According to the California Department of Industrial Relations, California had 680,152 workers' compensation claims in 2023, based upon first reports of injuries. This translates to 3.6 worker injuries per every 100 employees in the state. The National Safety Council reports that in 2021 to 2022, workplace and work-related accidents carried an average price tag nationally of $44,179.
Injured workers in California and nationwide need medical treatment, rehabilitation, and a source of income when they cannot work. If you are injured in a job accident, workers' compensation enables you to alleviate some of the financial burdens associated with a reduced ability to work or with recovery from injuries. Below, we describe the process and steps for filing a claim for workers' compensation benefits if you suffer an on-the-job injury.
The Benefits You Can Claim in Workers Compensation
Initially, you should understand that a workers' compensation claim does not require you to prove fault on the part of your employer. For instance, you need not allege or show that the employer failed to inspect or maintain its premises or equipment. Instead, you have a claim if you suffered an injury from an accident related to your employment or in the course and scope of employment.
At the same time, you cannot recover in a workers' compensation claim damages for pain and suffering or punitive damages. Further, the remedies under workers' compensation are generally the exclusive ones you can pursue against your employer for a work-related accident. That is, you normally cannot sue your employer in tort for personal injuries. The benefits afforded to injured workers are as follows:
Medical
California law obligates employers to provide medical treatment for work-related injuries. The assistance, along with other workers' compensation benefits, comes from workers' compensation insurance. All employers in California, regardless of number of employees, must carry workers' compensation insurance. The insurers or their administrators owe injured employees a duty to approve and pay for reasonable medical care. California Labor Code Section 3751 declares that physicians, therapists, hospitals, and other medical providers may not directly bill an employee known to have filed a workers' compensation claim or given a report of injury to the employer.
The type of care to which you are entitled is determined by guidelines furnished in the Medical Treatment Utilization Schedule. These address whether treatments “cure or relieve” the effects of the work-related injury within the meaning of California Labor Code Section 4600. Under the authority of California Labor Code Section 5307.27, the Administrative Director issues orders and regulations to determine the reasonableness of medical treatments for specific disorders such as injuries to extremities, sight impairments, post-traumatic stress arising from the accident, asthma, and other occupational diseases,
Disability
In a workers' compensation case, disability benefits compensate you for lost earning ability caused by a work-related accident. California categorizes these into permanent and temporary.
Permanent Disability. You may receive these benefits if the injury permanently limits your ability to work. "Permanent disability" arises after you have reached “maximum medical improvement” or recovery and impairment of your ability to work remains. In the claims process, you or your lawyer will need a physician's “permanent and stationary” report that explains the extent of the disability. This takes into account work restrictions, the nature and scope of the injury, future treatments (including surgeries or therapies) that might be necessary, whether you can resume your current employment or type of employment, and any preexisting conditions or medical issues not related to the accident.
If you have “permanent total disability”, you receive two-thirds of your average weekly wage for the remainder of your lifetime. If you reach “permanent partial disability,” your benefits are two-thirds of the average weekly wage for a set number of weeks. How long you get permanent partial disability depends on the nature of the disability.
Temporary Disability. Temporary disability applies when you are expected to recover to a point where you can perform your per-injury job. Benefits for temporary disability last until your doctor releases you back to work or otherwise determines that you can resume work. You get two-thirds of your average weekly wage until the point you return or can return to work.
Supplemental Payments
If the job injury renders you unable to return to the job, you can apply for “Supplemental Job Displacement Benefits.” This consists of a one-time payment of up to $6,000 for the expenses of training or education for alternate work. To qualify, you must have a permanent partial disability and not have been offered regular, modified, or alternative work by the employer. To qualify as modified or alternative work, the job must pay at least 85 percent of your pre-injury wage, last at least 12 months, and be located within a reasonable distance of where you live.
Those receiving the Supplemental Job Displacement Benefit may also apply for a one-time $5,000 “Return-to-Work Supplement Program” payment. This represents additional financial support from lost earnings caused by the injury.
Report the Injury to Your Employer
The claims process begins with your giving notice of the injury to your employer. California Labor Code Section 5400 requires you to notify your employer within 30 days after the accident or injury. You formally report the accident and injury by completing Form DWC 1, which the employer must give you within one business day after you tell a supervisor or manager about the accident.
With the notice, the employer can investigate the incident and your injuries to determine compensability under the workers' compensation law. Within 14 days after your report, the employer has the option to accept the claim, deny it, or defer its decision while it investigates. If your employer does not decide whether to accept or reject the claim within 90 days after the report, California law will presume that the employer has accepted your claim and that the injury is covered by workers' compensation.
Failure to report deprives you of the presumption and may even bar your claim. An employer may raise the failure to notify upon showing prejudice. This may take the form of, for example, the loss of video or photographic evidence of the incident or the unavailability of witnesses to dispute or question the employee's account of the accident.
Getting Medical Treatment
Even before the employer decides to honor or reject your claim, you are entitled to medical treatment after the accident. Specifically, the employer must authorize medical care such as examinations, prescriptions, rehabilitation, and other treatment up to $10,000 while it evaluates your claim.
When the Employer Rejects the Claim
If the employer denies your claim, you must submit a formal claim for workers' compensation with the Division of Workers' Compensation. This happens with an “Application for Adjudication of Claim” before the Workers' Compensation Appeal Board.
The form asks you to describe how you were injured and what you were doing at the time of injury. A properly written narrative is critical to avoiding dismissal of your claim for lacking a compensable injury. California workers' compensation law treats your injury as “work-related” if it resulted from a job activity or being in the work environment.
A number of scenarios fall outside of workers' compensation. These include:
*Personal errands, even at the place of employment, but outside of the employee's work hours
*Personal grooming, such as brushing teeth
*Injuries intentionally caused or inflicted by the employee
*Injuries or illness resulting from self-medication of a non-work injury
*The employee is commuting to or from work
*Participation in wellness or recreational activities sponsored by the employer if such are voluntary
*Horseplay or misconduct on the job
*Fight or physical encounter which the employee started
Deadline to File the Claim
Found in California Labor Code Section 5405, the workers' compensation statute of limitations for most claims is one year from the date of injury. If you allege injury from an occupational disease or cumulative injuries such as carpal tunnel syndrome, you have one year from the time you know or should have known that you suffered the disease or injury due to employment.
Hearings and Appeals
Workers' compensation judges conduct hearings on disputed claims. Along with the claimant and attorney (if one), the workers' compensation insurance claims representative will participate. The judge hears evidence concerning the cause of the claimant's injury and other matters to determine if the injury is compensable and what benefits the claimant is entitled to receive.
The losing party may petition the Workers' Compensation Appeals Board to reconsider a judge's final decision. This reconsideration is not a new evidentiary hearing. Instead, the Appeals Board determines whether the judge had sufficient evidence to support the decision, followed the applicable procedures and legal standards, and otherwise had a reasonable basis in the facts and evidence for the decisions. The existence of newly discovered evidence or a decision procured by fraud may also cause a judge's decision to be set aside.
California Courts of Appeal review Appeals Board decisions through a "Petition for Writ of Review." The appellate court reviews for errors of law and whether the grant or denial of the claim was supported by sufficient findings, evidence, and the law.
