by Labor Code section 5402, if an employer learns about the employee’s injury in another way, like if the worker informs their supervisor, this is similar to a written notice. An employee’s failure to notify the employer about an injury does not disqualify them from seeking compensation unless the delayed reporting causes the employer some adverse consequences.

You should inform your direct supervisor and ensure that you adhere to all the set protocols for reporting injuries. You should not stop after merely telling your employer that you suffered injuries in your workplace. You need to submit several documents to officially file a claim and continue with the workers’ compensation process:

  • A DWC-1 claim form
  • An Application for Adjudication of the claim
  • A declaration according to the Labor Code 4906 (g)
  • Document cover sheets and document separator sheets

Sometimes, a workplace injury may not manifest immediately. For example, specific workplace injuries develop over time and not from a single workplace injury.  In this case, you should inform the employer immediately you learn about the damage, and you believe that your illness is work-related.

No matter how the employer learns about an employee's injury, they will now have a chance to investigate your claim. The employer should provide the employee with the applicable claim form within one day of learning about the injury. The employee states the details regarding the incident on the injury claim form and then signs the document. Some of the points that an employee captures on the injury claim form include:

  • The date and specific time of the injury
  • The address or a description of the location where the workplace injury occurred
  • The type of damage and the affected body parts
  • Your social security details

When filling the injury claim form, you should ensure that you only provide accurate and reliable information. According to California law, any individual who intentionally makes a fraudulent or false statement or a material misrepresentation to enable them to obtain or deny workers' compensation benefits will be guilty of a felony.

When you submit the injury claim form to your employer, the employer will also complete a section of the form. Some of the information that the employer will fill in include:

  • The employer’s name
  • Their address
  • The date when the employer learned about the injury
  • The date when the employer received the injury claim form
  • The name and the address of the applicable insurance company
  • The employer’s signature
  • The insurance policy details

Filling The Relevant Claim Forms

The claim forms usually come off as a bit intimidating, especially with their abbreviations and long titles. After suffering an injury, you probably want as little stress as possible while filing a claim. Below are some of the documents that you need to know about:

The DWC-1 Form

This form is the primary workers’ compensation claim form. It will ask for specific details like your contact information and details of how you suffered an injury. You should outline every body part that was affected by the injury. Some injuries like nerve damage could radiate or signal damage on other body parts. Therefore, you should be careful and keep track of all the symptoms in other areas outside the injury site. After you fill the DWC-1 form, the employer will then submit this form to their insurer.

Application for Adjudication of Claim

You submit this form to the Workers' Compensation Appeals Board, commonly abbreviated as WCAB. While filling this form, you will need details of your employer’s worker’s compensation insurance company. You can either submit this form in person or do it via email with a proof form.

Document Sheets and Separator Sheets

These are pretty simple; you only need to print a cover sheet from the DWC website and include it with your claim forms. The separator sheet is placed after every form you have; they are more like dividers to ensure that your forms do not get mixed up.

Provision Of Required Notices

When your employer gets the completed claims form, they then forward the form to their insurer. The insurer will then provide you with notices that outline your various rights. Some of these rights are:

  • The applicable procedure in beginning the process of receiving workers’ compensation benefits
  • A detailed description of various forms of workers’ compensation
  • What will happen to your claim form after you submit it
  • From whom you can seek medical care for your injuries
  • The role played by the primary treating physician
  • Your right to change or select the treating physician according to subdivision of Labor Code Sec. 3550 and Sec. 4600
  • How you should access medical care when your workers’ compensation claim is pending
  • Your protection against discrimination according to Labor Code Sec. 132a
  • The employee’s right to disagree with the decisions that affect their claims

The Insurer Investigates The Claim

After submitting the claim form, the insurer will have up to 90 days to accept or deny the claim. The claim will be automatically accepted if the insurer does not decide within 90 days. The insurer should give you treatment of up to $10,000 even though they end up denying your claim.

While investigating the claim, the insurer may obtain your previous employment and prior medical treatment through a subpoena. The insurer may also question you under oath and have you evaluated by a doctor. The insurer will take these actions before accepting or denying your claim.

If the insurer denies your claim, they will send you a Notice of Denial of your workers’ compensation claim. If you wish to appeal the denial of your claim, you will have one year from when the claim was denied, which is the date indicated on the claim denial letter.

The Applicable Statute Of Limitations

Many insurance companies will use the statute of limitations as a basis to deny you compensation. Therefore, it is essential to ensure that you understand the timeline within which you should file a claim. The statute of limitations has an impact on your legal rights to access benefits within a specified period. Generally, the statute of limitation when filing a workers’ compensation claim is one year. However, different factors may delay this period. The one-year period commences at the most recent date when any of the following occur:

  • The date of your injury
  • Your last payment of permanent or temporary disability benefits
  • Your last medical treatment

The statute of limitations may not apply if your employer fails to give you a claim form or does not inform you that you have a right to file a worker's compensation claim. The employer has the role of informing all new employees about their entitlement to workers' compensation benefits. Employers must also post notices outlining the same in the workplace.

Receiving Documents From The Insurance Companies

The insurer should send several documents to you to notify you of:

  • Whether they have accepted or denied your claim
  • Your medical treatment appointment
  • Your medical evaluation appointment
  • When they will start and stop paying your temporary disability benefits and the rate, they will use
  • When they will start and stop paying your permanent disability benefits and the rate, they will use
  • A notice that outlines whether they have authorized or denied the medical treatment requested by your doctor.
  • Notice of all the relevant hearings that are related to your case

Receiving Compensation

After suffering a workplace injury, you may be entitled to the following benefits:

Medical Treatment

This includes costs for all medical, acupuncture, chiropractic, surgical, dental, and hospital care to relieve from the repercussions of the injury or cure you. You can choose a doctor from the approved MPN (Medical Provider Network). Your doctor should request treatment before providing medical services. Reasonable treatment is often approved, and this could include treatment medical providers situated out of state.

If the insurer denies your medical claim, you can still access medical treatment. Some medical providers will treat employees on a lien arrangement, meaning that they treat them without paying and then try to collect benefits from the insurer. These providers will not follow you to clear these medical costs, and neither will the costs be deducted from the settlement received from the workers' compensation claim. You could also fill a Medical Mileage Claim Form to seek reimbursement for the expenses incurred while driving to and from the doctor.

Temporary Disability Compensation

You can access temporary disability benefits if you can no longer continue working due to your injury. The temporary disability benefits usually amount to 2/3 of your former weekly pay. If you can work on a part-time basis, you will receive temporary partial disability benefits. This compensation translates to 2/3 of the income lost for the period you spend away from work. You can recover up to 104 weeks of your temporary disability compensation. Several factors could determine the applicable rate or the amount of the total permanent disability compensation in California.

EDD Compensation

The Employment Development Department, commonly abbreviated as EDD, pays SDI ( State Disability Benefits) when someone suffers an illness or an injury that is not work-related. If your work illness or injury is not granted, you could apply for the EDD benefits. However, if later on your injury is found to be work-related, the compensation benefits you received from the EDD  will be considered part of the disability benefits you would have gotten from your workplace injury.

Permanent Disability Compensation

Sometimes, a work injury might cause a permanent alteration in your medical condition. In this case, you will receive compensation for your loss. You will be considered to have suffered a permanent disability if your doctor establishes that your condition has stagnated and might not improve in the future.  Your permanent disability benefits will be calculated depending on:

  • Job type
  • Injury
  • Age
  • Change in your future earning capacity because of the injury or the illness.

When calculating the permanent disability benefits, experts commonly use the Disability Rating Schedule.

Death Benefits

These benefits will be available if a work injury causes the demise of a worker.  The benefits will vary depending on the deceased person’s dependents or family members. The dependents could receive a compensation of up to $320,000 split amongst them. The death benefits will also include $10,000 to cater for burial costs. 

Supplemental Job Displacement Compensation

The benefits will be available if an employee can no longer resume employment due to the injuries sustained. This benefit is usually given as a voucher of $6,000 to cater for job training.

Even after filing a workers’ compensation claim, the employer will allow you to continue working. It is an offense to discriminate against someone or terminate them because of filing a compensation claim.  If an employer cannot resume their regular duties due to the injuries suffered, the employer might offer them some lighter or modified duties. The altered or the lighter duties should have pay of at least eighty-five percent of the pay the worker was earning in their regular duties.

Specific guidelines are followed while calculating your workers’ compensation benefits. For example, despite suffering a work injury at work, you may have previously suffered an injury on some part of your body outside the work setting. In this case, you will only receive payment for the worsening of your condition because of the work injury. This is usually known as apportioning of a work injury and a pre-existing medical condition.  Your doctor will follow the AMA (American Medical Association) guidelines while determining your disability level. 

Solving Disputes With The Insurer

Things might not always go smoothly with the insurer. Usually, the insurer will have a distinct medical practitioner review the recommended treatment course. This review process is known as utilization review or med-legal exam. Sometimes, an employee will not agree with the insurer regarding some aspects of their claim. For instance, you may disagree with the insurer regarding the injury, the proposed medical treatment, temporary or permanent disability benefits, or any other part of the claim.

You may require having your issue handled by a judge in case of any dispute. To do this, you will have to apply for claim adjudication. You can file this application in any Appeals Board Office close to you. Upon filing this application, you will receive a case number. The next step involves filing a declaration of your readiness to continue. This form enables you to request a hearing to outline the specific issue that you can’t agree on.  Later, you will receive a Notice of Hearing informing you when you should appear in court and the judge who will handle your case. 

If the judge feels that a benefit was unreasonably denied or delayed, the judge might award a 25% penalty of up to $10,000. If the judge finds that the insurer denied or delayed a temporary or permanent disability accident, the insurer should pay you an automatic penalty of 10% even if the delay was by mistake.

Ending The Claim Process

You can decide to settle the claim with the insurer or have a judge decide on how much the insurer should award you for your injuries.  The settlement can be of two forms. You can obtain a flat sum of money to cater for your future medical treatment. You can also have the insurer continue to pay your medical expenses in the future. One plan pays you money right away, while the other continues paying you money over time. The judge may approve the two agreements.

You may enter an agreement with the insurer, commonly known as the stipulation, with a request for an award. This is an agreement regarding the temporary or permanent disability benefits. This agreement usually leaves the medical care open. The insurer will cater to all your medical care needs for the remaining part of your life. You will not get compensation for disability benefits at once. Instead, you will receive a payment for permanent disability benefits every two weeks, according to the rate set. This rate will vary depending on your level of disability.

 You can also enter a compromise and release agreement with the insurer. This agreement will end your case.  This agreement will settle the disability as well as your future medical costs.

The insurer will pay you an agreed lump sum amount within thirty days after settlement approval.  If you need future medical treatment for your damage, this will be your responsibility. 

Your Medicare status may affect your workers' compensation settlement. Therefore, you may require a Medicare Set Aside. This agreement outlines that part of the income you will get in the Compromise and Release agreement will cater to future medical treatment for work injuries sustained. Medicare may require you to cater to your workplace injury medical bills from your settlement amount until the money is over. With the agreement with the insurer, if you try to pay for your workplace injury treatment using Medicare, Medicare won’t pay until the money awarded in the settlement is over. 

If Your Settlement Case Goes To A Judge

If you disagree with the insurer and your case goes to the judge, the judge will listen to the issues and give a decision known as a Findings and Award.  The judge will have you provide testimony about the injury and check all your medical reports and other records related to your injuries before making the final decision. 

If you’re still uncomfortable with the judge’s ruling, you could appeal the decision by filing a petition seeking reconsideration. But, unfortunately, the appeal of a California workers' compensation claim could continue for years because it is a multi-level process.   

If The Employer Fires You Before You File A Claim

At times, you may have to file a workers’ compensation claim after the employer lets you go or you receive a notice of termination. In this case, you will have to prove that:

  • Your employer has notice of your injury before the layoff or the termination
  • There are medical records before the dismissal or the termination that show evidence that you suffered the said injuries
  • The injury occurred after receiving a notice of termination but before your last day at work
  • The injury is not a sudden or specific injury but one that occurred over some time. Therefore, it should be evident that you did not suffer any effects from the injury until after the notice of layoff or termination.

Find A Workers’ Compensation Attorney Near Me

After suffering a work-related injury, the process of filing a claim can be complicated and lengthy. However, with the guidance of an experienced workers' compensation attorney, the process is much simpler. Contact The Workers Compensation Lawyer Law Firm if you need reliable advice in filing a worker compensation claim in Los Angeles, CA. Call us at 424-501-9228 and speak to one of our attorneys.