California Workers' Compensation - The Basics of What you Need to Know

When California Workers' Compensation Applies - The Basics

Workers' Compensation Law

All employers in California must have valid workers' compensation insurance in force at all times. If the employer has valid workers' compensation insurance coverage at the time of the injury, then an injured employee cannot sue in civil court for personal injury damages. Instead, injured workers are limited to the benefits under California workers' compensation law.

Burden of Proof is on the Injured Worker

The injured worker has the burden to prove that their injury arose out of employment. It is the employees responsibility to show that it is reasonably probably that their work, at least in part, caused the injury. ¹ Similarly, the injured worker must prove entitlement to receive benefits due to the work injury.

Unfortunately, there is a widespread tendency for California workers comp insurance companies to administer their policies in ways that deny many injured workers their rights and therefore significant amounts of benefits. That's why it's important for you to read my article on collecting the necessary evidence to win your workers' compensation case.

The Workers' Compensation Claim Form (DWC-1) Starts the Process

There is an official California Department of Workers' Compensation form called a DWC-1 for reporting work-related injuries to your employer. It's official name is DWC-1. When an employee reports a work-related injury (requiring more than first aid), the employer is supposed to provide a DWC-1 to the injured worker to complete.

The employer is then required to complete their portion, provide the injured worker with a copy, and send it to the employer's workers' compensation insurance company or administrator. Also, the employer is to be proactive with procuring and paying for emergency medical treatment. If it's not an emergency, then medial treatment right away.²

Doctor Selection Rights And the Medical Provider Network (MPN)

Most employers and their insurance companies have established their own Medical Provider Network (MPN). The employer has the right to assign the employee's first Primary Treating Physician (PTP) who is to address the employee's right to compensation and prescribe treatment The employer is then required to notify the employee of their right to choose doctors within a validly established MPN for further treatment.³

If the adjuster is not providing the MPN list, then the injured worker should seek immediate help from a California workers' compensation lawyer.

Doctors outside of the network are not covered unless an exception applies. Here are some examples that put the insurance company on the spot to pay for treatment outside of the MPN:

1. Emergency medical care;
2. A neglect or refusal by the employer to provide medical care that results in a denial of care;
3. An illusory MPN, or one where no doctors are accepting patients;
4. Ineffective MPN treatment
5. The treatment is denied but is found to be reasonable and medically necessary by Independent Medical Review (IMR).⁴
6. The employee has predesignated a Primary Treating Physician (PTP) outside of the MPN;

Treatment with a specialist outside of the MPN should be authorized by the adjuster as necessary.⁴

Importance of Obtaining a Qualified Medical Evaluation (QME)

The Qualified Medical Evaluation offers the opportunity to obtain a Med-Legal evaluation of the injury at the employer's expense. The doctor is paid to perform an examination and prepare a report especially for the workers' compensation claim that addresses the legal aspects of the claim.

Many workers do not know that they are entitled to a QME. It is a missed opportunity to produce substantial medical evidence of permanent disability and the need for future medical care. Don't expect the adjuster to offer you a QME. If you haven't heard about it, it's probably time to call a work injury attorney nearby.

Supplemental Job Displacement Benefit (Voucher)

When the injured worker is permanently restricted from performing the essential functions of is job, the employer has no other option but to lay them off. This is known as job displacement and it entitles the employee to the supplemental benefit, also known as the Voucher. 3

It's something to keep in mind if you have had a serious work-related injury that will likely result in permanent loss of function that will inhibit you from performing essential job duties.

If you have lost your job due to a work-related injury or occupational disease, you should be hearing about this benefit from the adjuster. If not, it's time to reach out to Napolin. If you have received the Voucher, then read the Basics of Putting A Supplement Job Displacement Benefit (Voucher) to good use.