What is Workers' Compensation?

If you are injured on the job, or become ill due to your work, your employer has Workers’ Compensation insurance which pays your medical bills and a replacement wage if you need to lose time from work because of the injury or illness.

The State of California has required all employers to provide Workers’ Compensation insurance for nearly one hundred years. Before then, an injured worker had to sue his or her employer if there was an on-the-job injury, and then prove the employer was at fault before they could collect any reimbursement for the costs of their injury. Many injured workers devoted months to these lawsuits and ended up collecting nothing.

Today there is no need to show who was at fault for the accident which caused the injury. As long as you were at work when the injury occurred, and the injury was caused by work you were performing for your employer, then Workers’ Compensation will cover it.

Even some psychiatric conditions are covered by Workers’ Compensation, though there are some restrictions for eligibility if the injury is a psychiatric one.

Workers’ Compensation is different from State Disability or any health insurance which might be available to you. State Disability and health insurance are designed to assist you for non-work related medical problems and disabilities.

How do I file a claim?

Simply tell your supervisor that you have been injured on the job and he or she should refer you to a medical facility for treatment. If it is an emergency you should go to an emergency room or call 911, and tell the facility which treats you the condition is work related and, if possible, the information on CompWest as your employer’s Workers’ Compensation insurance company. Your employer should also give you a Claim Form (DWC-1) which you need to complete and return to your employer promptly. If you do not return the Claim Form right away you may not be eligible for all the benefits available to you.

What are the benefits?

Workers’ Compensation provides for Medical Treatment, Temporary Disability, Permanent Disability and Return to Work benefits. If you should die as a result of your injury there are Death Benefits available to your surviving dependents as well.

Medical Treatment

This is paid in full by Workers’ Compensation with no deductibles or co-pays. You should never receive a bill. The treatment needed to help you recover from the work related injury or illness is provided, though there are some limits with certain types of treatment.

Temporary Disability

If your doctor recommends you take time off from work because of your injury Workers’ Compensation provides that you receive 2/3 of your wages during the period your doctor feels you are unable to work. There is a maximum benefit of $728 a week for injuries which occur in 2004, and $840 for injuries which occur in 2005.The minimum rate through 2005 is $126 per week. Beginning in 2006 these maximum and minimum rates will be adjusted by the State of California for a cost of living factor. This benefit is not subject to any state or federal income taxes.

Here is an example of how your rate would be calculated:

Your wages: $800 per week

Multiply your wages by 2(2 X $800 = $1600), then divide that figure by 3($1600 divided by 3 = $533.33).

Your Temporary Disability rate would be $533.33 per week.

There is a three day waiting period before you are eligible to collect Temporary Disability, but the waiting period is waived if you are off work 14 days or more, or are hospitalized as a result of your injury or illness.

Temporary disability benefits can be paid up to two years from the date they begin. In certain serious cases, such as lung disease or severe burns, this two year limit is extended to five years.

The first Temporary disability check will be due to you on the 14th day following your report of your injury to your employer, or the 14th day of lost time from work, whichever is later. Once payments are begun the following payments will be issued every two weeks until your doctor releases you to return to work.

Permanent Disability

If you do not make a complete recovery from your injury or illness, additional cash payments will be made.

The weekly rate for Permanent Disability benefits is also two thirds of your wages, but there are lower maximum and minimum rates than for Temporary Disability. For injuries which occur in 2004 and 2005 the minimum rate is $105 per week, while the maximum rate is $200 per week for injuries which occur in 2004, and $220 per week for those which occur in 2005. For very serious injuries those rates increase to $250 per week (2004 injuries) and $270 per week(2005 injuries).

Once your doctor decides you have made as much of a recovery as possible from your injury or illness he will advise CompWest of this and provide a report detailing his findings on your permanent disability. He will also provide his opinion as to how much of this permanent disability was caused by your work injury and how much, if any, was caused by other factors. You are only entitled to Permanent Disability benefits for that portion of your disability which was caused by your work injury.

CompWest and you can agree to rely on your treating doctor’s opinion and use it to establish the amount of Permanent Disability payments you will receive. The doctor will use a Guide issued by the American Medical Association to translate your disability into a percentage number. The State of California has a formula which adjusts the rating provided by the doctor for the demands of your occupation, your age at the time of injury, and the likely lost wages your permanent disability will cause in the future. There is a table the State has issued which tells you how many weeks of payments you receive once the percentage of permanent disability is determined.

These permanent disability payments begin 14 days from the date your temporary disability payments end, and continue every two weeks until the full benefit is paid. If we do not know the exact amount of permanent disability, CompWest will continue the benefits until we have paid a reasonable estimate of the amount of permanent disability, with the balance, if any, paid once the actual amount is established.

Return To Work

If you are unable to work because of your injury, CompWest will work with your employer to see if there is a modified duty job available for you, or even an alternate job which you could perform while you are recovering.

If your permanent disability prevents you from returning to the job you were performing when injured, CompWest will explore with your employer whether either the modified or alternative work is available to you on a permanent basis. CompWest will notify you if such work is available. If so, there are no additional Return to Work benefits which can be provided to you. However, if no such permanent modified or alternate work is available, CompWest will notify you of this and, once your doctor determines you have reached maximum recovery from your injury, a voucher will be provided to you which you can exchange for the costs of school at a facility which specializes in providing new skills to disabled people. The greater the amount of your permanent disability, the larger the voucher amount will be, ranging from $4000 for lesser disabilities to $10,000 for those with the most severe disability.

Death Benefits

If your injury or illness causes your death, and you have people financially dependent on you, they can receive a Workers’ Compensation death benefit. This benefit is paid at a weekly rate which is the same as the Temporary Disability rate, but there is a higher minimum rate of $224 per week. As with Permanent Disability benefits, the total amount paid depends on the date you were injured. The number of dependents also affects the total amount of the benefit. For injuries in 2004 and 2005, if only one dependent exists, the benefit is $125,000. This is set to increase to $250,000 for injuries which occur after January 1, 2006. If two dependents exist, and they are totally dependent, the benefit is $145,000 for injuries which occur before January 1, 2006, and $290,000 for injuries which occur after that date. If any of your total dependents are under 18, they would continue to receive the death benefit until they reach age 18, even if that means the total paid exceeds the maximums. If you have a child who is physically or mentally incapacitated from earning, they would continue to receive the death benefit amount for the balance of their life.

In addition to these payments Workers’ Compensation provides for reimbursement of funeral expenses to a maximum of $5,000.

More on medical treatment

CompWest has entered into a contract with a network of physicians who have agreed to provide you with the medical treatment you need to recover from your injury and return to work. The only process which would allow you to treat with your personal doctor would be for you to notify your employer before your injury that you wish to be treated by your personal doctor should you suffer an injury. In order for you to qualify for this your employer has to make health insurance available to you, the physician you select must be familiar with your medical history and have access to your medical records, and he or she must agree to treat you for an industrial injury should it occur.

If you are seeing a doctor in the Medical Network you may still request a change of physicians if you are unhappy or unsure about your doctor’s recommendations. Simply advise your CompWest Examiner of your concern and a list of available physicians in the specialty which treats your injury will be provided to you. You can select a doctor from this panel as a second opinion. If you are still uncertain, you may even repeat this process and obtain a third opinion.

If you still have concerns or areas of disagreement after three opinions have been given you may still request an Independent Medical Review of your case. In this process the State selects a physician who will review your records or set an examination with you. If this physician also disagrees with the treatment recommendation of the treating physician, and makes alternate recommendations, you may go to any doctor you wish to have the alternate treatment provided.

Other things you should know

Illegal to Discriminate

It is illegal for your employer to discriminate against you for filing a Workers’ Compensation claim, or for even indicating intent to file a claim. If discrimination is proven you could receive reimbursement for lost wages, reinstatement to your job, increased Workers’ Compensation benefits, and reimbursement of your costs in bringing the claim.

Disagreements

Disagreements can arise in almost any situation. Though we at CompWest try to be reasonable and see every side of an argument, it is inevitable that there will be some issues on which we cannot agree. You have the right to consult and be represented by an attorney. His fee will be deducted from your permanent disability award.

You may also contact an Information and Assistance Officer at your nearest office of the State Division of Workers’ Compensation. The State employs Information & Assistance Officers who can provide you with written materials, at no cost, about Workers’ Compensation. The services of an Information & Assistance Officer are free to you. For the nearest office of the State Division of Workers’ Compensation you can look in the phone book under “Industrial Relations Department.” You may call 1-800-736-7401 for recorded information about the location of local offices, or visit the State Division of Workers’ Compensation website at http://www.dir.ca.gov/dwc.

There are times when differences are so great they cannot be resolved directly between the parties involved. The State has created the Workers’ Compensation Appeals Board to handle disputes between injured workers and their employers or insurance companies. The Appeals Board is a court of law. You may represent yourself or you may hire an attorney to represent you. However, the attorney will be paid a fee out of the permanent disability award made by the Workers’ Compensation Appeals Board judge. Generally, attorney fees are about 12 to 15% of the amount of permanent disability.

Another point to consider before deciding to obtain an attorney is that certain people will no longer be able to discuss your claim with you. Your Examiner at CompWest would be unable to discuss your case with you, as would the Information & Assistance Officer at the Workers’ Comp Appeals Board.

Timely Reporting is Critical

If you delay in reporting your injury it could cause a delay in your receipt of your benefits. You have a year from the date of your injury, or the date you knew your medical condition was related to your work, to file your claim. If benefits are being provided to you without a formal claim being filed, you have one year from the last date you received those benefits to file a claim for any remaining benefits you believe are owed to you. To protect your future rights, you should report every injury, no matter how slight. If it is more than a simple first aid situation, you should request a claim form be provided to you.

If your claim is denied, or you disagree with the amount of benefits being provided, you have the right to challenge the decision of CompWest Insurance, but there are legal deadlines for filing the forms at the Workers’ Compensation Appeals Board, so it is important that you avoid any delay.

Are There Other Benefits Available to Me?

If the injury is quite serious, and you are off work for a year or longer, you may be eligible for benefits from Social Security. For information, contact the nearest office of the Social Security Administration which is listed in the white pages of the phone book under “United States Government.” You may also discuss it with your employer or your Examiner at CompWest Insurance Company.

There is a state program called State Disability Insurance (SDI). Though similar to Workers’ Compensation, there are differences. Your employer pays the premiums for Workers’ Compensation Insurance and it takes care of on-the-job injuries. State Disability Insurance premiums are deducted from your paycheck and covers off-the-job injuries or illnesses. However, if you are not provided Workers’ Compensation benefits, or if there is a delay in deciding if your injury is work related, you may be able to get State Disability benefits. For information, call the local office of the State Employment Development Department which is listed in the government pages of your phone book.

More Information

If you have questions you can always ask your employer or your Claims Examiner at CompWest Insurance Company. A single phone call is often all it takes to resolve your problem. You can also receive recorded information or order free written materials about Workers’ Compensation by calling the State Division of Workers’ Compensation at 1-800-736-7401. The Division of Workers’ Compensation also has a website at http://www.dir.ca.gov/dwc. You may call and leave a message at the nearest local office of the Division of Workers’ Compensation and an Information & Assistance Officer will get back to you to explain your rights, address your problems, or provide other information. The address and phone number are posted at your work place and are listed in the State Government section of the phone book under “Industrial Relations Department.” There is no fee to you for using the services of an Information & Assistance Officer.

WORKERS’ COMPENSATION FRAUD IS A FELONY

Anyone who makes or causes to be made any knowingly false or fraudulent material statement for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony, and may be punished by imprisonment in county jail for one year, or in state prison for up to five years, and/or fined up to $150,000 or double the value of the fraud (whichever is greater), and ordered to pay restitution for any medical evaluations or treatment.
LC Sec. 1871.4