The Lost Files: Doctor Requires Head – Workers’ Compensation FAQs for Employees

In addition to the frequently asked questions provided below, employees are encouraged to reach out to the Division of Workers’ Compensation Information Services Center at 1-800-736-7401 during standard business hours for direct assistance from a representative.

Employees also have the option to contact a local office of the state Division of Workers’ Compensation (DWC) and connect with the Information and Assistance (I&A) Unit for guidance during regular business hours. Furthermore, free seminars designed for injured workers are available for attendance.

Informative fact sheets and comprehensive guides covering a wide array of topics can be accessed on the I&A Unit’s Web page, offering valuable resources at your fingertips.

Key Topics Covered in this FAQ:

The Basics of Workers’ Compensation
Understanding Employer Responsibilities
Navigating Medical Care Options
Temporary Disability Benefits Explained
Permanent Disability Benefits: What You Need to Know
Returning to Work After an Injury
Successfully Navigating the Workers’ Compensation System

Understanding the Basics of Workers’ Compensation

Q. What exactly is workers’ compensation?

A. Workers’ compensation is a legally mandated benefit that your employer is required to provide if you experience a work-related injury or illness. This coverage ensures that you receive necessary benefits if you are harmed due to:

• A specific incident at work, such as a back injury from a fall, chemical burns from a splash, or injuries sustained in a car accident while on delivery duties.

–or–

• Repeated exposures in the workplace, like developing carpal tunnel syndrome from repetitive motions or experiencing hearing loss from prolonged exposure to loud noise.

Q. How can I proactively prevent workplace injuries?

A. In California, employers are legally obligated to establish and maintain an Injury and Illness Prevention Program. This program must encompass comprehensive worker training, regular workplace inspections, and clear procedures for the prompt correction of any unsafe conditions identified. Actively engage with and learn about your employer’s program and promptly report any unsafe conditions to your employer. Should your employer fail to address these concerns, you have the recourse to contact Cal/OSHA, the state agency responsible for enforcing health and safety regulations.

Q. What steps should I take immediately following a job-related injury?

A. The first and most crucial step is to report the injury to your employer without delay, informing your supervisor as soon as possible. If your injury or illness developed gradually over time, it’s equally important to report it as soon as you become aware or suspect that it is work-related.

Prompt reporting is essential as it helps to prevent potential complications and delays in receiving your benefits, including any necessary medical care. Failing to notify your employer of your injury within 30 days, especially if this delay hinders their ability to thoroughly investigate the incident and the circumstances surrounding your injury, could jeopardize your right to receive workers’ compensation benefits.

Seek emergency medical treatment immediately if your condition requires it. Your employer may have designated medical facilities for initial treatment. When receiving care, ensure you inform the healthcare provider that your injury or illness is job-related.

Complete a workers’ compensation claim form and submit it to your employer. Your employer is legally required to provide or mail you this claim form within one working day after they are informed about your injury or illness. If your employer does not provide the form, you can download it directly from the forms page on the DWC website.

Q. Is it mandatory for me to fill out the claim form (DWC 1) provided by my employer?

A. Yes, absolutely. Submitting the completed claim form to your employer is the formal step that initiates your workers’ compensation case. This action sets in motion the process to secure all the benefits you are entitled to under state law. These benefits are comprehensive and include, but are not limited to:

• A legal presumption that your injury or illness is work-related if your claim is neither accepted nor denied within 90 days of your employer receiving your completed claim form.
• Access to up to $10,000 in medical treatment, adhering to medical treatment guidelines, while the claims administrator reviews your claim.
• Potential for increased disability payments if payments are delayed.
• A structured avenue to resolve any disagreements that may arise between you and the claims administrator concerning the work-related nature of your injury or illness, the medical treatment you are receiving, and your eligibility for permanent disability benefits.

Q. What specific benefits am I entitled to under workers’ compensation?

A. Workers’ compensation insurance offers five fundamental benefits:

For a complete understanding of workers’ compensation benefits, your rights, and responsibilities, consider attending a free seminar for injured workers at a local DWC office.

Q. What resources are available to assist me through this process?

A. Your local I&A officers are invaluable resources, and their services are provided free of charge. While they do not act as legal representatives in the same capacity as an attorney, they are dedicated to helping you understand how to effectively advocate for yourself. Attending a free seminar for injured workers at a local DWC district office is also highly recommended for a detailed explanation of workers’ compensation benefits, your rights, and obligations. Furthermore, you can schedule a private appointment with an I&A officer for personalized assistance at your convenience.

Additionally, the I&A page on the DWC website offers a wealth of information. Be sure to explore the fact sheets and guides specifically designed for injured workers. These resources provide answers to frequently asked questions about issues that may impact your benefits and offer step-by-step guidance on completing forms necessary to resolve claim-related issues at your local DWC district office.

Q. How can I determine the workers’ compensation insurance provider for my employer or another business in California?

A. In California, all employers are mandated to either secure a workers’ compensation insurance policy from an insurer licensed to operate in the state or to become self-insured. The DWC does not provide workers’ compensation insurance directly to employers and does not maintain records of employers and their respective insurers. To identify the workers’ compensation insurer for a specific employer, please visit the California Workers’ Compensation Coverage website. A comprehensive list of self-insured employers is available on the Self Insurance Plans Web page.

For more detailed information about workers’ compensation, you can also refer to the DWC’s Web page specifically designed for injured workers.

Q. I understand that independent contractors are not covered by workers’ compensation. How can I verify if I am correctly classified as an independent contractor?

A. There is no single, definitive definition for “independent contractor.” Labor law enforcement agencies and courts consider various factors when determining whether someone is an employee or an independent contractor. It’s important to note that some employers may misclassify employees as independent contractors to avoid responsibilities related to workers’ compensation and other payroll obligations. Simply being told by an employer that you are an independent contractor and therefore not covered by their workers’ compensation policy does not automatically make it 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 or methods of your work execution.
• Retains the right to terminate your services.
• Pays you an hourly wage or salary.
• Makes deductions for unemployment insurance or Social Security.
• Provides the necessary materials or tools for your work.
• Requires you to adhere to specific workdays or hours.

Q. What safeguards are in place for the personal information requested on DWC forms from injured workers? Is this information kept confidential?

A. The Division of Workers’ Compensation is committed to protecting your personal information. The information you provide is used exclusively for the purpose of administering workers’ compensation claims. For instance, if an injured worker provides their Social Security number (in full or part), the DWC uses it as a unique identifier to ensure that all documents are correctly associated with the respective workers’ compensation case. Unless legally authorized, the DWC cannot disclose the residential addresses or Social Security numbers of injured workers.

It’s important to be aware that certain case file information is accessible through the public information case search tool on the DWC website.

Q. What type of personal information is accessible through a public information search?

A. The public information search tool provides limited case details, such as the injured worker’s name, case number, case status, court location, employer name, a description of case events, and relevant dates. It may also list the body parts that were injured but does not include medical records or any case documents. The information available through this tool pertains solely to cases within the DWC’s adjudication unit and is intended to facilitate efficient case management within the court system. Any individual requesting access to this information must identify themselves, state the reason for their request, and is explicitly instructed not to share the information with anyone not authorized to receive it.

Injured workers should understand that once an Application for Adjudication of Claim is officially filed, case file information, including case documents, may be subject to disclosure under the California Public Records Act. Even under these circumstances, the DWC will not reveal an injured worker’s address or Social Security number to the requestor.

For further foundational information on workers’ compensation, please refer to the factsheet.

Understanding Employer Responsibilities in Workers’ Compensation

Q. What are my employer’s legal responsibilities under workers’ compensation laws?

A. Employers have specific duties both before and after a workplace injury or illness occurs.

Before an injury or illness happens, your employer is required to:

• Secure workers’ compensation insurance coverage or meet the requirements to become self-insured.
• Upon hiring a new employee, provide a workers’ compensation pamphlet that clearly explains the employee’s rights and responsibilities under the law.
• Display the official workers’ compensation poster in a prominent location within the workplace where it is easily visible to all employees.

After a work-related injury or illness is reported, your employer must:

• Provide you with a workers’ compensation claim form within one working day of being notified about the injury or illness.
• Return a completed copy of the claim form to you within one working day after receiving it from you.
• Forward the original claim form, along with the employer’s report of occupational injury or illness, to the designated claims administrator within one working day of receiving the claim.
• Within one day of receiving your claim, authorize up to $10,000 in appropriate medical treatment to address your injury or illness.
• Offer transitional work (light duty) options whenever feasible and appropriate.
• If you are a victim of a crime that occurred at the workplace, your employer is obligated to provide notice of workers’ compensation eligibility within one working day of the incident.

Q. Is my employer legally allowed to deduct a portion of my paycheck to cover workers’ compensation insurance costs?

A. No, absolutely not. Workers’ compensation insurance is considered a standard operational cost for businesses. Employers are legally prohibited from asking employees to contribute financially towards the insurance premium.

Q. Is my employer required to post a workers’ compensation notice in the workplace?

A. Yes, it is a legal requirement. Your employer must prominently display the “notice to employees” poster in a conspicuous location at the worksite, where it is easily seen by all employees. This poster provides essential information about workers’ compensation coverage and details on how to access medical care for work-related injuries. Failure to post this notice is considered a misdemeanor and can result in civil penalties of up to $7,000 for each violation.

Q. What happens if my employer is uninsured for workers’ compensation, and I get injured on the job?

A. Operating without workers’ compensation insurance is a serious criminal offense, classified as a misdemeanor. It can be penalized by a fine of up to $10,000, imprisonment in county jail for up to one year, or both. Additionally, the state can impose penalties of up to $100,000 against employers found to be illegally uninsured.

If you sustain a work-related injury or illness and discover that your employer lacks insurance coverage, the employer is personally responsible for covering all medical and related expenses arising from your injury or illness. It is highly recommended to contact the information & assistance officer at your local DWC district office for detailed guidance on your situation. It’s crucial to understand that workers’ compensation benefits are typically the exclusive remedy for workplace injuries only when your employer is properly insured. If your employer is illegally uninsured at the time of your work-related injury or illness, you retain the right to file a civil lawsuit against your employer in addition to pursuing a workers’ compensation claim.

Furthermore, you have the option to file a claim for benefits with the state’s Uninsured Employers’ Benefit Trust Fund (UEBTF). For comprehensive information on filing a claim with the UEBTF, please refer to DWC fact sheet F and guides 16, 16A, and 16B.

Q. What exactly is the Uninsured Employers’ Benefit Trust Fund (UEBTF)?

A. The UEBTF is a specialized unit within the Division of Workers’ Compensation designed to provide a safety net for injured workers. It may provide benefits to employees who are injured or become ill while working for an employer who is illegally uninsured. The UEBTF is proactive in seeking reimbursement for any benefits paid out from the responsible uninsured employer, utilizing all available legal means, including placing liens on the employer’s property.

Q. Where can I report an employer who is not providing workers’ compensation insurance?

A. You can report an uninsured employer to the nearest office of the Division of Labor Standards Enforcement. These offices are also listed in the state government section of the white pages of your local telephone directory under “industrial relations, labor standards enforcement.”

Understanding Medical Care in Workers’ Compensation

Q. What type of medical care am I entitled to receive for my work-related injury?

A. The workers’ compensation system in California mandates that doctors provide evidence-based medical treatment. This means that all treatments must be scientifically proven to be effective in treating or alleviating work-related injuries and illnesses. These approved treatments are detailed in a set of guidelines that specify which treatments are appropriate for particular injuries, including the recommended frequency, intensity, and duration of treatment.

To ensure adherence to evidence-based medical treatment, California has adopted a medical treatment utilization schedule (MTUS). The MTUS includes body region-specific guidelines derived from the American College of Occupational and Environmental Medicine’s (ACOEM) Practice Guidelines, as well as specific guidelines for acupuncture, chronic pain management, and post-surgical therapy. The DWC maintains a committee that continuously reviews new medical evidence and updates the guidelines accordingly.

Q. Do these medical treatment guidelines still apply if my workers’ compensation case has already been settled?

A. Potentially, yes. The treatment guidelines are generally considered to be the standard of care, even in cases that were settled before these guidelines were formally incorporated into workers’ compensation law in 2003. It is possible that your claims administrator may continue to authorize and pay for medical care that you have been receiving for your injury, even if it differs from the current guidelines. However, if you have concerns or questions about whether a specific type of medical treatment is still appropriate for your condition, and you are unable to resolve this with your claims administrator, you should contact your local information & assistance officer for guidance.

If your medical treatment has been denied, you have the right to request an expedited hearing before a workers’ compensation administrative law judge to seek resolution. Contact the information & assistance officer at your local DWC district office for assistance with this process.

Q. My claim is still under review, and the claims administrator has not yet accepted or denied it. However, I urgently need medical care for my injury. What are my options?

A. The claims administrator is legally obligated to authorize medical treatment within one working day after you submit a claim form to your employer, even while your claim is still being investigated. The total cost of medical treatment authorized during this investigation period is capped at $10,000. If the claims administrator is delaying or failing to authorize treatment promptly, it’s recommended that you discuss this legal requirement with your supervisor, another manager, or directly with the claims administrator. Specifically, request that they authorize necessary treatment immediately while your claim is being processed.

Q. Are there any limitations on the types or amount of certain medical treatments I can receive?

A. Yes, there are specific limitations for certain treatments. If your date of injury is in 2004 or later, you are generally limited to a total of 24 visits each for chiropractic care, physical therapy, and occupational therapy. However, this limit can be exceeded if the claims administrator provides explicit authorization for additional visits, or if you have recently undergone surgery and require post-surgical physical medicine.

Q. For how long can I continue to receive medical treatment for my injury?

A. You are entitled to receive medical treatment for as long as it is deemed medically necessary. However, it’s important to note that some treatments are subject to legal limitations, and all medical care must be evidence-based.

The MTUS outlines treatments that are scientifically validated to effectively treat or relieve work-related injuries and illnesses. It also provides guidance on the frequency, duration, and other aspects of treatment protocols.

If your treating physician recommends a treatment plan that goes beyond the MTUS guidelines, they must provide additional evidence to justify the medical necessity and effectiveness of the proposed treatment.

Furthermore, your doctor’s treatment plan may be subject to review by a third-party entity hired by the claims administrator. This process is known as utilization review (UR). All claims administrators are legally required to have a UR program in place. UR is used to determine whether to approve or deny treatment recommendations from your doctor.

Q. What is utilization review (UR) in the context of workers’ compensation?

A. Utilization review (UR) is a mandatory program that all claims administrators must implement to ensure that the medical treatment you receive is medically necessary. This program is used to evaluate and decide whether to approve the medical treatments recommended by your treating physician.

The state has established specific rules and regulations governing how UR processes must be conducted. If you believe that the UR company reviewing your doctor’s treatment plan is not adhering to these regulations, you have the right to file a formal complaint with the DWC.

For more detailed information about utilization review, please consult the factsheet.

Q. If my doctor’s request for treatment is denied through utilization review, what recourse do I have?

A. It is crucial to be aware of specific deadlines that you must meet to protect your rights in such situations. As of July 1, 2013, all medical treatment disputes, regardless of the date of injury, are resolved by physicians through a process called independent medical review (IMR). If a UR decision denies or modifies your treating physician’s request for medical treatment based on medical necessity, you can appeal this decision through IMR.

Along with the official written notification of denial or modification of your requested treatment, you will receive an IMR request form that is pre-filled but unsigned, along with a pre-addressed envelope. If you disagree with the UR decision, you must sign and mail this form using the provided envelope to initiate the IMR process.

For comprehensive details about the IMR process, including eligibility criteria, deadlines, and a link to the IMR request form, please visit the IMR FAQ page.

Q. What happens if I have already received medical treatment, but the claims administrator refuses to pay for it? Am I personally responsible for these medical bills?

A. In most cases, you will not be held responsible for these costs. This is typically an issue that needs to be resolved directly between your doctor and the claims administrator.

Q. What is a medical provider network (MPN)?

A. A medical provider network (MPN) is an organized group of healthcare providers established by your employer’s insurance company and officially approved by the DWC’s administrative director to provide medical treatment to employees injured on the job. Each MPN includes a diverse range of doctors, including specialists in work-related injuries and physicians with expertise in general medicine. If your employer participates in an MPN, your workers’ compensation medical care will be managed by doctors within this network. An exception to this is if you were eligible to pre-designate your personal physician and had completed this process before your injury occurred.

Q. What is a health care organization (HCO) in the context of workers’ compensation?

A. A health care organization (HCO) is an entity that has been certified by the DWC to deliver managed medical care services to injured workers.

Q. Who is considered the primary treating physician (PTP)?

A. Your primary treating physician (PTP) is the doctor who holds overall responsibility for managing and directing the medical treatment for your work-related injury or illness. Typically, your employer has the authority to select the PTP you will see for the initial 30 days of treatment. However, there are specific circumstances where you may be able to be treated by your pre-designated physician or medical group right from the start. If your physician indicates that you require ongoing treatment beyond the initial 30-day period, you may have the option to switch to a physician of your choosing. It’s important to note that different rules apply if your employer utilizes an HCO or an MPN.

Q. What is involved in the process of pre-designating a personal physician for workers’ compensation purposes?

A. Predesignating a personal physician is a formal process that allows you to inform your employer in advance that you wish to have your personal doctor provide treatment for any future work-related injuries. You can predesignate either a medical doctor (M.D.) or a doctor of osteopathy (D.O.) as your personal physician, but only if all of the following conditions are met:

1. You must provide written notice to your employer, before the date of the injury for which you are seeking treatment, that you are predesignating your personal physician or medical group. This notice must include the physician’s full name and business address.
2. On the date of injury, you must have existing healthcare coverage for non-occupational injuries or illnesses through a plan, policy, or fund.
3. Your personal physician or medical group must agree to be predesignated prior to the date of your injury.

The DWC provides a specific form for predesignating a personal physician, which is available on the forms page of its website.

Q. I prefer to be treated by my personal chiropractor or acupuncturist. How does that process work within workers’ compensation?

A. If your employer or their workers’ compensation insurer does not have an MPN, you may have the option to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. To be eligible for this change, you must have provided your employer with the name and business address of your personal chiropractor or acupuncturist in writing prior to the injury or illness occurring. There is a designated form called the “notice of personal chiropractor or personal acupuncturist” that you can use for this purpose. After your claims administrator has initiated your medical treatment with another physician for the initial 30-day period, you can then request to have your ongoing treatment transferred to your pre-designated personal chiropractor or acupuncturist.

However, it’s important to know that if your injury occurred on or after January 1, 2004, a chiropractor cannot continue to be your treating physician after you have received 24 chiropractic visits. If you still require medical treatment beyond this limit, you will need to select a new physician who is not a chiropractor.

Q. Does the 24-visit cap on chiropractic visits apply in all workers’ compensation cases?

A. No. The 24-visit limit on chiropractic visits does not apply to injuries that occurred before January 1, 2004. Additionally, this cap does not apply if your employer explicitly authorizes additional visits in writing. Furthermore, visits for specific post-surgical physical medicine and rehabilitation services are also exempt from this cap.

Q. What if I disagree with the treatment plan recommended by a doctor within the MPN?

A. If you disagree with the treatment approach suggested by your MPN doctor, you have the option to switch to another physician within the same MPN. You can also seek a second and even a third opinion from different doctors listed in the MPN. If you continue to disagree with the treatment recommendations after these steps, you can initiate an Independent Medical Review (IMR) to resolve the dispute. Refer to the detailed information about your MPN provided by your employer for specific procedures.

Q. What if I disagree with the MPN doctor’s opinions regarding my ability to return to work, whether I have a permanent disability, or my need for future medical treatment?

A. If your disagreement with the MPN doctor pertains to issues other than diagnosis or treatment, such as your capacity to return to work, permanent disability status, or future medical needs, you must request a Qualified Medical Evaluator (QME).

Q. What happens if a treatment request from an MPN doctor is denied by utilization review (UR) or the claims administrator?

A. When a treatment request is denied or modified through UR, you will receive a written determination letter. This letter will include an unsigned but completed IMR request form and a pre-addressed envelope. If you disagree with the denial or modification, you must sign and mail this form in the provided envelope to formally start the IMR process.

For comprehensive details about the IMR process, eligibility requirements, deadlines, and access to the IMR request form, please visit the IMR FAQ page.

Q. Who is responsible for determining the type of work I can perform while I am in recovery?

A. Your treating doctor is responsible for providing a medical report that clearly outlines:

• The specific types of work activities you are capable of doing and those you should avoid while recovering.
• Any necessary adjustments or modifications to your work schedule or job duties.

It’s essential for you, your treating doctor, your employer, and your attorney (if you have one) to review your job description together and discuss any necessary modifications to your job or work environment. For instance, your employer might offer a reduced work schedule or adjust your responsibilities to minimize certain physical demands.

If you disagree with your treating doctor’s assessment of your work capabilities, it is important to promptly communicate your disagreement in writing to the claims administrator to protect your rights.

Q. I do not have legal representation, and I disagree with the medical report from my doctor regarding my injury. What steps should I take?

A. You have the option to request a medical evaluation with a physician known as a Qualified Medical Evaluator (QME) in the following situations:

• If your workers’ compensation claim is being delayed or denied, and you need a medical evaluation to determine if the claim is payable.
• To assess whether you have a permanent disability as a result of your injury or if you will require future medical treatment.
• If you disagree with your treating physician’s opinions concerning your injury, work restrictions, or temporary disability (TD) status. However, it is important to note that a QME cannot provide opinions on a request for medical treatment. If your doctor’s treatment request is denied, and you disagree with the utilization review (UR) decision, you should instead request an Independent Medical Review (IMR).

If you are represented by an attorney, your attorney and the claims administrator can mutually agree on a doctor to conduct your medical evaluation. If you need to obtain a list of QMEs to choose from, you must complete the panel request form (QME 105) and mail it to the DWC Medical Unit. If you are unsure of what type of specialist should evaluate your injury, consult your treating physician for guidance.

Within 20 working days of receiving your request, the DWC Medical Unit will send a list (referred to as a panel) of three QMEs to both you and the insurance company. QME panels are generated randomly and are not affiliated with your employer or the insurance company.

Once you receive the QME panel list, you have 10 days from the print date and mailing date to select a QME from the list, schedule an appointment, and inform the insurance company of your chosen doctor and appointment date. If you fail to do so within this 10-day timeframe, the insurance company will have the right to select a doctor from the panel and schedule the appointment for you.

Q. What should I do if the claims administrator has sent me a QME panel request form?

A. You may be required to see a QME if the insurance company disagrees with some aspect of your claim. In such cases, the insurance company will provide you with the form to request a QME panel. When you receive this form, you have 10 days to request a QME list by sending the completed form to the DWC Medical Unit. If you do not submit the form within 10 days of receiving it, the insurance company will have the authority to request the QME list and select the type of doctor you will see.

Within 20 working days of the request, the DWC Medical Unit will mail a panel list of three QMEs to both you and the insurance company. These QME lists are randomly generated and do not represent either your employer or the insurance company.

After receiving the panel list, you have 10 days from the date it was printed and mailed to choose a QME from the list, make an appointment, and notify the insurance company of your selection and appointment date. If you do not complete these steps within 10 days, the insurance company will be entitled to select the doctor and schedule the appointment for you.

Q. What are the qualifications of a QME?

A. The DWC Medical Unit is responsible for certifying QMEs in various medical specialties. To become a QME, a physician must hold an active license to practice medicine in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists, dentists, optometrists, podiatrists, or acupuncturists.

Q. What is the difference between a QME and an AME?

A. If you are represented by an attorney, your attorney and the claims administrator have the option to agree on a doctor to perform a medical evaluation without going through the state’s QME system. The doctor they mutually agree upon is known as an Agreed Medical Evaluator (AME). If they cannot reach an agreement on an AME, they must then request a QME panel list from the DWC.

Q. I’m still confused about the QME process. Why is it necessary for me to see a QME?

A. Situations may arise where you or the claims administrator disagree with the opinions or findings of your treating doctor. There may be other medical disagreements in your claim that require resolution by a medical expert. Common areas of disagreement can include:

• Whether your injury was actually caused by your work.
• Whether you may need future medical treatment related to your injury.
• Whether you need to take time off work to recover.
• The determination of a permanent disability rating.

The report generated by the QME (or AME, if you are represented by an attorney) will play a crucial role in determining the workers’ compensation benefits you are entitled to receive.

Q. Can I challenge the findings of a QME if I disagree with their report?

A. Yes, you have options if you disagree with a QME’s report, but it’s important to act quickly as there are time limitations. Upon receiving the QME’s report, you should review it promptly to assess its accuracy. If you believe the report is inaccurate or incomplete, and you have an attorney, you should immediately discuss your concerns and options with them.

If you do not have an attorney and you believe there are factual errors in the QME’s report, you have the right to request a factual correction of the report. This request must be made within 30 days of receiving the report.

Similarly, the claims administrator also has the right to request a factual correction of the report.

Upon receiving a request for factual correction, the QME is required to file a supplemental report with the Disability Evaluation Unit (DEU), stating whether a factual correction is necessary to ensure the accuracy of the report. If corrections are needed, the QME must also clarify whether these factual corrections change any of the opinions stated in the original comprehensive medical report.

For further guidance, you can contact the Information and Assistance (I&A) officer at your local DWC district office.

If you are a union member, your collective bargaining agreement or labor-management agreement may provide access to an ombudsperson or mediator to assist with dispute resolution.

For more detailed information about QMEs and AMEs, please refer to the factsheet.

Understanding Temporary Disability Benefits

Q. What are temporary disability benefits in workers’ compensation?

A. Temporary disability (TD) benefits are payments provided to you if you experience wage loss because your work-related injury prevents you from performing your usual job duties while you are recovering. For more detailed information, please refer to the DWC fact sheet on TD.

Q. Are there different categories of temporary disability benefits?

A. Yes, there are two primary types of TD benefits. If your injury completely prevents you from working during your recovery, you will receive temporary total disability (TTD) benefits. If you are able to work but not at your full schedule or capacity while recovering, you will receive temporary partial disability (TPD) benefit payments.

Q. How much will I receive in temporary disability payments?

A. Generally, temporary disability benefits are calculated to be two-thirds of your gross (pre-tax) wages lost due to your work injury during recovery. However, there is a maximum weekly amount set by law that you cannot exceed. Your wages are calculated based on all forms of income you receive from your employment, including wages, food, lodging, tips, commissions, overtime pay, and bonuses. Wages can also include earnings from any other jobs you held at the time of your injury. It is important to provide proof of all earnings to the claims administrator so that all forms of income are considered when calculating your TD benefits. For current benefit rates, please refer to the benefits chart.

The minimum and maximum benefit rates are adjusted annually.

Q. What about TTD payments for workers who earn low wages?

A. Every employee who has earnings is entitled to receive TTD benefits if they qualify. TTD payments are calculated at two-thirds of the injured worker’s wages at the time of injury, subject to established minimum and maximum rates. Please consult the benefits chart for the current rate details.

The minimum TTD rate is recalculated each January 1st based on changes to the statewide average weekly wage (SAWW).

Q. When do temporary disability benefits begin and end?

A. TD payments typically start when your doctor states that you are unable to perform your usual work duties for more than three days, or if you are hospitalized overnight due to your injury. Payments are required to be made every two weeks. Generally, TD benefits cease when you are able to return to work, when your doctor releases you to return to work, or when your doctor determines that your medical condition has reached maximum medical improvement. For injuries occurring after April 19, 2004, TD payments are limited to a maximum of 104 weeks within a two-year period from the date of the first payment for most types of injuries. If your injury occurred after January 1, 2008, the TD payment period is limited to 104 weeks within a five-year period from the date of injury. However, for certain long-term injuries, such as severe burns or chronic lung disease, TD payments may extend beyond 104 weeks, up to 240 weeks of payment within a five-year period.

Q. Are temporary disability benefits subject to taxes?

A. No. Temporary disability benefits are not subject to federal, state, or local income taxes. Additionally, deductions are not made for Social Security taxes, union dues, or retirement fund contributions.

Q. Can my initial temporary disability payment be delayed?

A. Yes, in some situations. If the claims administrator is unable to immediately determine whether your injury is covered under workers’ compensation, they may delay your first TD payment while they conduct an investigation. This delay is typically not longer than 90 days. If a delay occurs, the claims administrator is required to send you a formal delay letter. This letter must explain the reason for the payment delay, specify what additional information the claims administrator needs to make a decision, and indicate when a decision will be reached. If further delays occur, the claims administrator must send you additional delay letters to keep you informed.

It’s important to note that if the claims administrator does not send you a letter formally denying your claim within 90 days after you filed your claim form, your claim is generally considered to be accepted in most cases.

Q. Is the claims administrator required to pay a penalty for delays in temporary disability payments?

A. Potentially, yes. If you have submitted your workers’ compensation claim form at least 14 days before a payment is due, and the claims administrator sends the payment late, they are obligated to pay you an additional 10 percent of the delayed payment as a penalty, which should be self-assessed and included with the late payment.

Q. Why am I receiving so many letters related to my workers’ compensation claim?

A. The claims administrator is legally required to keep you informed about your claim by sending letters that explain how payment amounts are calculated, the reasons for any delays in TD payments, explanations for changes in TD payment amounts, and the reasons for the termination of TD benefits. This communication is intended to keep you updated throughout the process.

Q. My temporary disability payments have stopped without any explanation. What should I do?

A. Your first step should be to contact your employer or the claims administrator to inquire about the reason for the payment cessation. If this does not resolve the issue, you should then contact your local DWC I&A officer for assistance.

For more detailed information on temporary disability benefits, please consult the factsheet.

Understanding Permanent Disability Benefits

Q. What are permanent disability benefits in workers’ compensation?

A. While most workers fully recover from workplace injuries, some may experience lasting medical issues. Permanent disability (PD) refers to any lasting impairment that results in a reduced earning capacity after you have reached maximum medical improvement. If your work-related injury or illness results in PD, you are entitled to permanent disability benefits, even if you are able to return to work.

It’s important to understand that PD benefits are limited. If you experience income loss due to your disability, PD benefits may not fully compensate for all lost income. Similarly, PD benefits may not cover losses that are not directly related to your ability to work. For more detailed information, please refer to the DWC fact sheet on PD.

Q. How is permanent disability determined in workers’ compensation cases?

A. The determination of whether your injury or illness has resulted in permanent disability is made by a medical doctor. Once your doctor concludes that your medical condition has stabilized, and no further significant improvement is expected, permanent disability is evaluated. At this point, your condition is considered to be permanent and stationary (P&S). Your doctor may also use the term maximal medical improvement (MMI) instead of P&S to describe this stage.

Once you reach P&S or MMI, your doctor will send a medical report to the claims administrator, indicating that you have a permanent disability. The doctor will also assess whether any portion of your disability is attributable to factors other than your work injury, such as pre-existing conditions or previous injuries. Assigning a percentage of your disability to non-work-related factors is known as apportionment.

Q. What happens after the doctor’s report on permanent disability is completed?

A. If your evaluation was conducted by a QME, the QME’s report is sent to both the claims administrator and the DWC’s Disability Evaluation Unit (DEU). A rater from the DEU will use the QME’s report and the Employee Disability Questionnaire that you completed at your QME appointment to calculate your PD rating. If you are represented by an attorney, the disability rating can be calculated by either the DEU or a private rating specialist.

You and the claims administrator both have the right to request a PD rating based on the report from your primary treating physician (PTP), but this is not an automatic process. To request a rating of your PTP’s report, you must complete a Request for Summary Rating Determination of Primary Treating Physician’s Report and submit it to the DEU, along with a copy of your PTP’s report.

The specific process used to calculate your disability rating can vary based on your date of injury and other factors. The PD rating is then used in a formula to determine the amount of PD benefits you will receive.

You have the right to receive copies of both the QME’s report and the reports from your PTP. It is important to review these reports carefully to ensure they are complete and accurate and do not omit any critical information. If you believe there are factual errors in the QME’s comprehensive report, you can request a factual correction, but you must do so within 30 days of receiving the report.

The QME will review your request and issue a supplemental report, indicating whether factual corrections are necessary for accuracy and whether any corrections affect the QME’s original opinions.

Q. What if I disagree with the doctor’s assessment of my permanent disability?

A. If you or the claims administrator disagree with your doctor’s findings regarding permanent disability, you have the right to seek an evaluation from a Qualified Medical Evaluator (QME). You must request a QME panel list from the DWC Medical Unit. The claims administrator will provide you with the necessary forms to request a QME panel. Your employer is responsible for covering the costs of the QME examination. You have a strict deadline of 10 days from the date the claims administrator informs you to begin the QME process to submit your request form to the DWC Medical Unit. Failure to submit the form within this 10-day period will give the claims administrator the authority to submit the request on your behalf and choose the type of doctor you will see.

It is critical to adhere to these specific timelines when filing your QME forms to protect your legal rights. Refer to DWC Information and Assistance Unit guide 2 for detailed instructions.

Once you receive the QME panel list from the DWC Medical Unit, you are required to select a doctor from the list, schedule your examination appointment, and inform the claims administrator of your chosen doctor and appointment date. You have 10 days from the date you receive the panel list to complete these steps. If you do not make the appointment within this 10-day period, the claims administrator may select a doctor from the panel and schedule the appointment for you.

If you are represented by an attorney, they can assist you in selecting a QME, or you may be evaluated by an Agreed Medical Evaluator (AME). An AME is a doctor that your attorney and the claims administrator mutually agree upon to conduct your medical examination. In such cases, you should discuss your options with your attorney.

Q. Can you provide more detail about the permanent disability rating and how it is calculated?

A. After your medical examination, the doctor will prepare a report detailing your impairment. Impairment refers to the functional limitations caused by your injury that affect your ability to perform normal daily life activities. The report will also address whether any portion of your disability is due to factors other than your work injury. The doctor’s report will conclude with an impairment rating number.

This impairment number is then used in a formula to calculate your percentage of disability. Disability, in this context, refers to how the impairment affects your ability to work. Factors such as your occupation, your age at the time of injury, and your future earning capacity are also considered in this calculation.

Next, any portion of your disability that is attributed to non-work-related factors is subtracted from the overall calculation.

Your final disability will be expressed as a percentage. This percentage of disability corresponds to a specific dollar amount of benefits, which is determined by the date of your injury and your average weekly wages at the time of the injury. A rating specialist from the DWC Disability Evaluation Unit (DEU) can assist in calculating your rating.

If your injury occurred between January 1, 2005, and December 31, 2012, your PD award may be increased or decreased by 15 percent, depending on whether you work for an employer with 50 or more employees and whether your employer offers you regular, alternative, or modified work.

Q. I disagree with the disability rating provided by the state disability rater. What are my options?

A. If you do not have an attorney, you can request the state DWC to review the disability rating. The DWC will assess whether any errors were made in the medical evaluation process or in the rating calculation. This review process is known as reconsideration of your rating. Refer to I&A guide 3 for more information. You also have the option to present your case to a workers’ compensation administrative law judge. Contact a state I&A officer for assistance. Workers who are represented by attorneys cannot request reconsideration. If you have an attorney, they can present your case to a judge.

Q. How much will I be paid in permanent disability benefits?

A. Permanent disability benefits are established by law. The claims administrator will determine your payment amount based on three key factors:

• Your disability rating (expressed as a percentage).
• The date of your injury.
• Your average weekly wages before you were injured.

Q. How and when are permanent disability benefits paid out?

A. Permanent disability benefits typically begin after temporary disability benefits end and your doctor indicates that you have some permanent effects from your injury. The claims administrator is required to start making PD payments within 14 days after your TD benefits cease. The claims administrator will choose a specific day for payments and will continue to make payments every two weeks until a reasonable estimate of your total disability benefit amount has been paid.

If you have not missed any time from work due to your injury, PD payments are due once the claims administrator becomes aware that your injury has resulted in a permanent disability.

Q. Why am I receiving so many notice letters regarding my permanent disability benefits?

A. By law, the claims administrator must keep you informed by sending letters that explain how your PD payment amounts were determined, when you will receive PD payments, the reasons for any delays in PD payments, and why PD benefits may not be payable in certain situations.

Q. Is the claims administrator required to pay a penalty for delays in permanent disability payments?

A. Yes. If the claims administrator sends a PD payment late, they are obligated to pay you an additional 10 percent penalty, which is self-assessed and added to the payment. This penalty applies even if there was a reasonable excuse for the delay and even if the claims administrator sends a letter explaining the delay. In cases where there was no reasonable justification for the delay, you could potentially be awarded a significantly larger penalty.

Q. How is my workers’ compensation claim ultimately resolved regarding permanent disability?

A. After the extent of permanent disability in your claim is determined, the claim is usually resolved through a settlement or an award of benefits. Any settlement or award must be formally approved by a workers’ compensation administrative law judge. If you have an attorney, they will typically assist you in obtaining this approval. If you do not have an attorney, the claims administrator should guide you through the process of obtaining the award. You can also seek assistance from the I&A officer at your local DWC district office. If your doctor has indicated that future medical treatment for your injury or illness may be necessary, the final award may include provisions for future medical care.

There are several ways to finalize your claim:

• Compromise and Release (C&R): You can resolve your entire claim through a lump-sum settlement known as a C&R. A C&R may be beneficial if you prefer to manage your own medical care and/or want a single lump-sum payment for your permanent disability. Typically, with a C&R, once you receive the lump-sum payment that has been approved by a workers’ compensation judge, the claims administrator will not be responsible for any further payments or medical care related to your claim.

• Stipulation (Stip): You can also agree to a settlement known as a stipulation or “stip.” A stip usually involves a specific sum of money for permanent disability and may include provisions for future medical treatment. Payments under a stip are typically made over time. A workers’ compensation judge will review and approve the stipulated agreement.

• Findings and Award (F&A): If you and the claims administrator cannot agree on a settlement, you can present your case to a workers’ compensation administrative law judge, who will make a decision regarding your permanent disability award. A judge’s decision is called a Findings and Award (F&A). An F&A usually consists of a sum of money for permanent disability and may also include a provision for the claims administrator to pay for approved future medical treatment.

Regardless of whether you agree to a stip or receive an F&A, the total amount of your PD benefit will be distributed over a set number of weeks. If you settle your case through a C&R, you will receive a lump-sum payment. If you are determined to have permanent total disability (PTD), you may be eligible to receive payments for the remainder of your life.

In most situations, your PD payments will start before the final determination of your total PD benefit amount is reached. This is because once your doctor indicates that you have a permanent disability, the claims administrator will estimate the amount you should receive and begin making payments to you while the final percentage of disability is being calculated.

Once the actual amount of PD benefits due has been definitively determined, any remaining amount owed beyond the initial estimate will be paid to you.

For more detailed information about permanent disability benefits, please consult the factsheet.

Understanding Returning to Work After Injury

Q. My primary goal is to return to work as soon as possible. How can I facilitate this process?

A. Injured workers who are able to return to their jobs as soon as it is medically safe and feasible tend to have better overall outcomes. They generally recover from their injuries more quickly and experience less wage loss. Your decision about returning to work will be influenced by your treating doctor, your employer, and the claims administrator. Maintaining open and frequent communication with all parties is crucial for achieving the best possible outcome.

If your treating doctor determines that you are medically unable to return to work during your recovery period, you cannot be legally compelled to go back to your job.

In some cases, it may be possible to return to work with certain work restrictions, especially if your employer is willing and able to make reasonable accommodations. For example, your employer might modify certain aspects of your job duties or provide you with specialized equipment to enable you to work safely within your restrictions.

If your doctor indicates that you can return to work with restrictions, but your employer is either unwilling or unable to accommodate these restrictions, you are not required to return to work under those circumstances.

In the meantime, depending on the nature and extent of your injuries, you may be eligible for temporary disability benefits, supplemental job displacement benefits, or permanent disability benefits.

Q. How is my ability to return to work determined after a work injury?

A. Returning to work in a safe and timely manner can play a significant role in your recovery process and can help minimize financial losses associated with being off work. Following a workplace injury, several individuals will be involved in determining when you can return to work and what type of work you can perform. These key individuals include:

• Your treating doctor.
• Managers or representatives from your employer.
• The claims administrator handling your workers’ compensation claim on behalf of your employer.

It’s important to recognize that doctors and claims administrators may not always have a complete understanding of the specific demands of your job or other potential job assignments within your company. This is why maintaining close and consistent communication throughout the return-to-work process is essential. You (and your attorney, if you have one) should actively communicate with your treating doctor, your employer, and the claims administrator about:

• The specific job duties you performed before your injury.
• Your current medical condition and the types of work activities you are now capable of doing.
• The types of work your employer might be able to offer you, considering your restrictions and capabilities.

Q. Is it possible to work in some capacity while I am still recovering from my injury?

A. Shortly after your injury, your treating doctor will conduct a medical examination and send a report to the claims administrator detailing your medical condition. If your treating doctor determines that you are able to perform some type of work, they should specify:

• Clear and specific limitations, if any, on your job tasks while you are recovering. These are known as work restrictions and are designed to prevent further injury or aggravate your existing condition. For example, a restriction might be “no work that requires repetitive bending or stooping.”
• Any necessary modifications to your work schedule, job assignments, equipment, or other working conditions to accommodate your recovery. For instance, providing a headset to avoid awkward neck and head positions.
• Conversely, if your treating doctor reports that you are completely unable to work during your recovery period, you cannot be required to work.

Q. I have been given work restrictions by my doctor. Does this mean I can still work?

A. If your treating doctor has indicated that you can return to work with specific work restrictions, any job assignment your employer provides must strictly adhere to these restrictions. Your employer may need to modify certain tasks or provide assistive equipment to accommodate your restrictions. Alternatively, your employer may state that they do not have any work available that aligns with your restrictions. In that case, you cannot be required to work.

Q. What if I have no work restrictions from my doctor?

A. If your treating doctor reports that you are able to return to your job without any restrictions, your employer is generally obligated to offer you the same job you held before your injury, at the same pay rate and with the same benefits. In this situation, your employer can require you to accept the job offer. This could occur relatively soon after your injury, or it might happen later in your recovery process as your condition improves.

Q. What should I do if my employer offers me a job after my injury?

A. If you receive a letter from the claims administrator stating that your employer is offering you work, it is critical to ensure that the offered job complies with the work restrictions outlined in your doctor’s medical report. The job offer could be in the form of:

• Regular work: This refers to your previous job, offered for a duration of at least 12 months, with the same wages and benefits you received at the time of your injury, and located within a reasonable commuting distance from your residence at the time of your injury.

• Modified work: This is your old job with certain modifications or adjustments that allow you to perform it within your work restrictions. If your doctor indicates that you will not be able to return to your original job, your employer is encouraged to offer modified work as an alternative to supplemental job displacement benefits (SJDB). The modified work must meet your doctor-prescribed work restrictions, be expected to last for at least 12 months, pay at least 85 percent of the wages and benefits you were earning at the time of your injury, and be within a reasonable commute from your home at the time of injury.

• Alternative work: This is a different job with your employer, which is new to you. Similar to modified work, if your doctor determines you cannot return to your previous job, your employer is encouraged to offer alternative work instead of SJDB. The alternative work must also comply with your work restrictions, be expected to last at least 12 months, provide wages and benefits that are at least 85 percent of your earnings at the time of injury, and be within a reasonable commuting distance.

If your employer offers you modified or alternative work, it’s important to be aware of the following:

• You may have a limited timeframe, typically 30 days, to accept the job offer. If you do not respond within 30 days, your employer may withdraw the offer.
• If you fail to respond to an offer of modified or alternative work within 30 days or if you reject the job offer, you will likely lose your eligibility for supplemental job displacement benefits.

Q. What if my employer does not offer me any work after my injury?

A. If you were injured between January 1, 2004, and December 31, 2012, and your employer has 50 or more employees, and they do not offer you regular, modified, or alternative work, your weekly permanent disability benefits will be increased by 15 percent.

If you were injured during the same period, but your employer has fewer than 50 employees, and they do not offer you regular, modified, or alternative work, your permanent disability benefits will not be affected and will not be increased.

For injuries that occurred on or after January 1, 2013, your permanent disability benefits will not be increased if you are not offered regular, modified, or alternative work, regardless of the size of your employer.

Q. Why are my permanent disability benefits potentially affected by a return-to-work offer?

A. Research and experience have shown that the longer an injured worker remains out of work, the lower the likelihood of them returning to work successfully. This can lead to greater wage loss and a diminished quality of life. Permanent disability benefits are not intended to fully replace lost income resulting from not returning to work. Therefore, provisions related to return-to-work offers were implemented to encourage and facilitate your return to your job as soon as it is medically appropriate.

However, it is recognized that returning to work may not be feasible for everyone in every situation. If your situation is complex or you need assistance in understanding available resources, it is advisable to consult with an I&A officer or another advocate of your choice.

Q. What happens if the job my employer offered to me does not work out in the long run?

A. Depending on your date of injury, you may still be entitled to supplemental job displacement benefits (SJDB) if the job offer does not last for 12 months, or if your disability prevents you from performing the required tasks of the job. If you have concerns about a job offer or its suitability, discuss them with your employer or the claims administrator. If you are unable to resolve the issue, contact a state I&A officer for guidance.

Q. How do I qualify for supplemental job displacement benefits (SJDB)?

A. If you were injured on or after January 1, 2004, and you are determined to be permanently unable to return to your usual job, and your employer does not offer you modified or alternative work, you may be eligible for SJDB. This benefit is provided in the form of a voucher that can be used to pay for educational retraining or skill enhancement programs at state-approved or state-accredited schools.

For injuries occurring on or after January 1, 2004, and before January 1, 2013, employees who do not return to work for their employer within 20 calendar days from the expiration of the time for making an offer of regular, modified, or alternative work will receive a voucher. The value of the voucher varies depending on your percentage of permanent partial disability:

• Up to a $4,000 voucher for permanent partial disability rated at less than 15 percent.
• Up to a $6,000 voucher for permanent partial disability rated between 15 and 25 percent.
• Up to an $8,000 voucher for permanent partial disability rated between 26 and 49 percent.
• Up to a $10,000 voucher for permanent partial disability rated between 50 and 99 percent.

Up to 10 percent of the voucher funds can be used for vocational or return-to-work counseling services.

The law also states that an employer is not obligated to provide SJDB to an employee if, within 30 days of the end of temporary disability payments, they make an offer of modified or alternative work that meets specific requirements, and the employee rejects or fails to accept this offer in the manner prescribed by the DWC administrative director.

For injuries occurring on or after January 1, 2013, the voucher amount is standardized at $6,000, regardless of the permanent disability rating. The voucher will be due within 20 calendar days from the expiration of the time for making an offer of regular, modified, or alternative work. The job offered must pay no less than 85% of the employee’s earnings at the time of injury and must be expected to last for at least 12 months.

Q. What if my employer offers me a modified or alternative job, and I choose not to accept it? Can I still receive the SJDB voucher?

A. No. For injuries that occurred between January 1, 2004, and December 31, 2012, if your employer sends you a notice of an offer of modified or alternative work within 30 days of your last temporary disability (TD) payment, and the offer meets certain legal requirements, and you do not accept the job, you will typically not be eligible for the SJDB voucher. The offer of modified or alternative work must meet the following conditions:

• You must have the physical and mental ability to perform the essential functions of the job.
• The job must be a regular position expected to last at least 12 months.
• The job must offer wages and compensation that are at least 85 percent of what you were earning at the time of your injury.
• The job must be located within a reasonable commuting distance from your residence at the time of your injury.

For injuries occurring on or after January 1, 2013, if the employer makes an offer of regular, modified, or alternative work within 60 days after the claims administrator receives the Physician’s Return-to-Work & Voucher Report, and the offer meets the same requirements as listed above, and you do not accept the job, you will not be eligible for the voucher.

Job offers should not be filed directly with the DWC.

Q. When can I expect to receive the SJDB voucher if I am eligible?

A. For injuries occurring between January 1, 2004, and December 31, 2012, if you are eligible for the voucher and your eligibility has not been settled as part of an overall settlement in your case, you will receive the voucher from the claims administrator within 25 calendar days from the date your disability award is issued by the workers’ compensation judge at your local Workers’ Compensation Appeals Board district office. For injuries occurring on or after January 1, 2013, the voucher is due 60 days after a treating doctor, AME, or QME declares you to be permanent and stationary and issues a report outlining your work capacities, provided that your employer does not offer you a qualifying job.

Q. When can I expect to receive payments specified in the SJDB voucher?

A. The claims administrator is required to issue reimbursement payments to you or make direct payments to the Vocational & Return to Work Counselor (VRTWC) and training provider within 45 calendar days from receiving the completed voucher, along with all necessary receipts and documentation.

Q. I disagree with my treating doctor’s opinion about the type of work I can handle. What are my options?

A. It is possible for different doctors to have varying opinions regarding a worker’s ability to perform job tasks safely. You have the right to question or disagree with a medical report written by your treating doctor regarding your work capacity. To dispute your doctor’s report about your ability to work:

• If you do not have an attorney, you must send a written letter to the claims administrator stating that you disagree with the report. This letter must be sent within 30 days of your receipt of the report.
• If you are represented by an attorney, you should contact your attorney immediately. The deadline for formally stating your disagreement is shorter, at 20 days.
• Following this, you can seek a medical evaluation from another doctor. For detailed information about obtaining a medical evaluation, you can contact the DWC Medical Unit at 1-800-794-6900.

For assistance in obtaining a medical evaluation, you can also contact a DWC I&A officer.

Q. I disagree with my employer regarding the work assigned or offered to me. What can I do?

A. If your employer assigns or offers you work that does not comply with the work restrictions specified by your treating doctor, you are not obligated to accept it. Contact a DWC I&A officer for more detailed guidance on how to proceed in such situations.

It is illegal for an employer to discriminate against you because you have requested workers’ compensation benefits or because you have a work-related disability. This form of discrimination is prohibited under California Labor Code section 132a, the federal Americans with Disabilities Act (ADA), and the California Fair Employment and Housing Act (FEHA).

However, it’s important to understand that an employer is not always legally required to offer you a job or to offer a specific job that you may desire. For instance, there may not be any available job positions that align with your doctor’s work restrictions.

Q. What if I do not receive any permanent disability rating (a zero rating), but I am still unable to return to work?

A. If you receive a zero permanent disability rating and are still unable to return to work, the DWC may not be able to provide further assistance within the workers’ compensation system. However, other forms of financial assistance may be available to you:

• State disability insurance (SDI) or, in limited circumstances, unemployment insurance (UI) benefits, which are paid by the state Employment Development Department (EDD).
• Social Security disability benefits, provided by the U.S. federal government for individuals with total disability.
• Benefits offered by your employer and/or union, such as sick leave, group health insurance, long-term disability insurance (LTD), and salary continuation plans.
• You may have grounds for a claim or lawsuit if your injury was caused by the negligence of someone other than your employer.

You should also be aware of the federal Americans with Disabilities Act (ADA), which prohibits discrimination against individuals with physical or mental impairments that substantially limit one or more major life activities, and who are otherwise qualified to perform the essential functions of a job. Employers are required to provide reasonable accommodations unless doing so would impose an “undue hardship” on their business. For information on the ADA, contact the Equal Employment Opportunity Commission at 1-800-USA-EEOC. Additionally, the state Department of Fair Employment and Housing administers the California Fair Employment and Housing Act (FEHA), which prohibits harassment or discrimination in employment, housing, and public accommodations. For more information on FEHA, call 1-800-884-1684.

Q. Can the SJDB voucher be settled for a cash payment instead?

A. No, not for injuries that occurred on or after January 1, 2013.

Q. Does the SJDB voucher have an expiration date?

A. Vouchers issued before January 1, 2013, do not expire. For vouchers issued on or after January 1, 2013, they will expire either two years from the date of issuance or five years from the date of injury, whichever is later.

Navigating the Workers’ Compensation System Effectively

Q. The workers’ compensation system seems very complicated. Should I consider hiring an attorney to help me?

A. Deciding whether to hire an attorney is a personal one that you need to consider carefully based on your individual circumstances. Many workers’ compensation claims are resolved successfully between injured workers and claims administrators without significant issues. You are not legally required to have an attorney, even if you have a disagreement with the claims administrator. However, if your case is particularly complex, you may find it beneficial to have legal representation. Your attorney’s fees are regulated and cannot be charged directly to you; instead, they are paid as a percentage of your workers’ compensation benefits, and must be approved by a workers’ compensation judge. If you choose not to hire an attorney, the I&A officer at your local DWC district office is available to assist you with your claim, free of charge. Even if you decide to hire an attorney, it is still advisable to educate yourself about your rights and responsibilities, maintain open communication with your employer and the claims administrator, and don’t hesitate to ask them questions throughout the process.

Q. I am experiencing problems getting my benefits processed. What resources are available to help me resolve these issues?

A. Your local I&A officers are an excellent resource, and their services are provided at no cost to you. While they do not act as legal counsel in the same way an attorney would, they are dedicated to helping you understand how to effectively advocate for yourself within the workers’ compensation system. Attending a free seminar for injured workers at a local DWC district office is also highly recommended to gain a comprehensive understanding of workers’ compensation benefits, your rights, and responsibilities. You can also schedule a private appointment with an I&A officer for individualized assistance at your convenience.

Additionally, the I&A page on the DWC’s website offers a wealth of information. Be sure to explore the fact sheets and guides designed for injured workers. These resources provide answers to common questions about issues that may affect your benefits and offer step-by-step guidance on completing forms and resolving claim-related problems at your local DWC district office.

Q. I have a disability and need assistance to access DWC services. Is there any support available for individuals with disabilities?

A. Yes. If you have a disability and require accommodations to utilize the services of the Division of Workers’ Compensation, you may be eligible for a reasonable accommodation. A reasonable accommodation is a form of assistance provided to individuals with disabilities to ensure equal access to and participation in DWC programs and services. These services include the Workers’ Compensation Appeals Board, the Information and Assistance Unit, the Retraining and Return to Work Unit, and the Disability Evaluation Unit. You can find more information about reasonable accommodations, including how to request one, on the disability accommodation page.

For more detailed information on receiving an Americans with Disabilities Act (ADA) accommodation, please visit the dedicated ADA page on the DWC website.

Q. Are there any other forms of financial assistance I can access besides workers’ compensation benefits?

A. Yes, there may be other benefits available to you, depending on your circumstances. These may include:

• Benefits paid by state and federal government programs, such as State Disability Insurance (SDI), unemployment insurance, and Social Security Disability Insurance (SSDI) payments.
• Benefits offered through your employer and/or union, such as sick leave, group health insurance, long-term disability (LTD) insurance, and salary continuation plans.
• You may be entitled to payments if your injury was caused by the negligence of a party other than your employer (third-party claims).

Q. How can I find out the current status of my workers’ compensation case?

A. If you are represented by an attorney, they should be keeping you informed about the progress of your case. If you do not have an attorney, you can contact the I&A officer at your local DWC district office to request a status update. The DWC also operates a call center that routes many calls to local offices. The call center staff is also equipped to provide you with status updates on your case.

March 2023