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FAQs Frequently Asked Questions
Do I need to file a claim? YES
When you are injured your employer is supposed to provide you with a workers compensation claim form or DWC-1 when notified of an injury. On this form you list your injuries, the date of the injury, and provide other basic information like your address etc.
THIS FORM IS IMPORTANT.
The DWC-1 starts the clock for discovery. Once the form is given to your employer, the WC insurance carrier has 90 days to accept or deny your claim. If the claim is not denied, then it is presumed you have a work injury and are entitled to be
You DO NOT need a Social Security number on the form to make a claim.
Application for Adjudication of Claim
The Application for Adjudication is a court document filed with the WCAB district office. It starts your legal proceedings. The Application can be obtained at the DIR/WC website on the forms page, or with the link below. Once filed you will received a Notice of Application from the Division of Workers Compensation within a couple of days. It has your case number, for example ADJ12345678.
After an application is filed, nothing else will happen until someone requests a court date by filing a Declaration of Readiness (DOR) The statute of limitations for filing a claim is one year from the date of injury or last medical treatment received. If you have questions about the statute of limitations (SOL) on a claim, speak with an attorney or the Information and Assistance office at the local WCAB district office.
You will need a case number to file for EDD benefits. Do no file for unemployment if you are filing a workers compensation claim.
To file for unemployment you must certify that you are able and willing to work, but you have no job. To file for State Disability you must certify you are unable to work and have no offer of modified work. They are mutually exclusive.
Temporary Disability TTD
Wage loss, total temporary disability or TTD, is paid biweekly at two thirds of your average weekly wage (AWW) up to about $1625 per week for a total of 104 weeks without special circumstances.
In order to qualify you must have a medical report saying you are not at maximum medical improvement and there is no offer of modified work. Once qualified for total or partial disability payments, you must have a work status report every (45) days to continue receiving this benefit. If carrier has stopped paying, the you can petition the WCAB for an Expedited Hearing (Trial) if you believe payments are due and you filed an Application with the court.
Permanent Disability PD
Permanent Disability or PD is paid biweekly at up to $290/week based upon your earnings. Permanent Disability Advances (PDAs) begin when your TTD stops or when a physician says you have reached Maximum Medical Improvement (MMI), also called Permanent and Stationary. Your treating physician should provide a PR-4 with a rating of your impairments as defined by the AMA guides 5th edition. At 70% PD you are entitled to a Life Pension. At 100% PD you are entitled to payments at the TTD rate for life.
Medical Treatment
All medical treatment is provided by the WC insurance carrier through its Medical Provide Network (MPN). Every WC carrier has its own provider network and there is no guarantee that a given physician is in the MPN. An example of a well known MPN is Concentra Occupational Health.
Concentra has treatment facilities statewide for industrial accidents. In fact, many people receive their first treatment at Concentra before being transferred to another provider. Unfortunately, in Mendocino county treatment at Concentra is performed by physician assistants who are by law not allowed to take a injured worker off work more than three days. This leads to unrealistic work restrictions which can stop payment of Temporary Disability Benefits and force an injured worker back to work too early. If you have been forced back to work, seek representation.
Utilization Review and Medical Treatment – Blog 01/12/2024
Job Retraining and Vouchers
Most vocational benefits were slashed from California workers compensation years ago. However, an injured worker who has not received a good faith offer of modified work on the proper form is entitled to a Supplement Job Displacement Benefit (SJDB) voucher which can be used for retraining, or at least helps retraining by providing access to educational programs.
The state has also established a Return to Work fund that pays each eligible workers a one time payment of $5,000. These benefit is provided after a worker is Permanent and Stationary simply because it is at that time an employer is informed of permanent work restrictions. Until that time all work restrictions are temporary so there is no way to know if an employer can accommodate a return to work.
All offers of Modified work must be made in writing on form DWC-AD form 10133.35.
Types of settlements
Stipulations with Request for Award
There a two customary ways to settle a California workers compensation case; Stipulations with Request for Award, or Compromise and Release. A stipulated settlement usually supports an open medical award, which is a life time award. Within five years of the date of injury a stipulated settlement can be reopened.
Compromise and Release
A Compromise and Release is a complete buy out of a workers compensation case. If the parties can reach an agreement, then the case is closed by a lump sum tax free payment to the injured worker. Attorney fees are paid as a portion of the lump sum, but by a separate payment to the attorney.
Special Needs Trust
A special needs trust is to protect individuals who are receiving public benefits, for example Medicaid or Children’s Health Insurance Programs (CHIP) from being disqualified because of payments in a workers compensation case. If you are receiving Federal or State benefits, these must be considered when settling a California workers compensation case.
If you need help with a Special Needs Trust contact the CPT Institute
Medicare and workers compensation settlements
Increasingly the Center for Medicare Services ( CMS) has been reviewing California workers compensation settlements to insure that no treatment costs are being passed on to Medicare. While CMS review is not mandatory, it is suggested for any settlement over $25,000, including attorney fees.
Medicare is considered a secondary payer. In other words, any costs associated with treatment of body parts claimed in a workers compensation case are to be paid outside of Medicare. If an injured worker settles a workers comp case with a lump sum payment, the worker must consider Medicare’s interest when settling the claim? Lump sum settlements over $25,000 require a Medicare Set Aside, which is a separate trust account created out of the settlement proceeds that pays for medical treatment. There are a host of issues created with a MSA. Suffice it to say, if you have a proposed MSA in your settlement, then you probably need an attorney.
Conditional Payments
Conditional Payments are claims by Medicare to recover costs that were incorrectly billed in your WC case(s). It does not matter if the information is incorrect, or that Medicare was paying for treatment to other body parts that were not involved in your workers compensation case. Once Medicare asserts a claim, all your federal benefits are at risk unless you properly draft your settlement paperwork and even then problems can arise.