1. The insurance company denied my workers' compensation claim, what do I do? 2. How do I pay a lawyer if I hire one? 3. My workers' compensation claim is accepted, but why isn't the insurance company paying me? 4. My workers' compensation claim is accepted, but the insurance company is denying my medical care, what do I do? 5. My employer fired me because of my injury, what do I do? 6. Can I get Vocational Retraining if I cannot return to my job because of my injury?
The insurance company denied my workers' compensation claim, what do I do?
If your workers' compensation claim or injury has been denied, you will need legal help right away. You should immediately contact a lawyer or an information and assistance officer (I&A) at the Workers' Compensation Appeals Board (WCAB). Information and Assistance may be reached at 1-800-736-7401. You need to file an application right away at your local Workers' Compensation Appeals Board, and you should immediately follow up with either a lawyer or with I&A. If you are unable to work and are in need of monetary assistance, then you should contact your local Employment Development Department and apply for State Disability Benefits. Medical care will also be a problem if the insurance company denies your case. Your doctor may be willing to give you treatment on a lien basis. In such a situation the doctor would submit a lien in your case and attempt to recover his or her treatment costs when your claim is litigated. If you cannot find a doctor willing to follow the lien procedure, then you should consider any private health insurance you have.
If you feel that the insurance company has treated you unfairly, you may consider filing for an audit of the insurance company. You can do so at: http://www.dir.ca.gov/dwc/audit.html There is no guarantee that the WCAB will audit the insurance company. However if they do, then it is likely that they will force the insurance company to provide any benefits that you are owed based upon the evidence in your case. The insurance company may also be fined if the WCAB finds that their conduct towards you was unjust.
How do I pay a lawyer if I hire one?
A Judge at the Workers' Compensation Appeals Board must approve any fees paid to your attorney. The fees paid to lawyers in the workers' compensation system are rather strictly regulated. The fee is typically 12% to 15% of the benefits awarded. Usually the insurance company will pay your attorney directly at the conclusion of your case from the benefits that are owed to you. You should never have to pay your lawyer directly. If your case is lost and you have no recovery, then the lawyer does not get paid and you owe your attorney nothing.
My workers' compensation claim is accepted, but why isn't the insurance company paying me?
This is perhaps the most common question we receive in workers' compensation litigation. To answer the question it is important to understand the basic monetary entitlements under the workers' compensation laws. There are two basic types of monetary obligations for the insurance company. The first is temporary disability, and the second is permanent disability. These are the only monetary obligations the basic workers' compensation law provides for. Unfortunately both of these benefits were severely restricted by a change in the law in 2004. Temporary disability was capped at 2 years and permanent disability was cut by about 60%. In sum, workers' compensation in California has seen benefits to workers slashed to unconscionable levels. There is very little political will to help workers and the insurance lobbying efforts will likely continue to depress benefits to workers for the forseeable future.
If you are not working and your doctor is stating that you are too disabled to work, then you should be receiving temporary disability. The insurance company will only pay temporary disability if you have an accepted injury and your doctor is indicating that you are completely unable to work. Conversation is worth nothing in workers' compensation, your doctor must state this in writing. Your doctor must document that you are completely unable to work due to your work caused injury. If you are not working and not receiving any temporary disability, then you need to get a note from your doctor immediately. The insurance company will likely stop paying temporary disability if any doctor releases you to return to work or declares your condition permanent and stationary or if the doctor has declared that you have reached maximum medical improvement. If your temporary disability checks have stopped it is very likely that some doctor has declared your condition stationary or released you to return to work or the two year cap on temporary disability has been met. Again, the main player in establishing your right to temporary disability is your doctor. If there is a dispute with the insurance company about your entitlement to temporary disability, then you may consider applying for State Disability Benefits (SDI) through your local Employment Development Office (EDD) until the dispute is resolved.
My workers' compensation case has been accepted, but the insurance company is denying my medical care, what do I do?
If you have an accepted injury, then the insurance company must provide all medical care which is reasonable and necessary to cure or relieve the injury. Often the insurance company will object to the recommendations of your doctor. They may complain about the frequency, duration, type, or reasonableness of your doctor's recommendations. Unfortunately, multiple recent reforms in the law have seriously hindered your ability to get medical care. The insurance company will likely send every medical request your doctor makes to a process called utilization review (UR). Unfortunately, UR will typically deny each and every request your doctor makes. Typically the best approach to this problem is for your doctor to draft a clear report indicating exactly what the recommended treatment is and why it is important for you to receive the treatment. As with temporary disability, the doctor is the key player here. Again, conversation is worth nothing, your doctor must put his or her recommendations in writing. Even if your doctor does this however, you will still likely have to go to court to get medical treatment because of the stonewall you will likely face from the UR process.
California’s worker’s compensation system now uses a process called independent medical review (IMR) to resolve disputes about the medical treatment of injured employees. Medical treatment disputes will be resolved by physicians through a process known as IMR, rather than through the often cumbersome and costly court system.
A request for medical treatment must go through a “utilization review” process to confirm that it is medically necessary before it is approved. If utilization review denies, delays or modifies a treating physician’s request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR.
The costs of IMR are paid by employers who are required by law to provide you with all medical treatment that is reasonable and necessary to cure or relieve the effects of your injury.
It is the claims administrator’s responsibility to:
Send you a copy of the utilization review (UR) decision letter on a request for treatment, and, if applicable, the supporting recommendation by a utilization review organization
Send the completed IMR application form (DWC IMR-1 form) to you if the UR decision delays, denies or modifies the request for treatment
Make sure the IMR application form is the correct DWC IMR-1 form (not MPN-IMR form, not a modified or self-created form)
Clearly indicate type of review on the application, either expedited (EXP) or regular (REG). Expedited reviews must be accompanied by a physician statement of necessity or the UR must have been conducted in an expedited manner
Indicate whether liability is being disputed on the application. If liability is disputed, IMR is not available until the liability issue has been resolved. For claims that are under investigation and for which liability has not yet been denied, IMR is available within the first 90 days after the claim is presented, for medical treatment costs up to $10,000.
Before you submit a request for IMR, it is very important do the following:
Include a copy of the complete utilization review (UR) determination with the IMR application form that was provided to you by your claims adjustor
Sign the IMR application form before submitting a request for IMR
Send the signed IMR application and the UR determination within 30 days of receiving the UR determination to the address on the form.
If utilization review denies, delays, or modifies a requested medical treatment for an accepted claim, the claims administrator must send you a notice of denial along with a partially completed IMR request form.
To request IMR, you must submit an application for IMR and mail the following information within 30 days of receiving the utilization denial to the address below:
DWC - IMR c/o Maximus Federal Services, Inc. PO Box 138009 Sacramento, CA 95813-8009
The decision from IMR is binding on both parties and cannot be appealed to a Judge by either party.
We recommend that you sign all IMR applications and send them to Maximus. This will begin the IMR process for denied medical treatment. We also recommend that you call Maximus at 855-865-8873 for the status of your IMR request.
Finally, you do have the right to change your doctor within the insurance companies medical provider network.
My employer fired me because of my injury, what do I do?
If you are fired or "laid off" because of your injury, you should follow up with a lawyer immediately. Discrimination against injured workers is prohibited by both State and Federal laws. Under the California Labor Code (Section 132a), your employer may not discriminate against you because of your work injury. In addition, the California State Department of Fair Employment and Housing administers the laws prohibiting harassment or discrimination in employment. They may be reached at 1-800-884-1684. The Federal Americans with Disabilities Act (ADA) prohibits discrimination against workers with physical or mental impairments. Under the ADA, your employer may be required to provide reasonable accommodations for your disability. For further information, call the Equal Employment Opportunity Commission at 1-800-USA-EEOC
Can I get Vocational Retraining?
No. This program has been eliminated and replaced with a Voucher/Return-to-Work Supplement Program. For injuries occurring after January 1, 2013, the Voucher is set and capped at $6,000.00. Having such a voucher may qualify you for the Return-to-Work Supplement Program (RTWSP).
A one-time $5,000 Return-to-Work supplement is issued to an injured worker who meets the eligibility criteria. The amount of this supplement may be adjusted by the director of DIR based on further studies conducted by the director in accordance with Labor Code section 139.48.
Eligibility for RTWSP:
An applicant must have a date of injury (DOI) on or after Jan. 1, 2013 and have received a Supplemental Job displacement Benefit (SJDB) voucher for said injury.
What is the deadline for applying:
The application for the supplemental benefit must be received by the RTWSP within one year from the date the Supplemental Job Displacement Benefit (SJDB) voucher was served on the applicant or within one year from April 13, 2015, the implementation date of the regulations, whichever is later.
How to apply:
The application for this one-time supplemental payment is available online and can be completed from any computer which has access to the internet at //www.dir.ca.gov/RTWSP/RTWSP.html.
You will need the following information to complete the application:
SJDB voucher or SJDB voucher proof of service, the ADJ number, and the SJDB voucher in .pdf or .tiff format for uploading and attaching to the online application.
What if I am denied the supplement and I disagree with the RTWSP’s eligibility decision?
If you disagree with the final eligibility decision, you can appeal to the WCAB within 20 days of the service of the eligibility decision by filing a Petition for Reconsideration and serving a copy of the petition on the RTWSP, 1515 Clay St, 17th Floor, Oakland, CA 94612.
Need further assistance or have questions regarding eligibility?
Contact RTWSP staff at firstname.lastname@example.org or 510-286-0787 Monday-Friday, 8:00-5:00 p.m. PST.
Can I get Vocational Retraining if I cannot return to my job because of my injury?
The short answer is No. In 2004 the right to vocational retraining was eliminated. The right to vocational retraining was replaced with a "supplemental job displacement voucher" program. The entitlement to the voucher only comes once the case is over. If your doctor states that you are permanently unable to do your usual job, and your employer does not offer you permanent modified work, you may qualify for the supplemental job displacement voucher. It comes in the form of a non-transferable voucher that can be used to pay for educational retraining or skill enhancement, or both, at state-approved or state-accredited schools. The voucher covers school tuition, fees, books and expenses required by the school for training. No more than 10% of the value of the voucher can be used for vocational & return to work counseling. If eligible, you should receive the voucher from the insurance carrier within 45 days from the date of your settlement. The insurance carrier should have completed lines 1 - 8 of the voucher and you are then responsible for completing lines 9 - 19. Lines 9 - 12 must be completed when using a vocational counselor. Your attorney can provide you recommendations for a vocational counselor upon request. If you do not select a counselor, you do not need to complete lines 9 - 12. The training provider you select should assist you in completing the lines 13 - 19 on the voucher. You can contact the Bureau for Private Postsecondary and Vocational Education (BPPVE) at www.bppve.ca.gov to get a list of accredited training providers in your area. When you have completed the voucher, you must sign and date it before sending it back to the insurance carrier. You must also attach any receipts or invoices for direct payment to you, the training provider, and/or the vocational counselor. Payment should be made within 60 days from the date the insurance carrier receives the voucher.
The amount of the voucher depends on the amount of your final PD award: Less than 15% = $4,000 voucher Between 15% and 25% = $6,000 voucher Between 26% and 49% = $8,000 voucher Between 50% and 99% = $10,000 voucher
Again, for injuries on or after January 1, 2013, the Voucher is set at $6,000.00 and the RTWSP may apply.
Workers' Compensation Law
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