According to the law in California, you are entitled to compensation if you are injured or fall ill while at work. The Workers’ Compensation Insurance provides employee coverage and is one of the best programs that can compensate you in an unfortunate situation. Some of the benefits you are entitled to under the program include permanent disability benefits, hospital stay, medical benefits, supplemental benefits, death benefits, temporary disability, and lost wage benefits. Located in Orange County, CA, The Workers Compensation Attorney Group is an accomplished law firm with a successful track record in numerous workers’ compensation cases. In this article, we will provide an insight into the various compensation benefits offered by the Workers’ Compensation program.
Hospital and Medical Benefits
When you are insured, your employer is obligated to provide you with medical care in case of a work-related injury or sickness. The medication provided should be scientifically proven and tested to cure and relieve you of your injuries or illnesses effectively. Also, the hospital and medical benefits you receive should not be limited in terms of amount and duration. That is, they should be provided until you are fully healed and able to resume work as usual. Besides, the employer has to offer you with the benefits irrespective of whether you attended your job or not.
Expenses Covered Under Hospital and Medical Benefits
Section 4600 of the California labor code outlines the costs covered under the medical and hospital benefits. They include:
- Surgical
- Medical
- Acupuncture
- Chiropractic and hospital-related treatments
Such treatments include nursing, surgical and medical provisions, aiding tools like crutches among other devices and facilities offered.
However, unlike other benefits under the workers’ compensation, you are limited to 24-hour appointments of physical therapy, occupational therapy, and chiropractic therapy. If you require any additional appointments, you will have to notify the claims administrator who will then write an authorization for the requested addition.
Before you are taken for any medical treatment, the claims administrator, as well as your employer, will demand that you are subjected to Utilization Review (UR). These reviews help in determining whether medication is necessary for your work-related injuries or not. After that, a treatment meant to relieve you from the injury reasonably is arranged for you. While providing medical attention, physicians must adhere to scientifically oriented medical and nursing procedures. In California, the division of workers’ compensation recommends that the treatment of injured workers follow the Medical Treatment Utilization Schedule (MTUS). If you are treated following different guidelines other than MTUS, the claims administrator will be responsible for the expenses.
Can I get treatment from my own doctor?
Typically, employers have specific physicians or healthcare facilities which they have selected. In the event of injuries requiring treatment, your employer will organize for your treatment in the specified healthcare facility. However, if you are not satisfied with these doctors, you can opt for your doctor or a medical facility of your choice.
Before the injury, you are required to notify your employer in writing about the medical facility or the physician of your preference in case of such occurrences. The notice sent to your employer must be endorsed by the medical practitioner of your choice to show that they accept the duty to treat you in the event of a work-related injury. The doctor should not bill you after treating you for damages or illnesses related to work. Doing so will be viewed as a crime.
The physician or the medical facility handling your injuries must send a report to the Claims Administrator. The report provides details about:
- The type of your injuries
- The actual cause of your injuries
- The possible treatment plan
- The types of work you can engage in while recuperating
In case you need a copy of the report, the claim administrator and your physician should supply it.
What happens if I don’t agree with the physician’s reports?
If you don’t believe in the physician’s medical report concerning your injuries or illnesses, your attorney should respond immediately by sending a written notice to the claim administrator. The notice explains why you disagree with the report and is presented by your doctor. The attorney should ensure that they send the letter within twenty (20) days of receiving the report. The physician’s opinion may then be challenged.
The Claim Administrator will discuss the issue with your attorney and may agree to have an 'Agreed Medical Evaluator’ (AME). If disagreement continues, a request is sent to the California division of workers’ compensation. The body will seek a way out, and through their doctor, a report describing your injury is produced. This report will significantly influence the amount of the medical and hospital benefits available for you. Thus, your attorney should be careful enough to appoint a qualified physician who will provide a brief description of your injuries.
Temporary Disability and Lost Salaries
When you are injured at work, you may not be able to resume working while recuperating. This period is referred to as a disability period. During this time, workers’ compensation entitles you to temporary disability benefits. However, the payment is for a narrow period. Thus, temporary disability payments refer to benefits paid to you to make up for the wages you lost while you were recovering. You accurately receive these benefits if:
- You are hospitalized overnight
- You doctor reports that you are not able to work as usual for more than three (3) days
- During the recovery period, your employer hasn’t provided you with another job in which the wage equates to the one you lost due to injuries or illnesses
As an injured worker, you must inform your employer of your physician’s advice not to resume work until you are able. It would be best if you also let your employer know of the period you were on duty and record them on the 'Absence and Additional Time Worked Report form' commonly known as STD 634 form. Once your doctor reports that you can resume work, the payments for temporary disability ceases.
Before receiving the payments for temporary disability, you will be forced to wait for three (3) days which need not be consecutive. This period will be waived only if:
- You were hospitalized
- The illnesses or injuries were caused by crime related offense
- If you were disabled for not less than fourteen (14) days
Section 4650 of the California labor code demands that:
✔ The payment for temporary disability is effected within fourteen (14) days from the day your employer learns of your work-related injuries – an exemption is given where your employer decides to contest your claims regarding Workers’ Compensation,
✔ The claim adjuster should make the payment fourteen (14) days from the day you were injured. This is only applicable if your doctor reported of restrictions your injuries caused regarding the type of work you can do, and;
✔ Payments should be made to you bi-weekly provided that you are still eligible for the benefits. The source of the payment will be the California State Compensation Insurance funds.
There are three distinct types of Temporary Disability benefits offered in the state of California: they include:
Temporary Disability
Under this category, two (2) forms of benefits are identified, namely; Temporary Partial Disability and Temporary Total Disability.
You are entitled to Temporary Partial Disability if you can engage in selected types of work while you are recuperating. The work, your employer, offers you during this period is safer with a reduced workload. Consequently, the amount you will earn is lower than the legal limit, i.e., two-thirds of the total wage difference.
The advantage with temporary partial disability payment is that it is not subjected to taxes. Additionally, you are not required to use the amount received to contribute to unions, retirement funds, or social security taxes. The law in California also allows you to increase your temporary disability payments to your full payment using the leave credits you have accumulated.
Unlike temporary partial benefits, the amount payable for temporary total disability equals two-thirds of the amount you used to earn weekly before you were injured. The calculation is based on your wages before being taxed. However, the minimum and maximum limits are determined by the law. Thus; if two-thirds of your salary exceeds the set maximum, you are likely to receive below two-thirds of your salary. Similarly, if the two-thirds of your wages are lower than the set maximum, then you are likely to receive higher than two-thirds of your salary
Industrial Disability Leave
You may be entitled to these benefits if you are one of the active members of the California State Teachers Retirement System (CalSTRS), or California Public Employees' Retirement System (CalSTRS). Industrial disability leaves substitute temporary disability benefits.
Industrial Disability benefits are made available to you for a maximum of fifty-two (52) weeks within the bracket of two (2) years from the day you were injured. Your Industrial Disability pay will be based on your full net salary during the initial twenty-two (22) days of being disabled. After that, your payment will be two-thirds of your gross pay. If the amount you receive for this benefit is lower than your full net salary, the law allows you to supplement it with the leave credits that you have so far accrued.
Supplementation
While you are getting Temporary Disability payments, you also earn yourself leave credits the way you used to collect while working. You can always use the accumulated leave credits to supplement your disability benefits until your full net pay is attained. However, your supplemented temporary disability benefits should not exceed your net pay. You can get leave credit for supplementation from any of the following orders:
✔ Vacation leave
✔ Sick leave
✔ Compensation time off or any other type of credit left
You may opt to specify other different orders as well.
Factors determining the amount you will receive for supplementation benefits
Many factors determine the quantity of leave credit needed to supplement your temporary disability benefits. The factors include your:
✔ Monthly salary
✔ The duration or days worked on temporary disability
✔ Pay period days as well as any other payments that you receive during the payment period
Supplemental benefits differ from temporary disability pay in many aspects. For instance;
Temporary disability is paid by the California State Compensation Insurance Fund who often sends the supplemental benefits directly into your account. On the contrary, the supplementation payments are paid by the California State Controller’s Office.
While the temporary disability is not subjected to any mandatory and voluntary deductions, the supplementation is subjected to such deductions. Among the necessary deductions are the taxes union contribution, garnishment, and retirement fund contribution. The voluntary contributions include health, vision, dental benefits as well as life insurance. However, these deductions are only made if you have enough leave credits. During deduction, the mandatory deductions are considered first.
When will I stop receiving Temporary Disability Benefits?
Your eligibility for temporary disability benefits payments is terminated when:
- The physician assigned to you reports that you can resume your job as usual. The payment is terminated whether you return or you don't
- When you return to your initial post or an alternative which meets the maximum wage limit required for temporary total disability
- If your doctor reports that your condition is permanent and stationary and that no treatment can improve your condition any further. Also, the worsening of your condition will exempt you from receiving temporary disability payments.
Permanent Disability Benefits
You are eligible for permanent disability benefits if your injuries are permanent and you cannot recover from them. You can also be entitled to these benefits if the injuries you suffered caused you mental or any physical problem that bars you from functioning as usual. During this moment, the types of work you can engage will be limited. Several factors determine the amount payable as permanent disability benefits. They include:
✔ The kind of illness or injuries you suffered
✔ The date of your injuries
✔ The medical situation as per the medical report
✔ The degree or percentage at which the work can be blamed to have caused the injuries relative to other possible causes
✔ Salaries you use to receive before the injuries
✔ Your age
✔ Occupation
✔ Adjustment factor
Your primary treating doctor is significant in determining your permanent disability condition. This physician is a qualified medical examiner who is licensed and considered fit by the California division of workers’ compensation to carry out any medical assessment for cases related to workers’ compensation.
Physicians Report
You are considered permanently disabled if your primary treating doctor reports that your situation is 'permanent and stationary.' This statement implies that your condition will no longer get worse or better.
As the injured party, you should work closely with your employer, claims administrator as well as your primary treating doctor. With them, you could talk about:
- The work you were engaging in before your injuries
- Your medical conditions as well as what form of work you can do while in this state
- The kind of work that your employer is willing to give you
It is worth noting that the report presented by your primary physician should contain the rating of your disability. The score will be used by the disability evaluation unit of the division of workers' compensation to make a verdict on your permanent disability benefits. Specifically:
✔ 100% rating implies that you have Permanent Total Disability
✔ 1%- 99% suggests that you have Permanent Partial Disability
The law entitles you as an injured worker, to ask for the report describing your disability. In case you have any dispute about any part of the report, you can send a letter to the claim administrator requesting your need to challenge the report. It would help if you did this within twenty (20) days from the day you receive the information. You can also let your attorney discuss with the claim administrator about the rating of your disability. In most cases, the two usually reach an agreement. However, if they don’t agree, your case could be forwarded for discussion by the workers’ compensation judge who would then make a verdict.
If you are described to have a permanent partial disability, you will collect the full sum of the permanent disability benefits within a specified number of weeks. If you are considered to have a permanent total disability, you will receive the disability benefits payments for the remaining part of your life. Often, the payments for permanent disability begin fourteen (14) days from the day that you receive your last temporary disability payments. If you were not a beneficiary of temporary disability benefits, your payments for a permanent disability should begin fourteen (14) days from the day the claim administrator was informed of your permanent disability condition. These payments will then be made after every fourteen (14) days.
Supplemental Benefits
Also termed as Supplemental Job displacement benefits. These benefits are made available to assist in your retraining and skill improvement. You receive these payments if:
- You qualify for Permanent Disability
- Your employer is not ready to offer your job position back
- You do not go back to your former employer
These benefits require you to have at least been rated as permanently partially disabled. Your employer should not have given you any job; whether regular or a modified one within the time frame of sixty (60) days from the day the claim administrator received your report about a return or resume to work.
How are supplemental benefits paid?
The claim administrator offers you a voucher within twenty (20) days beginning from the last day your employer could have provided you with a modified, regular, or an alternative job. The voucher sent to you is non-transferable and redeemable for a maximum of six thousand ($6000) dollars. However, you cannot redeem the voucher as part of other forms of settlement.
The voucher implies that your educational training cost and also the skill development in recommended schools will be paid. The expenses which the voucher caters for include:
✔ Tuitions fees
✔ Tools
✔ Book supplies, and any other costs you will incur during the retraining period
Additionally, the voucher caters for the expenses incurred when acquiring certifications, licenses, and courses that prepare you for exams and any assessments.
Before the payment is scheduled, you are required to ask the officers at the Division for Workers’ Compensation to provide you with an outline of the institutions qualified for return to work counseling. Once you have chosen the institution, you should supply them with the voucher. Consequently, the administrator will send the payment directly to the institution or the counselor.
Death Benefits
At worst and on rare occasions, work-related injuries may cause your death. In these situations, your children and spouse should receive payments. Any other member of the family who was depending on you partially or wholly in terms of finances can also be entitled to the payments. The amount payable as death benefits depends on the number of dependents. The lesser the dependents, the higher the amount, and vice versa.
If there are minors who were depending entirely on you, they are entitled to continue receiving death payment until they turn eighteen (18) years old even after the specified amount has been cleared. Disabled minors are allowed to receive the amount for the rest of their lives. The rate at which the death benefits are paid is similar to that of total temporary disability benefits.
Note that: if the deceased died within one (1) year from the time of injury, you should submit the application form for death benefits within one (1) year from the day the death occurred, or one (1) year from the day the deceased persons' benefits was made available. Additionally, the dead will be accorded a decent burial made through reimbursement of not more than ten thousand ($10,000) dollars.
Other benefits that California gives workers apart from the workers’ compensation benefits include:
✔ State disability benefits
✔ Unemployment insurance benefits
✔ State disability insurance benefits
These benefits are mostly made available when the workers’ compensation denies you the claims for the benefits or delays in effecting your payment.
Find A Orange County Workers Comp Lawyer Near Me
The California Workers’ Compensation Insurance gives various benefits to workers who suffer job-related injuries. The process of obtaining the benefits may be complicated, with details such as eligibility criteria, and unknown benefits available to you.
The Workers Compensation Attorney Group in Orange County, CA, is always available to help workers to receive workers' compensation benefits when they are injured. If you have any questions regarding your workers’ compensation claim or wish to hire a competent workers’ compensation attorney, call us today at 562-485-9694, and we will address your issues.
