What Are the Legal Requirements for Filing a Work Injury Claim in California?

In California, every employer is required to have worker's compensation (with a very few exceptions for larger employers who can prove they are self-insured in a manner that is accepted by the state). This system provides for all employees to receive medical benefits and wage replacement in the event of an injury on the job, regardless of who is at fault for the injury.

However, injured employees usually cannot bring any kind of personal injury claim or lawsuit against their employer, regardless of the circumstances. The idea is to ensure that workers get seamless, smooth coverage for their legitimate needs without having to fight for them while injured, while, at the same time, reducing litigation burdens on the system.

Step 1: Talking With a Corona Work Injury Attorney

The first step is to talk with an injury attorney as quickly as you can. This will allow you to more fully understand the details of your case and what you should do next. In many cases, an employee will be covered by worker's compensation. In some cases, such as if you're an independent contractor, you may not be and may need to choose another avenue for compensation. Additionally, if a third party not related to your employer was actually responsible for your injury, even if it happened at work, you may be able to bring a liability claim against that third party. Your lawyer can help you with all of this.

Beyond this, simply filling out all the paperwork related to a work injury claim can be very difficult to do right, and the state does not have a sympathy for those who make mistakes. It's important to get things done quickly and to do it right to unlock all the benefits you are due. Your lawyer will also make sure that your employer is fulfilling all their obligations, such as authorizing immediate payment for medical treatment while the claim is being processed, providing you with light duty work during your recovery (if that is feasible given your situation), and more. Your lawyer can also help you appeal claims, negotiate for more if your claim is being undervalued, and help you deal with a situation where an employer does not have the proper insurance.

Step 2: Reporting

You must report your injury to your employer quickly. If you don't report within 30 days, you likely will not be able to make a worker's compensation claim. But it's always wise to make this report as quickly as possible, not only to avoid missing the deadline but also to ensure that there's no question your injuries have been caused by the accident that happened at work. Once you report the injury, your employer is required to give you a claim form within a day. You can also get a claim form on your own from the state government.

You will need to fill out this claim and give it to your employer, and you should do this as quickly as possible because this is what initiates the whole process. If your claim isn't accepted or denied within 90 days, then the state considers it automatically accepted. You are also entitled to up to $10,000 in medical treatment compensation for medical needs that fall within the state guidelines during the time that you are waiting for the claim to be processed. If the claim is delayed, you are also entitled to extra disability benefits.

Step 3: Responding to the QME (If There Is One)

If the insurance company disagrees with something in your claim regarding your injury, they may send you a QME form. QME stands for "Qualified Medical Evaluator," and this is a request from the insurance company that you see an independent doctor to evaluate your injuries. You have 10 days from receiving this to request a list of QME medical professionals near you, and if you do not do so in a timely fashion, the insurance company can choose the type of doctor that they want you to see and DWC will choose three QMEs of that type and send the details to you and insurance company.

You then have 10 days to choose one and book an appointment. If you do not, the insurance company can do so. If you disagree with the report that the QME makes, you can dispute it, but you must act very quickly and on the advice of your attorney.

Step 4: Follow Your Lawyer's Advice

After following the above three steps, you should be receiving the benefits you're entitled to. If you're not, you need to talk through with your lawyer what next steps to take. This will depend entirely on your specific circumstances and whatever argument the insurance company is making about your claim.

What Benefits Am I Entitled To?

Medical Benefits

Workers compensation should reimburse you for 100% of your medical expenses for everything that is clearly related to the injury and treatments that are acceptable under the law as reasonable for your condition.

Wage Benefits

There are three types of wage benefits: Temporary Total Disability (TTD), Temporary Partial Disability (TPD), and Permanent Disability benefits. TTD pays you about 2/3 of your gross wages while you're recovering when you cannot work at all. TPD is for when you can work, but not at the same job or the same number of hours as before. After subtracting the income you are able to bring in, TPD then pays 2/3 of the rest. Permanent benefits extend benefits for those who cannot ever return to work at the same income level as before.

What Qualifies As An Injury?

Worker's comp not only covers obvious physical injuries that happen due to accidents but also repetitive injuries that develop over time, such as carpal tunnel syndrome. If you're dealing with a repetitive injury, you must report it to your employer within 30 days of your doctor tying the diagnosis to your work.

Mental health is also covered, but only under very specific circumstances. These are known as "psychiatric injuries" under the law, and there is a fairly high burden of proof here. You must show that you have a mental health issue that has been properly diagnosed under accepted criteria, that you have required medical treatment or experienced disability because of it, that you have worked for your employer for at least six months (unless the injury resulted from a sudden and catastrophic event at work, such as a shooting), and you must actually be able to show evidence that it is your employment that is the primary cause of your injury.

If you are suffering from a work injury and need to make a claim here in California, reach out to Cesar Ornelas Injury Law in Corona, CA today. We also serve workers in New Mexico and throughout Texas.