Worker’s Compensation In California

Acceptance or Denial of Claim

After submission of a worker’s compensation claim to the employer, the employer’s work comp insurance carrier will investigate the claim. If there is no dispute factually, meaning then facts denote a work injury, then the carrier could and should accept the claim and provide medical and monetary benefits. If there is a dispute as to what happened to cause the injury or there is the potential for the injury being preexisting, the claim could be delayed for 90 days for the carrier to investigate. If the injured worker (applicant) is unrepresented, the insurance adjuster can send investigators to speak to the applicant and create a case to deny the claim. An unrepresented applicant can be asked any question at all and won’t know legally if they must answer, so they most often answer every question trying to prove their case, which works directly against them. If the applicant obtains initial representation by the Law Offices of Nicholas Sheedy, the adjuster nor their investigator can speak to the applicant without their attorney present. The adjuster’s recourse is to assign their own counsel and set the deposition of applicant where the attorney will protect privacy interests and other concerns to protect the applicant. The Law Offices of Nicholas Sheedy protects the applicant during deposition from irrelevant inquiries and overreaching fishing expeditions searching for ways to get out of paying proper and entitled benefits on the claim.

• Denied Claim: If the work comp claim is denied by the insurance carrier, their attorney will gain all the applicant’s medical records through subpoenas and set a qualified medical evaluation (QME) with a doctor to determine if they think the injury is workplace related. While the claim is in denied status, the applicant must treat privately, either through their private insurance if they have any, or through Medical. The Law Office of Nicholas Sheedy will properly guide the applicant in this scenario to gain proper care in the meantime. If the QME tenders a report in applicant’s favor, the insurance adjuster could accept the claim and provide work comp benefits from there forward. If the. Adjuster still has a factual or medical dispute then the case could be set with a WCAB judge to determine if the injury actually happened and arose and was caused in the scope and purpose of the applicant’s employment.
• Accepted Claim: Once the insurance carrier accepts the claim or after trial the WCAB judge finds in favor of the applicant, the applicant would be due care and income at once from the carrier. These benefits include wage loss aka temporary disability, medical care, permanent disability, and vocational rehabilitation. These will be all discussed in turn. 

Temporary Disability Benefits

Once the claim has been accepted, Temporary Disability (TD) benefits are due to applicant. The worker’s comp primary treating physician (PTP) must give work restrictions that the employer cannot accommodate. The applicant is due roughly 2/3 their income, but tax free, bringing their take home income to about the same as if working full duty. TD benefits can continue for a maximum duration of 2 years. This benefit will cease also if the PTP or the QME finds the applicant to be “permanent and stationary” meaning that the medical condition had plateaued in that may not be getting much better bit nor is it much worse. If the medical condition is still not stable after 2 years, then the applicant should apply for State Disability Insurance (SDI) to gain another year of monetary benefits from State of California’s EDD department in an amount much similar to that of TD.

• When TD ends the applicant may or may not be able to return to work depending on the permanent work restrictions given by the PTP or QME. If the applicant is able to return to work, they would still be due permanent disability benefits as well as future medical dare (FMC) on the injury for life (with a caveat or much uncertainty regarding FMC to be discussed later). If the applicant is not able to return to work, my office would direct them to gain SDI benefits and discuss other options such as gaining different employment or even applying for federal Social Security Disability Insurance (SSDI) benefits, which will also be discussed later. Also the applicant would be entitled to worker’s comp vocational rehabilitation (VR) benefits which will also be discussed later herein.

Permanent Disability (PD) Benefits

PD is a term of art that has different meanings in different contexts. It means something totally different if discussing work comp or SSDI. In work comp it denotes “the percentage of jobs the applicant can no longer perform due to their work injury.” An applicant having permanent disability does not always mean that they can no longer perform their prior job. For example, a secretary who suffered a fall at work breaking her leg and later having PD denoting no more running, climbing, or jumping would be able to continue her usual and customary secretarial job as these functions would not be in a secretary’s job description to run, jump, etc.