MEDICAL TREATMENT, SUBJECT TO AUTHORIZATION.

In workers’ compensation, the employer can select which doctor the injured worker must go to for the first visit but after, the injured worker can elect to designate his/her primary treating physician. If the employer is part of a valid Medical Provider Network (MPN) proper notices were served, and other MPN requirements are met, then the injured worker must choose the primary treating physician from the MPN. That primary treating physician will be responsible for evaluating and treating, which includes requesting medical treatment that the doctor believes is reasonably medically necessary to cure or relieve the effects of the injury.

Timeline for Request for Authorization & Utilization Review

All treatment requests must be submitted on a form called a Request for Authorization Form (RFA). Once the doctor’s office faxes in the request for authorization form to the proper entity adminsterrating the workers' comp claim, then its Utilization Review department has 5 business days to either certify or deny the medical treatment. Even if the workers’ compensation claim is an accepted claim, the specific medical treatment requested by the doctor still has to be authorized in order for the injured worker to get medical treatment.

If a timely denial is made, there is a process to submit an application for independent medical review to a company called Maximus which has the authority to overturn the denial of that specific treatment.

If the denial was not timely made, then the injured worker can seek a court hearing and ask the judge to decide on the question of whether the medical treatment requested by the doctor is reasonably medically necessary.

TEMPORARY DISABILITY BENEFITS

Temporary disability benefits (TD benefits) replaces the worker’s lost wages, in order to maintain a steady stream of income. If an employee is unable to work because of a work related injury or illness, because the doctor takes the injured worker off work or the doctor indicates work restrictions that the employer cannot accommodate, then the injured worker is deemed to be temporarily totally disabled and should receive temporary total disability benefits – which is paid every two weeks. If the injured worker can only work part time as a result of the injury, then the injured worker may be deemed temporarily partially disabled and may be entitled to temporary partial disability. benefits. The amount of the temporary total disability (TTD) benefits is two thirds of the injured worker’s gross wages, subject to a maximum amount. 

When Temporary Disability Benefits Begin

For injuries that occurred after January 1, 2008, TD benefits are payable up to two years, within a five year period starting from the date of injury. .

PERMANENT DISABILITY BENEFITS

At some point, a primary treating physician, Qualified Medical Evaluator or Agreed Medical Evaluator will declare that the injured worker has reached Maximum Medical Improvement (MMI) and will declare the injured worker permanent and stationary. (P&S). This means that the doctor has found the injured worker’s condition has plateaued and not likely to get better or worse, without or with medical treatment, looking ahead into the next foreseeable year. At this juncture, the doctor is supposed to conduct a med-legal evaluation which includes a thorough examination. If the doctor finds that the injured worker still has residual impairment from the injury, the doctor will opine on the level of impairment called whole person impairment (WPI), based on a book called the American Medical Association Guidelines, 5th Edition.

The whole person impairment is then converted into a permanent disability number. The permanent disability, as discussed above, is based in part on the American Medical Association Guidelines and a rating formula., which calculates a final percentage number. Permanent disability is calculated using a formula which takes account an injured workers' whole person impairment, a 1.4 FEC modifier, occupation and age.

Permanent disability is equated into a percentage number which determines the monetary amount an injured worker will receive. In workers’ compensation, there is a permanent disability indemnification chart that indicates exactly how much each percentage of permanent disability equates to in monetary compensation.

If the parties agree that to the permanent disability number, then parties can begin settlement discussions.

Two types of Settlements in Workers’ Compensation

There are two types of settlements. The first is called a Request for Stipulated Award, which if approved by the court, settles only the permanent disability portion of the case. The second type of settlement is called a Compromise and Release, which approved by the court, settles permanent disability, future medical care, and all other issues underlying the workers’ compensation claim.

However, the injured worker should note that if workers’ compensation claim is settled by Compromise and Release which includes future medical care, the injured worker is obligated to consider Medi-care’s interest.

JOB DISPLACEMENT VOUCHERS

If an injury causes permanent disability, then the applicant is entitled to $6,000 Supplemental Job Displacement Voucher (SJDV) Benefits unless Defendant makes an offer of regular, modified, or alternative work lasting at least 12 months, within 60 days after Defendant’s receipt of the permanent and stationary report indicating permanent disability. Cal. Lab. Code 4658.7(b). The voucher can be used for retraining. The State of California’s Eligible Training Provider List can be viewed at https://edd.ca.gov/en/Jobs_and_Training/Eligible_Training_Provider_List

DEATH BENEFITS

An injured worker's estate including wife, dependents or children may be entitled to death benefits if the injured worker dies as a result of a work injury, condition or disease, caused or aggravated by work conditions.