Suffering a work-related injury can be a stressful experience. Navigating the workers’ compensation system while focusing on recovery can feel overwhelming. This guide provides answers to frequently asked questions to help you understand your rights and the process, particularly when it comes to medical care and choosing the right Injury Case Doctor.
This information is for employees in California. For personalized assistance, you can contact the Division of Workers’ Compensation Information Services Center at 1-800-736-7401 during business hours or visit a local office. Free seminars for injured workers are also available for a comprehensive overview of your benefits and responsibilities.
Topics Covered in this Guide:
- The Basics of Workers’ Compensation
- Employer Responsibilities in Workers’ Comp Cases
- Medical Care and Choosing Your Injury Case Doctor
- Temporary Disability Benefits Explained
- Understanding Permanent Disability Benefits
- Returning to Work After an Injury
- Navigating the Workers’ Compensation System Effectively
The Basics of Workers’ Compensation {#the-basics-of-workers-compensation}
Q. What exactly is workers’ compensation?
A. Workers’ compensation is a system mandated by California law that requires employers to provide benefits to employees who experience job-related injuries or illnesses. This coverage applies whether your injury is from a single incident at work, like a fall or chemical burn, or from repeated exposure over time, such as carpal tunnel syndrome or hearing loss due to noise.
Q. How can I proactively prevent workplace injuries?
A. California employers are legally required to implement an Injury and Illness Prevention Program. This program should include comprehensive worker training, regular workplace inspections, and clear procedures for promptly addressing and correcting unsafe conditions. Actively participate in your employer’s safety program, report any unsafe conditions immediately, and if your employer doesn’t take action, contact Cal/OSHA, the state agency responsible for enforcing workplace health and safety regulations.
Q. What steps should I take immediately after a workplace injury?
A. The first and most crucial step is to report your injury to your supervisor as soon as possible. Even if you believe the injury or illness developed gradually, report it as soon as you suspect it’s work-related. Prompt reporting is essential to avoid delays and complications in receiving benefits, including necessary medical care. Failing to report within 30 days could potentially jeopardize your right to workers’ compensation benefits if it hinders your employer’s ability to investigate the incident.
Seek emergency medical attention if your injury requires it. Your employer may have designated medical facilities for initial treatment. Always inform the healthcare provider that your injury is job-related.
Complete a workers’ compensation claim form (DWC 1) and submit it to your employer. Your employer is legally obligated to provide you with this form within one working day of being notified about your injury or illness. If they don’t, you can download it from the DWC website.
Q. Is it mandatory to fill out the claim form (DWC 1) provided by my employer?
A. Absolutely. Submitting the completed claim form to your employer officially initiates your workers’ compensation case. This action triggers the process to ensure you receive all eligible benefits under California law. These benefits can include:
- A legal presumption that your injury is work-related if your claim isn’t accepted or denied within 90 days of submitting the claim form.
- Access to up to $10,000 in medical treatment while your claim is under review.
- Potential increases in disability payments if they are delayed.
- A formal process to resolve disputes regarding the work-related nature of your injury, medical treatment, or permanent disability benefits.
Q. What are the core benefits I’m entitled to under workers’ compensation?
A. Workers’ compensation insurance in California provides five fundamental benefits:
- Medical care: Coverage for medical treatment to help you recover from your injury. This includes seeing an injury case doctor and specialists when needed.
- Temporary disability benefits: Wage replacement payments if you are temporarily unable to work due to your injury.
- Permanent disability benefits: Payments if you have a lasting disability after reaching maximum medical improvement.
- Supplemental Job Displacement Benefits (SJDB): A voucher to help pay for retraining or skill enhancement if you can’t return to your previous job.
- Death benefits: Payments to your dependents if you die as a result of a work-related injury or illness.
For a detailed explanation of these benefits, attend a free seminar for injured workers at a local DWC office.
Q. What resources are available to help me understand the workers’ compensation system?
A. Information and Assistance (I&A) officers at your local DWC office are an invaluable free resource. They offer guidance and support to help you understand the system and your responsibilities. While they don’t act as legal representation, they empower you to navigate your claim effectively. Consider attending a free seminar for injured workers or scheduling a private appointment with an I&A officer for personalized assistance.
The DWC website’s I&A page also offers extensive resources, including fact sheets and guides on various workers’ compensation topics. These materials can provide quick answers to common questions and step-by-step instructions for resolving claim-related issues.
Q. How can I determine the workers’ compensation insurance provider for my employer or another California business?
A. California law mandates that all employers must either obtain workers’ compensation insurance from a licensed insurer or become self-insured. The DWC does not directly provide insurance or maintain records of employer-insurer relationships. To find an employer’s insurance provider, visit the California Workers’ Compensation Coverage website. For a list of self-insured employers, refer to the Self Insurance Plans Web page.
For general information about workers’ compensation, the DWC’s website for injured workers is a helpful resource.
Q. How do I know if I’m an employee covered by workers’ compensation or an independent contractor who isn’t covered?
A. The distinction between employee and independent contractor isn’t always clear-cut. Labor law agencies and courts consider several factors to determine your status. Some employers misclassify employees as independent contractors to avoid workers’ compensation and other employment responsibilities. Simply being labeled an independent contractor by your employer doesn’t make it legally true. A genuine independent contractor typically has significant control over how their work is performed. You are likely NOT an independent contractor if the entity paying you:
- Dictates the details and methods of your work.
- Has the authority to terminate your employment.
- Pays you an hourly wage or salary.
- Makes deductions for unemployment or Social Security taxes.
- Supplies your materials or tools.
- Requires you to adhere to specific work hours or days.
Q. How is my personal information handled when requested on DWC forms? Is it kept confidential?
A. The DWC strictly uses your personal information to administer workers’ compensation claims. For instance, your Social Security number is used as a unique identifier to ensure accurate case file management. The DWC is legally bound to protect the confidentiality of your residence address and Social Security number, unless legally authorized to disclose them.
Be aware that limited case information is accessible through the DWC’s public information case search tool.
Q. What personal information is accessible through a public information search?
A. The public search tool provides limited case details such as your name, case number, status, court location, employer name, a brief case description, and key dates. It may also list injured body parts but does not include medical records or case documents. This tool is designed to enhance case processing efficiency within the DWC’s adjudication unit. Users accessing this information must identify themselves, state their reason for access, and are prohibited from sharing the information with unauthorized individuals.
It’s important to know that once an Application for Adjudication of Claim is filed, case file information, including documents, may be subject to disclosure under the California Public Records Act. Even in such cases, your address and Social Security number remain protected by the DWC.
For more fundamental information about workers’ compensation, refer to this factsheet.
Employer Responsibilities in Workers’ Comp Cases {#employer-responsibilities-in-workers-comp-cases}
Q. What are my employer’s legal obligations regarding workers’ compensation?
A. Employers in California have several responsibilities both before and after a workplace injury or illness occurs.
Before an injury/illness:
- They must secure workers’ compensation insurance or qualify as self-insured.
- Upon hiring, they must provide employees with a workers’ compensation pamphlet outlining employee rights and responsibilities.
- They are required to prominently display the official workers’ compensation poster in the workplace.
After an injury/illness:
- They must provide you with a workers’ compensation claim form within one working day of you reporting a work-related injury or illness.
- They must return a completed copy of the claim form to you within one working day of receiving it from you.
- They must forward the claim form, along with their employer’s report of occupational injury or illness, to the claims administrator within one working day of receiving your claim form.
- Within one day of receiving your claim, they must authorize up to $10,000 for appropriate medical treatment. This is crucial for getting you immediate care from an injury case doctor.
- They should provide transitional or light-duty work when medically appropriate.
- If you are a victim of a workplace crime, they must notify you of workers’ compensation eligibility within one working day of the incident.
Q. Can my employer deduct workers’ compensation insurance costs from my paycheck?
A. No. Workers’ compensation insurance is a mandatory business expense for employers. They cannot legally ask employees to contribute to the cost of insurance premiums.
Q. Is my employer required to post a workers’ compensation notice in the workplace?
A. Yes. Employers must display the “Notice to Employees” poster in a visible location at every worksite. This poster provides essential information about workers’ compensation coverage and directions for obtaining medical care for work-related injuries. Failure to post this notice is a misdemeanor offense and can result in civil penalties up to $7,000 per violation.
Q. What happens if my employer is uninsured and I get injured at work?
A. Operating without workers’ compensation insurance is a criminal offense, classified as a misdemeanor. Penalties can include fines up to $10,000, imprisonment in county jail for up to one year, or both. Additionally, the state can impose penalties up to $100,000 on illegally uninsured employers.
If you sustain a work-related injury or illness and your employer lacks insurance, the employer is directly liable for all medical expenses and benefits related to your injury. Contact the Information & Assistance officer at your local DWC district office for guidance. It’s important to know that workers’ compensation benefits are only the exclusive remedy for workplace injuries when your employer is properly insured. If your employer is illegally uninsured, you have the option to file a civil lawsuit against your employer in addition to a workers’ compensation claim.
You can also file a claim with the state’s Uninsured Employers’ Benefit Trust Fund (UEBTF). Refer to DWC fact sheet F and guides 16, 16A, and 16B for detailed information on UEBTF claims.
Q. What is the Uninsured Employers’ Benefit Trust Fund (UEBTF)?
A. The UEBTF is a specialized unit within the Division of Workers’ Compensation. It is designed to provide benefits to workers injured or made ill while employed by illegally uninsured employers. The UEBTF actively seeks reimbursement from these employers through all available legal means, including placing liens on their property.
Q. Where can I report an employer for not having workers’ compensation insurance?
A. You can report uninsured employers to the nearest office of the Division of Labor Standards Enforcement. These offices are listed under “industrial relations, labor standards enforcement” in the state government section of your local phone directory’s white pages.
Medical Care and Choosing Your Injury Case Doctor {#medical-care-and-choosing-your-injury-case-doctor}
Q. What type of medical care am I entitled to for my work injury?
A. California’s workers’ compensation system mandates evidence-based medical treatment. This means that doctors, including your injury case doctor, must utilize treatments scientifically proven to effectively treat and alleviate work-related injuries and illnesses. These treatments are detailed in the Medical Treatment Utilization Schedule (MTUS), which outlines effective treatments, their frequency, intensity, and duration for various injuries.
California has adopted the MTUS, incorporating guidelines from the American College of Occupational and Environmental Medicine (ACOEM), along with specific guidelines for acupuncture, chronic pain, and post-surgical therapy. The DWC maintains a committee that continuously reviews new medical evidence and updates the MTUS guidelines accordingly.
Q. Do these medical treatment guidelines apply to cases that were settled before 2003?
A. Yes, they generally do. The treatment guidelines are considered the standard of care, even for cases settled before their formal adoption into workers’ compensation law in 2003. While your claims administrator may continue to approve previously authorized treatments, any questions about the appropriateness of ongoing treatment should be discussed with your claims administrator or your local Information & Assistance officer.
If your medical treatment is denied, you have the right to request an expedited hearing before a workers’ compensation administrative law judge to resolve the issue. Contact your local Information & Assistance officer for assistance.
Q. What if my claim is still under review, but I urgently need medical care?
A. California law requires claims administrators to authorize medical treatment within one working day of receiving your claim form, even while the claim is being investigated. This immediate treatment authorization is capped at $10,000. If authorization is delayed, immediately discuss this legal requirement with your supervisor, management, or the claims administrator and request immediate treatment authorization pending the claim decision.
Q. Are there restrictions on certain types of medical treatments?
A. Yes. For injuries occurring in 2004 or later, there are limits on chiropractic, physical therapy, and occupational therapy visits—typically 24 visits each—unless additional visits are pre-authorized by the claims administrator or are required post-surgery.
Q. For how long can I receive medical treatment?
A. You are entitled to receive medically necessary treatment for as long as needed. However, treatment must be evidence-based and align with the MTUS guidelines. If your doctor recommends treatment outside MTUS guidelines, they must provide evidence justifying its medical necessity and effectiveness.
Furthermore, your doctor’s treatment plan may undergo utilization review (UR) by a third-party hired by the claims administrator. UR is a mandatory process for all claims administrators to ensure the medical necessity of recommended treatments.
Q. What is Utilization Review (UR)?
A. Utilization review (UR) is a process used by claims administrators to assess the medical necessity of your proposed treatment plan. It ensures that the treatment recommended by your injury case doctor or specialist is appropriate and evidence-based. All claims administrators are legally required to have a UR program.
California has specific regulations governing how UR must be conducted. If you believe the UR process is not being followed correctly, you can file a complaint with the DWC.
For more detailed information on UR, consult this factsheet.
Q. What are my options if my doctor’s treatment request is denied through UR?
A. You have the right to Independent Medical Review (IMR) to dispute a UR denial. As of July 1, 2013, IMR is the process for resolving medical treatment disputes for all injury dates. If UR denies or modifies your treating physician’s treatment request due to medical necessity, you can request an IMR.
You will receive an IMR request form and a pre-addressed envelope with the denial letter. To initiate the IMR process, you must sign and mail this form.
For complete information on the IMR process, eligibility, deadlines, and the request form, please visit the IMR FAQ.
Q. What if I’ve already received treatment, but the claims administrator refuses to pay? Am I responsible for the bill?
A. Generally, you are not responsible for payment in such situations. This is a matter that needs to be resolved between your doctor and the claims administrator.
Q. What is a Medical Provider Network (MPN)?
A. A Medical Provider Network (MPN) is an approved network of healthcare providers established by your employer’s insurance company. It’s designed to treat employees injured on the job. MPNs include doctors specializing in work-related injuries and various medical experts. If your employer uses an MPN, you will typically need to receive medical care from doctors within this network, unless you pre-designated your personal physician before the injury.
Q. What is a Health Care Organization (HCO)?
A. A Health Care Organization (HCO) is certified by the DWC to provide managed medical care to injured workers. Like MPNs, HCOs direct your medical care within a network of providers.
Q. Who is my Primary Treating Physician (PTP)?
A. Your Primary Treating Physician (PTP) is the doctor who has primary responsibility for managing your medical treatment. Often, your employer selects your PTP for the first 30 days of treatment. However, under certain conditions, you may be able to see your pre-designated physician or medical group right away. After 30 days, you might be able to switch to a doctor of your choice, especially if further treatment is needed. MPNs and HCOs have specific rules regarding PTP selection.
Q. How do I pre-designate my personal doctor?
A. Predesignation allows you to formally notify your employer in writing that you wish to be treated by your personal physician (M.D. or D.O.) in case of a work injury. To predesignate, you must meet these conditions:
- Provide written notice to your employer before your injury, including your physician’s name and business address.
- Have existing health insurance coverage for non-occupational injuries or illnesses on the date of injury.
- Ensure your personal physician agrees to be pre-designated.
The DWC provides a form for predesignating a personal physician on its website.
Q. Can I be treated by my personal chiropractor or acupuncturist?
A. If your employer or their insurer does not have an MPN, you may be able to switch to your personal chiropractor or acupuncturist after initially seeing a doctor chosen by the claims administrator for the first 30 days. To be eligible, you must have given your employer written notice of your personal chiropractor or acupuncturist’s name and address prior to the injury. A form for “notice of personal chiropractor or personal acupuncturist” is available from the DWC.
For injuries on or after January 1, 2004, a chiropractor cannot remain your treating physician after 24 chiropractic visits. If you require further medical care beyond this limit, you will need to choose a non-chiropractor physician.
Q. Does the 24-visit limit for chiropractic care apply in all cases?
A. No. The 24-visit cap does not apply to injuries occurring before January 1, 2004. It also does not apply if your employer explicitly authorizes additional visits in writing or for post-surgical physical medicine and rehabilitation services.
Q. What if I disagree with the treatment plan from an MPN doctor?
A. If you disagree with your MPN doctor’s treatment recommendations, you have the right to switch to another physician within the MPN. You can also seek a second and third opinion from other MPN doctors. If disagreements persist, you can pursue an Independent Medical Review (IMR) to resolve the dispute. Consult the MPN information provided by your employer for specific procedures.
Q. What if I disagree with the MPN doctor’s opinion on my ability to return to work, permanent disability, or future medical needs?
A. If your disagreement with the MPN doctor is not about diagnosis or treatment, but rather about return to work, permanent disability, or future medical care, you must request a Qualified Medical Examiner (QME) to evaluate these issues.
Q. What if an MPN doctor’s treatment request is denied by UR or the claims administrator?
A. Similar to denials from any treating physician, if an MPN doctor’s treatment request is denied or modified by UR or the claims administrator, you will receive an IMR form with the denial letter. You can use this form to request an IMR to appeal the decision.
For detailed information on this process, consult the IMR FAQ.
Q. Who determines what type of work I can do during my recovery?
A. Your treating doctor is responsible for outlining your work capabilities and restrictions in a medical report. This report should specify:
- The types of tasks you can and cannot perform while recovering.
- Any necessary adjustments to your work schedule or job duties.
You, your doctor, employer, and legal counsel (if applicable) should discuss your job description and any needed modifications. This might include a reduced work schedule or temporary adjustments to your responsibilities.
If you disagree with your treating doctor’s assessment, it’s crucial to promptly notify the claims administrator in writing to protect your rights.
Q. I don’t have an attorney and disagree with my doctor’s report about my injury. What should I do?
A. You can request a medical evaluation from a Qualified Medical Evaluator (QME) in several situations:
- If your claim is delayed or denied, and you need a medical evaluation to determine claim eligibility.
- To assess permanent disability or the need for future medical treatment.
- If you disagree with your treating physician’s opinions regarding your injury, work restrictions, or temporary disability status. (Note: QMEs do not address treatment requests. For treatment denials, you need to pursue IMR).
If you are represented by an attorney, they and the claims administrator may agree on an Agreed Medical Evaluator (AME) instead of a QME. If you are not represented, you’ll need to request a QME panel list from the DWC Medical Unit using the panel request form (QME 105). Your treating physician can help you determine the appropriate medical specialty for the QME.
Within 20 working days of your request, the DWC Medical Unit will send a panel of three QMEs to you and the insurance company. These QMEs are randomly selected and do not represent either party.
You have 10 days from the date the list is mailed to select a QME, schedule an appointment, and inform the insurance company of your choice and appointment date. If you miss this deadline, the insurance company can choose the QME and schedule the appointment.
Q. What if the claims administrator sends me a QME panel request form?
A. If the insurance company disagrees with an aspect of your claim, they may initiate the QME process by sending you a QME panel request form. In this case, you have 10 days to request a QME list from the DWC Medical Unit. Failure to do so within 10 days allows the insurance company to request the panel and choose the medical specialty of the QME.
The DWC Medical Unit will then provide a panel of three QMEs within 20 working days. Again, you have 10 days to select a QME, schedule, and notify the insurer. If you don’t meet this deadline, the insurer can make the selection and appointment.
Q. What are the qualifications of a QME?
A. The DWC Medical Unit certifies QMEs across various medical specialties. A QME must be a licensed physician in California, including medical doctors (MDs), doctors of osteopathy (DOs), chiropractors, psychologists, dentists, optometrists, podiatrists, and acupuncturists.
Q. What is the difference between a QME and an AME?
A. An Agreed Medical Evaluator (AME) is a doctor jointly agreed upon by your attorney and the claims administrator when you are represented by counsel. This avoids using the state-provided QME panel system. If agreement on an AME is not possible, a QME panel list must be requested.
Q. Why is seeing a QME sometimes necessary?
A. QMEs are needed to resolve medical disputes in your workers’ compensation case. These disputes can arise when you or the claims administrator disagree with your treating doctor on issues such as:
- Whether your injury is work-related.
- Your need for future medical treatment.
- Your ability to return to work.
- Your permanent disability rating.
The QME’s (or AME’s) medical report is crucial in determining the benefits you receive. Therefore, choosing a qualified injury case doctor as a QME is important.
Q. Can I challenge a QME’s opinion if I disagree with it?
A. Yes, but time is limited. Review the QME report immediately upon receipt to assess its accuracy. If you disagree and have an attorney, discuss your options with them.
If you don’t have an attorney and believe the QME report contains factual errors, you can request a factual correction within 30 days of receiving the report. The claims administrator also has this right.
Upon a factual correction request, the QME must issue a supplemental report to the DWC’s Disability Evaluation Unit (DEU), indicating if corrections are necessary for accuracy and whether these corrections change the QME’s original opinions.
Contact your local DWC district office’s Information & Assistance officer for further guidance. If you are in a union, you may also have access to an ombudsperson or mediator as per your collective bargaining agreement.
For more information about QMEs and AMEs, refer to this factsheet.
Temporary Disability Benefits Explained {#temporary-disability-benefits-explained}
Q. What are temporary disability benefits?
A. Temporary disability (TD) benefits are wage replacement payments if you lose income because your work injury prevents you from performing your usual job duties while you recover. See the DWC fact sheet on TD for detailed information.
Q. Are there different types of temporary disability benefits?
A. Yes, there are two types:
- Temporary Total Disability (TTD): Paid if you are completely unable to work during recovery.
- Temporary Partial Disability (TPD): Paid if you can work part-time or in a reduced capacity while recovering, resulting in wage loss.
Q. How much will I receive in TD payments?
A. Generally, TD benefits are two-thirds of your gross (pre-tax) wages lost due to your injury, subject to legal maximum weekly limits. Your wages are calculated based on all income sources from work, including wages, food, lodging, tips, commissions, overtime, and bonuses. Income from other jobs held at the time of injury is also considered. Provide proof of all earnings to the claims administrator. Refer to the benefits chart for current benefit rates, as minimum and maximum rates are adjusted annually.
Q. What about TTD payments for low-wage workers?
A. All employees with earnings are entitled to TTD benefits, calculated at two-thirds of their wages at the time of injury, subject to minimum and maximum rates. The minimum TTD rate is recalculated annually based on changes to the statewide average weekly wage (SAWW). Consult the benefits chart for current rates.
Q. When do TD benefits start and stop?
A. TD payments begin when your doctor states you can’t perform your usual work for more than three days or if you are hospitalized overnight due to your injury. Payments are made every two weeks. TD benefits typically end when you return to work, your doctor releases you to work, or your doctor declares your condition has reached maximum medical improvement. For injuries after April 19, 2004, TD is limited to 104 weeks within a 2-year period from the first payment for most injuries. For injuries after January 1, 2008, it’s 104 weeks within 5 years of the injury date. Certain long-term injuries like severe burns or chronic lung disease may qualify for up to 240 weeks of TD payments within a five-year period.
Q. Are TD benefits taxable?
A. No. TD benefits are not subject to federal, state, or local income taxes. They are also exempt from Social Security, union dues, and retirement fund contributions.
Q. Can my first TD payment be delayed?
A. Yes, in certain circumstances. If the claims administrator is uncertain about your claim’s coverage, they may delay your initial TD payment for investigation, usually not exceeding 90 days. If a delay occurs, they must send you a delay letter explaining the reason, outlining needed information, and stating when a decision will be made. Additional delay letters are required for continued delays. If a denial letter isn’t sent within 90 days of filing your claim form, your claim is generally considered accepted.
Q. Is the claims administrator penalized for delayed TD payments?
A. Potentially. If you filed your claim form at least 14 days before the payment due date and the payment is late, the claims administrator must automatically add a 10% penalty to the payment.
Q. Why am I receiving numerous letters?
A. Claims administrators are legally obligated to keep you informed by sending letters explaining payment calculations, reasons for TD delays, changes in payment amounts, and the termination of TD benefits.
Q. My TD payments stopped without explanation. What should I do?
A. First, contact your employer or claims administrator to inquire. If unresolved, reach out to your local DWC I&A officer for assistance.
For more information on TD, consult this factsheet.
Understanding Permanent Disability Benefits {#understanding-permanent-disability-benefits}
Q. What are permanent disability benefits?
A. Permanent disability (PD) benefits are provided when a work injury results in a lasting impairment that reduces your earning capacity after you’ve reached maximum medical improvement. Even if you return to work, you may still be entitled to PD benefits if you have a permanent impairment. PD benefits are limited and may not fully compensate for lost income or non-work-related losses. See the DWC fact sheet on PD for more details.
Q. How is permanent disability determined?
A. A doctor, often your injury case doctor or a QME, assesses whether your injury has caused permanent disability. PD evaluation occurs after your condition stabilizes and is unlikely to change further, a state known as permanent and stationary (P&S) or maximal medical improvement (MMI).
Once you reach P&S/MMI, your doctor will report to the claims administrator about your PD and determine if any portion of your disability is due to factors other than your work injury, such as pre-existing conditions. This is called apportionment.
Q. What happens after the doctor’s PD report is submitted?
A. If a QME evaluates you, their report is sent to the claims administrator and the DWC’s Disability Evaluation Unit (DEU). A DEU rater uses the QME’s report and your Employee Disability Questionnaire to calculate your PD rating. If you have an attorney, rating can be done by the DEU or a private rater.
You or the claims administrator can also request a rating of your primary treating physician’s (PTP) report, but this is not automatic. You must submit a “Request for Summary Rating Determination of Primary Treating Physician’s Report” (DEU 102) to the DEU along with the PTP’s report.
The PD rating calculation process can vary based on your injury date and other factors. The PD rating is used in a formula to determine your benefit amount. You have the right to receive copies of both QME and PTP reports. Review them carefully for completeness and accuracy. If you find factual errors in a QME report, you can request a factual correction within 30 days. The QME will then issue a supplemental report addressing the corrections and their impact on their opinions.
Q. What if I disagree with the doctor’s PD assessment?
A. If you or the claims administrator disagree with your doctor’s PD findings, you can seek evaluation from a Qualified Medical Examiner (QME). Request a QME panel list from the DWC Medical Unit. The claims administrator will provide the necessary forms. Your employer covers the QME exam costs. You have 10 days from when the claims administrator instructs you to begin the QME process to submit your request to the DWC Medical Unit. Missing this deadline allows the claims administrator to choose the doctor’s specialty.
Adhere to strict timelines for filing QME forms to protect your rights. Consult DWC Information and Assistance Unit guide 2 for details.
Upon receiving the QME panel list, you must select a doctor, schedule an exam, and notify the claims administrator within 10 days. Failure to do so allows the claims administrator to select the QME and schedule the appointment.
If you have an attorney, they can assist in QME selection or you can be evaluated by an Agreed Medical Evaluator (AME), jointly chosen by your attorney and the claims administrator. Discuss your options with your attorney in this case.
Q. Can you explain how the PD rating is calculated in more detail?
A. After your medical examination, the doctor will write a report detailing your impairment, which is how your injury affects your ability to perform normal life activities. The report will also address apportionment, indicating if any part of your disability is due to non-work-related factors. The report concludes with an impairment number.
This impairment number is then used in a formula to calculate your percentage of disability, which reflects how the impairment impacts your ability to work. Factors like your occupation, age at injury, and future earning capacity are also considered. Any disability attributed to non-work factors is then subtracted.
Your final disability is expressed as a percentage, which corresponds to a specific dollar amount based on your injury date and pre-injury average weekly wages. A rating specialist from the DWC DEU can assist in calculating your rating.
For injuries between January 1, 2005, and December 31, 2012, your PD award may be adjusted by 15% (increased or decreased) depending on your employer size (over or under 50 employees) and whether they offer regular, modified, or alternative work.
Q. What if I disagree with the PD rating from the state disability rater?
A. If you are unrepresented, you can request the DWC to review the rating for errors in the medical evaluation or rating process. This is called reconsideration of rating. See I&A guide 3 for details. You can also present your case to a workers’ compensation administrative law judge. Contact a state I&A officer for assistance. Workers with attorneys cannot request reconsideration; their attorneys handle disputes before a judge.
Q. How much will I be paid for my permanent disability?
A. PD benefit amounts are legally defined. The claims administrator calculates your payment based on:
- Your disability rating (percentage).
- Date of injury.
- Your pre-injury wages.
Refer to the PD benefits schedule for specific amounts.
Q. When and how are PD benefits paid?
A. PD benefits typically start after temporary disability benefits end and your doctor indicates permanent impairment. Payments must begin within 14 days of TD ending and are usually made bi-weekly until a reasonable estimate of your total PD amount is paid. If you didn’t miss work, PD payments begin when the claims administrator becomes aware of your permanent disability.
Q. Why am I receiving so many notice letters about PD benefits?
A. Claims administrators are required to send letters explaining PD payment calculations, payment schedules, reasons for delays, and reasons for non-payment of PD benefits.
Q. Is there a penalty for delayed PD payments?
A. Yes. A 10% penalty is automatically applied to late PD payments, even if there’s a valid reason for the delay and a delay explanation letter is sent. Substantial additional penalties may be awarded if there is no reasonable excuse for the delay.
Q. How is my workers’ compensation claim finally resolved?
A. Claim resolution usually involves a settlement or award after the PD amount is determined, requiring approval from a workers’ compensation administrative law judge. If you have an attorney, they will guide you through this process. If not, the claims administrator should assist you, and you can also seek help from the I&A officer at your local DWC district office. If future medical treatment is anticipated, the settlement or award may include provisions for it.
You can resolve your claim through a lump-sum settlement called a Compromise and Release (C&R), which gives you control over future medical care and provides a lump sum for PD, but typically ends the claims administrator’s liability for further payments or medical care after settlement approval.
Alternatively, you can agree to a Stipulation (stip), which usually includes a sum of money and provisions for future medical treatment, with payments made over time, subject to judge review.
If settlement isn’t reached, you can go before a workers’ compensation administrative law judge who will issue a Findings and Award (F&A), typically consisting of a sum of money and provisions for future medical treatment paid by the claims administrator.
In Stipulations or F&As, PD benefits are paid over a set number of weeks. C&R provides a lump sum. Permanent Total Disability (PTD) benefits are paid for life.
In most cases, PD payments start before the final PD amount is determined. The claims administrator estimates the amount and begins payments, with any remaining balance paid once the final PD percentage is calculated.
For more details on permanent disability, consult this factsheet.
Returning to Work After an Injury {#returning-to-work-after-an-injury}
Q. I’m focused on returning to work. How can I facilitate this?
A. Returning to work as soon as medically feasible improves recovery outcomes and reduces wage loss. Your return-to-work plan involves communication and cooperation between you, your doctor, your employer, and the claims administrator. Honest and frequent communication is key for the best results.
If your doctor determines you are medically unable to return to work during recovery, you cannot be compelled to work.
However, you might be able to return to work with restrictions if your employer can accommodate them. This might involve job modifications or providing adaptive equipment. If your doctor approves restricted duty, but your employer cannot accommodate these restrictions, you are not required to return to work. In the meantime, depending on your injury, you may be eligible for temporary disability, supplemental job displacement benefits, or permanent disability benefits.
Q. How is my ability to return to work assessed?
A. Safe and timely return to work is beneficial for recovery and financial stability. Several parties are involved in determining your return-to-work plan:
- Your treating doctor.
- Employer representatives/managers.
- The claims administrator handling your case.
Effective communication is vital because doctors and claims administrators may not fully understand your job demands or potential modified roles. Maintain open communication with your doctor, employer, and claims administrator (and your attorney, if applicable) regarding:
- Your pre-injury job duties.
- Your current medical condition and work capabilities.
- Potential job modifications your employer could offer.
Q. Can I work while recovering?
A. Soon after your injury, your treating doctor will assess you and send a report to the claims administrator detailing your medical condition. If the doctor indicates you can work, they should specify:
- Clear work restrictions, if any, to prevent further injury (e.g., “no repetitive bending”).
- Any needed workplace modifications to your schedule, tasks, equipment, or working conditions (e.g., “provide headset to avoid neck strain”).
- If the doctor deems you unable to work at all during recovery, you cannot be required to work.
Q. I have work restrictions. Can I still work?
A. If your treating doctor provides work restrictions, any job offered by your employer must adhere to these limitations. Your employer might modify your tasks or provide assistive equipment. If your employer cannot provide work within these restrictions, you are not obligated to work.
Q. What if I have no work restrictions?
A. If your doctor releases you to full duty without restrictions, your employer typically must reinstate you to your previous job with the same pay and benefits. You can be required to accept this job offer, whether it’s shortly after the injury or later in your recovery.
Q. What kind of work can my employer offer?
A. If your claims administrator’s letter indicates a job offer, it must align with your doctor’s work restrictions. Offers may include:
- Regular work: Your old job, for at least 12 months, at your previous wage and benefits, within a reasonable commute.
- Modified work: Your previous job with adjustments to accommodate your restrictions. If your doctor indicates you cannot return to your prior job, your employer is encouraged to offer modified work instead of supplemental job displacement benefits (SJDB). Modified work must meet your restrictions, last at least 12 months, pay at least 85% of your previous wage and benefits, and be within a reasonable commute.
- Alternative work: A different job with your employer. Similar to modified work, if you cannot return to your old job, employers are encouraged to offer alternative work instead of SJDB. It must meet your restrictions, last at least 12 months, pay at least 85% of your previous wage and benefits, and be within a reasonable commute.
If modified or alternative work is offered:
- You may have only 30 days to accept. Failure to respond may lead to withdrawal of the offer.
- Rejecting or failing to respond to a valid offer may disqualify you from supplemental job displacement benefits (SJDB).
Q. What if my employer does not offer me work?
A. For injuries between January 1, 2004, and December 31, 2012, if your employer has 50+ employees and does not offer regular, modified, or alternative work, your weekly PD benefits increase by 15%. For employers with fewer than 50 employees in this period, PD benefits are not affected by a lack of offer. For injuries on or after January 1, 2013, PD benefits are not changed regardless of employer size if no job offer is made.
Q. Why are my PD benefits linked to a return-to-work offer?
A. Research shows that prolonged absence from work decreases the likelihood of return, leading to greater wage loss and reduced quality of life. PD benefits are not designed to fully compensate for lost earnings, so these provisions encourage a prompt and safe return to work when medically possible. However, return to work is not always feasible for everyone. Consult an I&A officer or advocate if your situation is complex or you need to explore other available resources.
Q. What if the job my employer offered doesn’t work out?
A. Depending on your injury date, you might still be eligible for SJDB if the job lasts less than 12 months or your disability prevents you from performing the job duties. Discuss concerns with your employer or claims administrator. If unresolved, contact a state I&A officer.
Q. How do I qualify for Supplemental Job Displacement Benefits (SJDB)?
A. If injured on or after January 1, 2004, and permanently unable to return to your usual job, and your employer doesn’t offer other work, you may qualify for SJDB. This is a voucher to help cover retraining or skill enhancement at state-approved schools.
For injuries between January 1, 2004, and January 1, 2013, voucher amounts vary by PD percentage:
- Up to $4,000 for PD < 15%.
- Up to $6,000 for PD 15-25%.
- Up to $8,000 for PD 26-49%.
- Up to $10,000 for PD 50-99%.
Up to 10% of the voucher can be used for vocational counseling. If a qualifying job offer is made within 30 days of TD ending and you reject it, you may lose SJDB eligibility.
For injuries on or after January 1, 2013, the voucher amount is $6,000 regardless of PD rating, due within 20 days of the deadline for a job offer if no offer is made. The job must pay at least 85% of your pre-injury earnings and last at least 12 months.
Q. If my employer offers modified or alternative work and I decline, can I still get the voucher?
A. No. For injuries between January 1, 2004, and December 31, 2012, rejecting a qualifying offer of modified or alternative work within 30 days of your last TD payment makes you ineligible for the voucher. Qualifying offers must:
- Be within your capabilities.
- Be a regular position lasting at least 12 months.
- Pay at least 85% of your pre-injury wages and benefits.
- Be within a reasonable commute.
For injuries on or after January 1, 2013, rejecting a qualifying offer made within 60 days of the claims administrator receiving the Physician’s Return-to-Work & Voucher Report similarly disqualifies you from the voucher. Qualifying offer conditions remain the same. Job offers should not be filed with the DWC.
Q. When will I receive the SJDB voucher?
A. For injuries between January 1, 2004, and December 31, 2012, if eligible and your eligibility isn’t settled, you’ll receive the voucher within 25 days of your disability award from the Workers’ Compensation Appeals Board. For injuries on or after January 1, 2013, the voucher is due 60 days after a doctor declares you permanent and stationary and issues a report outlining your work capacities, if no job offer is made.
Q. When can I expect voucher payments?
A. Claims administrators must issue reimbursements to you or direct payments to the Vocational Return to Work Counselor (VRTWC) and training provider within 45 days of receiving the completed voucher, receipts, and documentation.
Q. I disagree with my doctor’s opinion about my work capacity. What can I do?
A. You have the right to challenge your treating doctor’s report on your work abilities. To dispute it:
- If unrepresented, send a letter to the claims administrator disagreeing with the report within 30 days of receipt.
- If represented, contact your attorney immediately; the deadline is 20 days.
- You can then seek a medical evaluation from another doctor. Contact the DWC Medical Unit for information on medical evaluations.
For help obtaining a medical evaluation, contact a DWC I&A officer.
Q. I disagree with my employer about assigned or offered work. What can I do?
A. You are not obligated to accept work that doesn’t meet your doctor’s restrictions. Contact a DWC I&A officer for guidance. It’s illegal for an employer to discriminate against you for requesting workers’ compensation or having a work-related disability under California Labor Code section 132a, the ADA, and FEHA. However, employers are not always required to offer you a specific job or any job if suitable positions within your restrictions are not available.
Q. What if I have zero PD rating but cannot return to work?
A. The DWC may not be able to provide further assistance in this specific situation, but other resources may be available:
- State Disability Insurance (SDI) or, rarely, Unemployment Insurance (UI) from the Employment Development Department (EDD).
- Social Security Disability Insurance (SSDI) from the U.S. government for total disability.
- Employer and union benefits like sick leave, group health insurance, long-term disability insurance (LTD), and salary continuation plans.
- Legal action if your injury was caused by a third party.
The Americans with Disabilities Act (ADA) and the California Fair Employment and Housing Act (FEHA) protect individuals with disabilities from discrimination. Employers are required to provide reasonable accommodations unless it causes undue hardship. Contact the Equal Employment Opportunity Commission (EEOC) or the Department of Fair Employment and Housing (DFEH) for information on ADA and FEHA.
Q. Can the SJDB voucher be settled for cash?
A. No, not for injuries on or after January 1, 2013.
Q. Does a voucher expire?
A. Vouchers issued before January 1, 2013, do not expire. Vouchers issued on or after January 1, 2013, expire two years after issuance or five years from the injury date, whichever is later.
Navigating the Workers’ Compensation System Effectively {#navigating-the-workers-compensation-system-effectively}
Q. The workers’ compensation system seems complicated. Should I hire an attorney?
A. This is a personal decision. Most workers’ compensation claims are resolved without issues between workers and claims administrators. You are not required to have an attorney, even if disputes arise. However, complex cases may benefit from legal representation. Your attorney’s fees are paid from a portion of your benefits and are not directly charged to you. If you choose not to hire an attorney, I&A officers at your local DWC district office can assist you. Regardless of legal representation, it’s important to understand your rights and responsibilities, communicate with your employer and claims administrator, and ask questions.
Q. I’m encountering problems getting my benefits. What help is available?
A. I&A officers are a valuable, free resource. They provide guidance to help you understand and act on your own behalf, though they don’t offer legal representation. Attend free seminars for injured workers or schedule private appointments with I&A officers for personalized support. The DWC website’s I&A page offers extensive information, including fact sheets and guides to answer common questions and assist in resolving claim issues at local DWC district offices.
Q. I have a disability and need assistance to access DWC services. Is there any support?
A. Yes. If you have a disability and require accommodations to use DWC services, you may be eligible for reasonable accommodations. Reasonable accommodations ensure equal access and participation in DWC programs and services, including the Workers’ Compensation Appeals Board, I&A Unit, Retraining and Return to Work Unit, and Disability Evaluation Unit. Find more information on requesting accommodations on the disability accommodation page. For further information on ADA accommodations, refer to the Americans with Disabilities Act page.
Q. Besides workers’ compensation, are there other forms of financial assistance I can explore?
A. Yes, other benefits may be available, including:
- State and federal government benefits like State Disability Insurance (SDI), Unemployment Insurance (UI), and Social Security Disability Insurance (SSDI).
- Employer and union benefits such as sick leave, group health insurance, long-term disability insurance (LTD), and salary continuation plans.
- Potential payments if your injury resulted from a third party’s actions.
Q. How do I check the status of my workers’ compensation case?
A. If you have an attorney, they should provide regular updates. If you are unrepresented, contact the I&A officer at your local DWC district office for a status report. The DWC also operates a call center that can provide case status updates when you call local offices.
March 2023
Disclaimer: This information is for general guidance only and not legal advice. Consult with a legal professional for advice tailored to your specific situation.
Understanding Workers’ Compensation Benefits: A visual guide to the different types of benefits available to injured workers in California.
Official logo for the Division of Workers’ Compensation, highlighting its role in the California Department of Industrial Relations.
Information and Assistance Unit Symbol: Representing the DWC’s resource for injured workers seeking help and guidance.
