No matter how trained or skilled an employee is or how many safety procedures are in place, workplace accidents can happen anytime to anyone. So, each employee and employer must become aware of the workers’ compensation plan’s ins and outs that are activated when an employee gets involved in a workplace accident, injury, or incident. To help you know about this program, we have created a complete guide on California Workers’ Compensation Program. 

Requirements in California for Workers’ Compensation Insurance

People or entities with even one employee working in California need to take workers’ compensation insurance. If you are a roofer, you still need workers’ compensation insurance even if you don’t have an employee. Independent contractors may or may not be covered by the insurance policy of the hiring company.

In 2015, a new labor law, AB5, extended the wage and benefit protections to ensure the inclusion of gig economy workers like freelancers, cab drivers, etc. 

If a business is located elsewhere, but an employee is working in California, the employer needs to provide worker compensation insurance. 

What is Workers’ Compensation?

Now that we’ve covered workers’ compensation insurance let’s move to the core topic- what is workers’ compensation. In simple words, if a person gets injured on the job, the employer of that person is required by law to pay for workers’ compensation benefit. 

The benefit is available if a person is getting hurt by one event like slipping on the floor and injuring the spine. It is also applicable if a person gets hurt due to repeated exposures at work, like losing your hearing due to constant noise. 

Exceptions

You should know that workers’ compensation covers only some psychological or stress-related injuries that are caused by a job. Also, it might not cover injuries that are reported after an employer intimates an employee that the person will be terminated or laid off. 

What Are Workers’ Compensation Benefits?

The workers’ compensation benefits can include a lot of things. A few examples are:

  • Medical Care

The expenses incurred on helping you to recover from an illness or injury are covered by your employer. It includes everything from medical tests, cost of medicines, travel costs, doctor visits, and other vital expenses for the treatment. 

  • Temporary Disability Benefits

If you lose your job or wages as your injury prevents you, you will be paid by the employer to recover in a stress-free manner. These payments stop when you recover. 

  • Permanent Disability Benefits

In case your injury is permanent, and you are not fit to do a job ever, you will get payments from your employer for the rest of your life. 

  • Supplemental Job Displacement Benefit

Also known as SJDB, this voucher is good for people who want to return to work after an injury or an accident. To be eligible for this voucher, a person should be eligible for receiving permanent disability benefits, and other conditions should be met, like the employer isn’t offering a person work, and a person can’t return to the former employer. The Supplemental Job Displacement Benefit is only available for people who were injured on the job in 2004 or later than that. 

In case a person’s injury occurred during or after 2013, a person can get not just the SJDB but also a one-time payment that comes under the Return-to-Work Supplement Program.

  • Death Benefits

If a person dies due to a workplace accident, injury, or incident, the spouse, children, or other dependents of the person will get some benefits if they prove to be worthy of it. 

What to Do If You Get Injured at Work?

If you get injured at work, you should seek medical attention immediately and then bother about workers’ compensation and other such stuff. After all, health is the true wealth. Here are a few steps you can follow if you get involved in a workplace injury, accident, or incident in California. 

  • Get Medical Attention

When you are injured on the job, and the injury seems serious, seek medical attention immediately by visiting the emergency room on your own or asking someone to take you there. In case the injury is not severe, you can ask your employer about which doctor you need to see. Many employers in California prefer if their employees visit a specific doctor only. If the doctor your employer has suggested fails to diagnose you or give you the treatment you need, you can request a second opinion. 

  • Report the Injury

If the injury is severe and you don’t have time to report to the employer, make sure that you report the injury after you have been given proper medical attention. Please don’t make the mistake of waiting too long, as it might mean that you might lose your eligibility to workers’ compensation benefits. Remember, as per California’s workers’ compensation laws, if you don’t report your injury to the employer within 30 days of getting injured, you might not get the benefits you deserve. Similarly, if someone suffers a work-related death, their employer should be notified by the loved ones of that person.

  • File a Claim

The next step is to file a formal workers’ compensation claim, i.e., fill the Form DWC-1. In case your employer doesn’t provide you with this form, you can download it directly from the Department of Industrial Relations. After receiving the form, the employer will file it with the workers’ compensation insurance company they have hired. You can check whether the form was filed or not, you can ask for a copy of the filed form.

  • Keep All Communication Records with Your Employer

Ensure you keep the communication records regarding the workplace injury, accident, or incident with your employer. It will help you to get your claim processed smoothly and prove any lies your employer might come up with to avoid giving you the benefits you need and deserve. If needed, talk to a workers’ compensation expert like the team of Laura M. Wilson & Associates Inc. to guide you through the process. 

What to Do After the Employer Files the Claim?

You have a year from the date of your injury to ensure the submission of the DWC-1 claim form. But it is advised that you don’t wait long and initiate the submission process as soon as you can. After completing the employer’s section, your employer needs to forward it to the insurance company. 

You should know that a day after submitting the claim form to the employer, the employer is legally bound to authorize the medical treatment needed for your illness or injury. 

You can receive up to USD 10,000 in medical treatment while you wait to decide the workers’ compensation claim. 

Your employer’s insurance company has 14 days to decide on your claim after the submission of the claim by your employer. There can be three outcomes. First is the company will accept the claim and give you the services and benefits you are entitled to. The second could be if the insurance company decides to investigate your claim and takes 90 days to do that. The third is if the claim is denied. In such cases, you might need the help of an expert like the team of Laura M. Wilson & Associates Inc. 

Reasons for Denial of Workers’ Compensation Claim and What You Can Do About it?

There can be many reasons why a workers’ compensation claim is denied. Some of them are:

If your employer or the insurance company hired by the employer thinks that your job did not cause the injury or illness.

If you made a mistake in filing the paperwork correctly.

In case you failed to file the claim on time.

What to Do If a Workers’ Compensation Claim is Denied?

As per California law, if your workers’ compensation claim is denied, you can make an appeal before the WCAB or Workers’ Compensation Appeals Board. The process includes requesting a hearing by filling and submitting an Adjudication of the Claim form. After you submit the same, you will get a workers’ compensation case number. Post that you need to file a Declaration of Readiness to Proceed form. The next step is to get a hearing date from WCAB. 

If your claim was denied because the employer or the insurance company didn’t believe your illness or injury is due to the work, you could check the AOE/COE (Arising Out of Employment/Course of Employment) box that is present on the Declaration of Readiness to Proceed form. Also, check the priority conference box. These little steps will ensure that you get an expedited hearing. 

You might be required to get your illness or injury reevaluated. In case you don’t agree with the evaluation, you can ask for a second opinion from a different doctor. The insurance company can also ask for a second opinion if they don’t like the evaluation. 

In case the denial was not due to the insurance company or employer thinking that your injury or illness is not work-related, WCAB might schedule a pretrial conference. In this conference, the WCAB judge will help reach a settlement. If the attempts to reach a settlement fail only, then a trial is held. In most cases, the need for trial doesn’t arise, and the matter is settled in favor of the injured or ill worker. 

The trial, if it happens, is like an informal trial without a jury. In this, an administrative law judge will hear the case and let both sides submit their case before they reach a decision. In case the decision is not in your favor, you can appeal that decision via a Petition for Reconsideration. The second trial, if it happens, will be held before a different judge. The decision of this trial will be issued in 30 to 90 days. 

How Is Workers’ Compensation Premium Calculated?

Several factors are used in calculating the workers’ compensation. Some of them are:

  • Classification 
  • Open Rating 
  • Premium Modification
  • Experience Modification
  • Prospective Rating
  • Premium Audit

What is Workers’ Compensation Fraud?

With time, workers’ compensation fraud cases have increased as people file fraudulent statements or submit false reports/fake documents to obtain or deny workers’ compensation benefits. It is a felony to file such statements, documents, or reports, and the law applies to all employees, employers, medical service providers, and claim adjusters. 

If you are receiving the temporary disability payments benefits like Labor Code 4850 benefits or disability pay and earned money by performing any work, you need to report it. If you fail to do it, it is considered a violation of the law. 

In California, workers’ compensation fraud is a serious offense, and if you are convicted, you can be asked to pay a fine of USD 150,000 or face up to 5 years in prison.

It is a fact that most workers’ compensation cases filed by employees are genuine, and most employees want nothing but appropriate medical attention and sufficient compensation for lost wages until they can return to work. If a person cannot return to work for medical reasons, they want sufficient funds to ensure that they and their dependents can survive the tough times. 

Contact the Right People to Know About California Workers’ Compensation Program

The team of Laura M Wilson & Associates Inc. understands this, which is the key reason we are here to help. No matter whether you need help with SJDB, RTWSP, Expert Witness Services, Vocational Rehabilitation Counseling Services, and Transferrable Skills Analysis, you can trust us to provide you with quality assistance. All the experts working for us are very skilled, empathetic, and competent. They would take the time to listen to your problem, come up with an adequate solution and help you get the right answers. All you need to do is be honest with them, and they will help ensure that you get what you want, be it returning to work with dignity or getting the SJDB on time. We work with you and for you. Call us toll-free on (800) 531-5608 to know how we can help you best. Good Luck!

References

https://www.dir.ca.gov/injuredworkerguidebook/Chapter1.pdf

http://www.insurance.ca.gov/01-consumers/105-type/95-guides/09-comm/WorkersCompensation.cfm

https://dominguezfirm.com/work-accident-lawyer/workers-compensation-a-complete-guide/

https://www.workcompone.com/california