WORKERS' COMPENSATION FOR INJURED WORKERS
The purpose of workers' compensation is to ensure that a worker who is injured in the course of employment, (regardless of fault of any party in most cases), will have adequate compensation while the worker is unable to work, and will be provided with medical treatment that is reasonably required to cure and relieve him or her from the effects of the injury.
In California, if you have a work related injury, the workers' compensation law provides medical care for employees and, in most cases, provides benefits while the injured worker is recovering from the injury and after the recovery. In order to ensure coverage for employees, California law requires that employers carry workers' compensation insurance or be self insured.
There are two types of work related injuries:
A "specific injury" is a type of injury that is caused by a specific event. For example, back injury due to lifting or falling on a specific date.
A "continuous trauma injury" is a type of injury that is caused by repetitive movements, or caused by repetitive exposure to stress or toxins over time. For example, pain due to repetitive lifting, pulling, reaching or typing over several months or years; or lung, internal or heart problems due to exposure to toxins or work stress over a period of time.
The workers’ compensation laws provide benefits to injured employees including medical treatment, temporary disability, permanent disability, job displacement voucher, death benefit, and return to work fund. These benefits serve different purposes.
TYPES OF BENEFITS
1. MEDICAL TREATMENT
Medical treatment is provided to facilitate the injured worker's recovery and to maximize his or her productive employment. In 2013, changes to the law in regards to appealing denials of medical treatment took effect, requiring the appeals to be filed with independent medical review (IMR).
Initial Medical Care Within 24 hours
If the work related injury occurred after April 19, 2014, the employer is required to provide medical care up to $10,000 within 24 hours of the injured worker filing a claim form up until the claim is denied.
Reasonable Medical Care to Cure or Relieve Effects of Work Injury
If there is work related injury and liability for the injury is not denied by the employer or insurance carrier, the employer is required to provide reasonable medical care to cure or relieve the effects of the work related injury. Medical treatment may include doctors (physicians, surgeons, internists, orthopedist, psychologist, chiropractors,) hospital care, surgical care, medicines, and medical supplies.
There are limits to certain types of medical treatment: 1) 24 chiropractic and 24 physical therapy visits for injuries occurring after January 1, 2004; and 2) 24 occupational therapy visits for injuries occurring after April 19, 2004.
Medical Provider Network and Health Care Organizations
If your employer has established a Medical Provider Network (MPN) to treat injured workers, an injured worker generally has to treat within the MPN network, unless the injured worker predesignates a doctor, or the employer's violation in MPN regulation resulted in a denial of medical care. What constitutes denial of care under the new the new law will be more clear as more case law develops. For more information, read Blogs on this website.
If an employer has established a contract with a health care organization (HCO), the injured worker may be required to be treated by the employer's HCO for up to six months before being able to change doctors.
2. 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, the injured worker may be entitled to temporary disability benefits during recovery.
When Temporary Disability Benefits Begin
If an injury causes temporary disability, the first payment of TD benefits must be made not later than 14 days from the date the employer has knowledge of the injury and accepts liability for the work injury. Payment after the first TD payment is made every two weeks from the date of the first payment.
Generally, TD benefits are not recoverable for the first three days of missed work unless the injured worker is temporarily disabled and misses more than 14 days of work, or the injured worker is hospitalized due to the injury. For purposes of calculating the waiting period, the day of the injury shall be included unless the employee was paid full wages for that day.
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. For injuries that occurred between April 19, 2004 and 2007, TD benefits are payable up to two years from the date of the first TD payment.
Amount of Temporary Disability Benefits
The amount of TD benefits is two thirds of the injured workers' average weekly salary, but up to the maximum amount allowed by law.
For an injury that occurred in 2014, the maximum TD benefit is capped at $1,074.64 per week.
For an injury that occurred in 2013 , the maximum TD benefit is capped at $1,066.72 per week.
3. PERMANENT DISABILITY BENEFITS
Permanent disability benefits (PD benefits) compensates for actual incapacity to work and for physical impairment of the worker’s body, as a result of a compensable industrial injury. Under recent changes to the workers' compensation laws, there has been an increase in PD benefits. For example, the PD minimum weekly rate has changed from $130 to $160, and the maximum weekly rate has changed from $230 to $290 over the last two years.
The permanent disability 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. PD is equated into a percentage number which determines the amount and the time period an injured worker will receive this benefit.
Generally, if the injury is compensable and causes PD, the first payment on the actual or estimate (if possible) PD must made within 14 days after the last date of temporary disability benefits. However, under the new law, permanent disability advances (PDAs) are no longer required when temporary disability benefits ends (after 1/1/13), and
1. If the injured worker’s employer offers a return to work job offer to the injured worker which is greater than 85% of what the injured worker was making at the time of his/her injury; or
2. If the injured worker is earning at least 100% of what he or she was making at the time of DOI at another position.
Note: Even if either of the above two exception applies, this does not mean that the injured worker will not receive PD benefits. This only means that the injured worker will not get any "Advances" (early payment) for his/her PD until he/she reaches MMI or P&S status (determined by a primary treating physician's, an Agreed Medical Examiner's, or a Panel Qualified Medical Examiner's Maximum Medical Improvement (MMI) or Permanent & Stationary (P&S) report/s), and after any issues regarding the injured worker's PD is resolved.
It is very important to note that injured workers are obligated to disclose all prior injuries causing disabilities upon request.
For more information regarding PD, please see the State of California Department of Industrial Relations link: http://www.dir.ca.gov/dwc/WorkerscompensationBenefits.htm
4. JOB DISPLACEMENT VOUCHERS
An injured worker will qualify for a supplemental job displacement voucher if 1) the injury occurred after January 1, 2005; and 2) the injurer worker was not offered a permanent or modified job with the employer which offers 85% or more of the wages the injured worker earned before the injury.
5. 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.