a guide to workers’ compensation for clinicians in … guide to workers’ compensation for...

Puerto Rico Workers’ Comp guide Farmworker Justice

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A Guide to Workers’ Compensation for

Clinicians in Puerto Rico Serving Farmworkers

By Shelley Davis Farmworker Justice

I. INTRODUCTION This guide is designed to provide health professionals in Puerto Rico who serve farmworkers with an introduction to the workers’ compensation law in the Commonwealth. Using a question and answer format, it: 1) offers a brief description of the workers’ compensation system; 2) explains the key roles that the clinician can play in the process; 3) provides a timeline of critical deadlines; and, 4) includes copies of relevant forms. II. BACKGROUND AND OVERVIEW OF WORKERS’ COMPENSATION What is workers’ compensation? Workers’ compensation is a system of employer-provided insurance that offers benefits to employees who suffer a job-related injury or illness. These benefits:

• Cover needed care and rehabilitation services, including medical treatment, surgery, physical therapy, hospitalization, laboratory tests, and medications;

• Provide partial payment of wages for the time period when temporarily-disabled employees cannot work;

• Pay workers who suffer a permanent disability; and, • Cover burial costs and provide monetary support for surviving dependent family

members (when the work-related injury or illness is fatal). Why should clinicians learn about workers’ compensation? It’s worth taking the time to become familiar with the workers’ compensation law in Puerto Rico for several reasons. Farmworkers need these benefits. Without them, many farmworkers with a job-related injury or illness would forego needed treatment or their families would go into debt in order to secure it for them. Farmworker families would also be destitute while the injured


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worker was out of work. For these reasons, Migrant Health Center staff should educate workers about workers’ compensation and advise them on how to obtain these benefits. Does Puerto Rico’s law apply? To determine whether the law of the Commonwealth or a state applies, it is necessary to find out where the employee became ill or injured. A worker from Puerto Rico who suffers an injury while working in California will be covered by the workers’ compensation law of California. By contrast, a worker who is injured in Puerto Rico will be covered by the law of Puerto Rico. Are migrant and seasonal farmworkers covered by workers’ compensation? Under the law of Puerto Rico, agricultural workers, including sharecroppers, are entitled to workers’ compensation insurance coverage. Only “casual” workers, those who do not work in the employer’s regular business, are excluded from coverage. Are undocumented farmworkers covered by workers’ compensation? Undocumented farmworkers are entitled to workers’ compensation benefits when they are injured at work in Puerto Rico. After they have received medical treatment and are stabilized, however, the State Insurance Fund Corporation (in Spanish, Corporacion del Fondo del Seguro del Estado, CFSE) may report them to Immigration and Customs Enforcement (ICE) authorities. What must an injured worker prove in order to secure workers’ compensation benefits? Typically, employees must show that they: 1

• Suffered an injury or illness in the course of employment; • Notified the employer of the injury shortly after it occurred; • Are an employee of the entity identified as the employer; • Have followed all the health care providers’ instructions, including when to return to

work and any work restrictions; and, • The degree of remaining permanent disability, if any, after reaching a permanent and

stationary level. What is the degree of proof required? The worker must prove all elements of a claim for a physical injury by a preponderance of the evidence. Preponderance of the evidence means that it is more likely than not that the claim is true. Supporting evidence must be based on objective facts and reasonable inferences from them. Conjectural or speculative statements will be ignored.2 When weighing the evidence, reasonable doubt will be resolved in favor of the worker. Thus, in a case where the evidence is 50% vs. 50%, the claim will be approved.

1 www.cfse.gov.pr 2 Morell Morell v. Comision Industrial de P.R., 110 D.P.R. 709, 710 (P.R. 1981) citing Alonso Garcia v. Comision Industrial de P.R., 103 D.P.R. 712, 715 (P.R. 1975).


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The preponderance of the evidence standard, however, requires far less certainty than a clinician would ordinarily require to make a diagnosis (i.e., 80%-90% certainty). If a worker is seeking benefits for a mental illness, she must provide “convincing” evidence that the condition is work-related.3 III. THE ROLE OF THE HEALTH CARE PROVIDER How does a worker initiate a workers’ compensation claim? When a traumatic injury occurs, a worker has five (5) days to submit a claim form, which is usually completed by the employer (Informe Patronal, CSFE-373, attached as Exhibit A). In non-emergency cases, during regular working hours, the employee should bring the form to the nearest office of the State Insurance Fund Corporation (for locations of the SIFC offices, please see Appendix A.). At that facility, doctors will examine the worker and provide any needed immediate care, devise a plan of action and give the patient an appointment for necessary follow-up treatment. If specialized treatment is required, the clinicians at the Corporation will provide a referral to a specialist. In emergency cases (or after normal working hours), an injured worker should go to an emergency room or after-hours clinic to seek care. Hospital care should also be provided until the patient is stabilized (this treatment will be covered by the State Insurance Fund Corporation). In the event of an occupational illness, a worker has three (3) years to submit a claim form. This time period will be extended for a latent illness, until the worker should have known she was suffering from a work-related disease. If the worker’s claim is denied or she disagrees with the treatment plan, she can appeal the decision to the Industrial Commission.4 Who can treat workers that have workers’ compensation claims? Most treatment for workers’ compensation claims will be provided by clinicians employed by or under contract with the State Insurance Fund Corporation. Migrant Health Centers or other clinicians who would like to handle workers’ compensation claims can apply to become contractors with the State Insurance Fund Corporation. To treat patients with workers’ compensation claims, clinicians or chiropractors must be licensed to practice in Puerto Rico.

3 Morell Morell v. Comision Industrial de P.R., 110 D.P.R. 709, 710 (P.R. 1981). 4 www.cipr.gobierno.pr. Escrito de Apelacion (Appeal Form), attached as Exhibit B.


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What steps should a health care provider take when handling a patient with a possible work-related injury or illness? As noted above, in non-emergency cases a worker should ordinarily seek initial treatment from the clinicians of the State Insurance Fund Corporation. However, in emergency cases or during the hours when the SIFC offices are closed, patients can seek care at a clinic or emergency room of a hospital. In the latter cases, the health care professional should provide all necessary treatment and these costs will be covered by the SIFC. Follow-up treatment, however, will be provided by clinicians designated by the SIFC. What are the key responsibilities of health professionals who have contracted with the SIFC in handling workers’ compensation cases? Health care providers should take a thorough patient history that includes occupational and environmental exposures, and secure all appropriate tests to determine the nature, cause and extent of the injury or illness. When needed, appropriate referrals should be made for specialized care. Based on these medical findings, the SIFC will determine whether or not the injury or illness is work-related, and hence whether it is covered by the workers’ compensation system. Why is it important to consult the patient in formulating a treatment plan? Health care providers should fully discuss treatment options with patients to ensure that the patient is in agreement with the treatment option selected and able to comply with the provider’s instructions. For example, does the patient have access to transportation for follow-up appointments? These considerations are important because a patient’s failure to comply with a clinician’s instructions could result in the reduction or termination of benefits. Can an illness or injury be covered by workers’ compensation when work activity is not the sole cause of the condition? When a combination of factors causes the illness or injury, workers’ compensation will cover the condition if work activity was a major contributing cause. Does the employee need to prove fault or lack of contributory fault in order to secure workers’ compensation benefits? Workers’ compensation is generally a no-fault system. There are, however, a limited number of exceptions to this rule. For example, an employee may be denied benefits if illegal drug or alcohol use were a contributing cause of the injury. What are the primary obstacles that keep workers from filing workers’ compensation claims? The most frequently cited obstacle is fear of employer retaliation. Although such retaliation is illegal and would result in a substantial penalty to the employer if proved, many workers are


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unwilling to risk job loss for the uncertain prospect of obtaining financial compensation in the future. Other obstacles include lack of knowledge of the availability of benefits, inability to navigate the workers’ compensation system (especially for low literacy patients), pressure from co-workers, and undocumented status.5 Does a worker need legal assistance to obtain workers’ compensation benefits? A recent report6 found that low-wage immigrant workers were much more likely to secure needed benefits when they had legal assistance in handling their claims. In any case involving significant costs, the health professional should consider recommending that the worker retain a lawyer to pursue the claim. To obtain a referral, the patient can contact the local legal services agency or the Puerto Rican Bar Association. To contact the offices of Puerto Rico Legal Services, please call:

• San Juan: 787-764-0823 • Mayaguez: 787-832-5770

How do disputed claims get resolved in the workers’ compensation system? When a dispute arises (e.g., concerning the rejection of a claim or disagreement with benefits offered), the parties may request an administrative hearing before the Industrial Commission. To initiate this action, a worker should file an Escrito de Apelacion, Exhibit B. Appeals from the administrative process are heard in court. What steps may migrant health centers need to take prior to accepting workers’ compensation cases? As noted above, in order to handle workers’ compensation cases in Puerto Rico, a migrant health center must enter into a contract with the SIFC. To prepare for accepting workers’ compensation cases, health centers may consider taking the following steps:

• Securing additional training for clinical staff in occupational medicine as well as obtaining consultant services from a board-certified occupational medicine specialist who has handled many workers’ compensation cases;

• Providing staff an orientation to Puerto Rican workers’ compensation law; • Setting up appropriate billing protocols; • Scheduling longer visits for workers’ compensation patients; and • Adjusting clinician productivity requirements to take into account the time that must be

spent completing necessary reports.

5 Lashuay N, Harrison R. Barriers to Occupational Health Services for Low-wage Workers in California: A Report to the Commission on Health and Safety and Workers’ Compensation. California Department of Industrial Relations, April 2006. Available at http://www.dir.ca.gov/Chswc/chswc_whatsnew2006.html (accessed June 26, 2007) 6 Id.


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IV. IMPORTANT DEADLINES 1. The worker must ordinarily notify the employer of a traumatic injury within five days or

illness within three years of its occurrence or when the worker should have learned of it. 2. To initiate a claim, the employer normally completes the Informe Patronal, CSFE-373,

attached as Exhibit A. 3. During normal work hours, in non-emergency cases, the worker should go to the nearest

offices of the SIFC to receive immediate treatment. In emergencies or after-hours, the worker can seek treatment at an emergency room or clinic.

4. If the claim is denied or the worker disagrees with the benefits offered, the worker can file an Escrito de Apelacion, attached as Exhibit B, to request a hearing before the Industrial Commission. Key Forms The following forms are attached: 1. Informe Patronal, CSFE-373, attached as Exhibit A. 2. Escrito de Apelacion, Exhibit B 3. Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility (available in

English and Spanish) References Lashuay N, Harrison R. Barriers to Occupational Health Services for Low-wage Workers in California: A Report to the Commission on Health and Safety and Workers’ Compensation. California Department of Industrial Relations, April 2006. Available at http://www.dir.ca.gov/Chswc/chswc_whatsnew2006.html (accessed June 26, 2007). The contents of this publication are solely the responsibility of Farmworker Justice and Migrant Clinicians Network and do not necessarily reflect the official views of the Bureau of Primary Health Care or the Health Resources and Services Administration.


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Appendix A – Service Directory of Corporacion del Fondo del Seguro del Estado Oficina Central Urb. La Riviera Carr. # 21, Esq. Ave. De Diego Bo. Monacillos Río Piedras, P.R. PO Box 365028 San Juan, P.R. 00936-5028 (787) 793-5959 (787) 781-0925 Neg. Seguros Oficinas Regionales 1. Oficina Regional de Aguadilla Sr. Orlando Aldebol Borrero Director Ejecutivo Carr. Estatal # 2 (Frente al Estadio Canena Márquez) Bo. Caimital Bajo, Aguadilla, P.R. PO Box 336 Aguadilla, P.R. 00605-0336 (787) 882-2700/2720 (787) 891-7255 Div. Seguros (787) 822-3170 Fax 2. Oficina Regional de Arecibo Sr. Ramón Ruiz Nieves Director Ejecutivo Ave. Miramar Carr. # 2, Km. 78.7 Barrio Obrero Arecibo, P.R. PO Box 4055 Arecibo, P.R. 00614-4055 (787) 878-5757 (787) 879-2570 Div. Seguros (787) 880-6537 Fax 3. Oficina Regional de Bayamón


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Sra. Sylvia Abreu Rodríguez Directora Ejecutiva Interino Carr. Estatal # 2 Bo. Juan Sánchez Bayamón, P.R. PO Box 248 Bayamón, P.R. 00960-0248 (787) 782-8250 (787) 782-6130 Div. Seguros (787) 273-9899 Fax 4. Oficina Regional de Caguas Sra. Sara Rosario Vázquez Directora Ejecutiva Ave. Luis Muñoz Marín Urb. Santa Juana Edif. Mercantil Caguax Caguas, P.R. PO Box 425 Caguas, P.R. 00726-0425 (787) 746-2010 (787) 746-3967 Div. Seguros (787) 746-0570 Fax 5. Oficina Regional de Carolina Sr. Fernando Muñoz Hernandéz Director Ejecutivo Carr. PR # 3, Ave. 65 de Infantería Intersección carr. 887 Bo. San Antón (Al lado Plaza Escorial) Carolina, P.R. PO Box 858 Carolina, P.R. 00986-0858 (787) 757-6850/6852 (787) 750-5220 Div. Seguros (787) 762-5574 Fax 6. Oficina Regional de Humacao Sra. María J. Díaz Cuevas


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Directora Ejecutiva Ave. Boulevard del Río 2 Carr. Estatal # 3 Humacao, P.R. PO Box 9212 Humacao, P.R. 00792-9212 (787) 852-1400 (787) 852-5405 Div. Seguros (787) 852-9020 Fax 7. Oficina Regional de Mayagüez Sr. José Ortiz Mercado Directora Ejecutiva Ave. Corazones 1040 Bo. Sábalo, Mayagüez, P.R. PO Box 1570 Mayaguez, P.R. 00681-1570 (787) 833-8700 (787) 833-6464 Div. Seguros (787) 265-5155 Fax 8. Oficina Regional de Ponce Sr. Manuel Franco Figueroa Director Ejecutivo Ave. Santiago de los Caballeros 2136 (Al lado del Centro Judicial) Ponce, P.R. PO Box 330949 Ponce, P.R. 00733-0949 (787) 848-4545 (787) 842-2385 Div. Seguros (787) 259-8659 Fax 9. Oficina Regional de San Juan Lcdo. Ariel Acosta Jusino Director Ejecutivo Urb. Caribe Calle Ponce de León 1579 Sector El Cinco, Km. 6.3


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Río Piedras, P.R. PO Box 42006 Minillas Station San Juan, P.R. 00940-2006 (787) 282-7400 (787) 767-4632 Div. Seguros (787) 767-4779 Fax Dispensarios Intermedios 1. Dispensario Intermedio de Cayey Sra. Egna E. Díaz Rivera Subdirectora Ejecutiva Auxiliar Ave. Antonio R. Barceló 1800 Bo. Montellano, Cayey, P.R. PO Box 372260 Cayey, P.R. 00737-2260 (787) 738-6700/6722 (787) 263-4014 Pólizas (787) 263-4736 Fax 2. Dispensario Intermedio de Corozal Sra. Madeline Landrón Pérez Subdirectora Ejecutiva Auxiliar Barrio Pueblo, desvío Norte Carretera estatal 159, Km. 13.9 Corozal, P.R. PO Box 594 Corozal, P.R. 00783-0594 (787) 859-0200 (787) 859-0335 Pólizas (787) 859-1475 Fax 3. Dispensario Intermedio de Fajardo Sra. Celia I. Flecha Santana Subdirectora Ejecutiva Auxiliar Ave. Marcelito Gotay (Al lado Antigua Central y nuevo Centro Judicial) Sector El Batey


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Fajardo, P.R. PO Box 1207 Fajardo, P.R. 00738-1207 (787) 801-5959 (787) 801-2945 Pólizas (787) 801-2900 Fax 4. Dispensario Intermedio de Guayama Sr. Arnaldo Santiago Berríos Subdirector Ejecutivo Auxiliar Ave. Pedro Albizu Campos Carr. PR # 53 (Desvío Sur al lado del Hospital Cristo Redentor) Guayama, P.R. PO Box 1199 Guayama, P.R. 00785-1199 (787) 864-0095 (787) 864-1350 Pólizas (787) 864-7006 Fax 5. Dispensario Intermedio de Manatí Sra. Aleida Sánchez Vega Subdirectora Ejecutiva Auxiliar Carr. # 2, Km. 48.3 interior Urb. Félix Córdova Dávila (Detrás del Correo Federal) Manatí, P.R. PO Box 896 Manatí, P.R. 00674-0896 (787) 854-2495 (787) 854-0506 Pólizas (787) 884-4009 Fax 6. Dispensario Intermedio de Utuado Sr. Carlos F. Arocho Ocasio Subdirector Ejecutivo Auxiliar Carretera 111 Interior 611 Km. 1.7 Avenida Fernando Rivas Dominicci


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Bo. Viví Arriba Utuado, P.R. PO Box 571 Utuado, P.R. 00641-0571 (787) 894-8213/8214 (787) 894-2434 Pólizas (787) 894-1234 Fax 7. Dispensario Intermedio de Yauco Sra. Madeline Ortiz Navarro Subdirectora Ejecutiva Auxiliar Bo. Susúa Baja Carr. 127, Km. 2.3 interior Yauco, P.R. PO Box 415 Yauco, P.R. 00698-0415 (787) 267-1120 / 1110 (787) 856-1260 Pólizas (787) 267-1074 Fax Dispensarios Locales 1. Dispensario de Coamo Sra. Irma G. Reyes Santiago Oficial Administrativo Edificio Gubernamental, 1er. piso Carr. Coamo a Villalba #150 Coamo, P.R. PO Box 1702 Coamo, P.R. 00769-1702 (787) 825-6520 (787) 825-0116 Fax 2. Dispensario de Jayuya Sra. Carmen C. Rivera Alfonso Oficial Administrativo Calle Guillermo Esteves # 100 (Al lado de La Gloria) Jayuya, P.R.


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PO Box 215 Jayuya, P.R. 00664-0215 (787) 828-6371/4230 (787) 828-3922 Fax 3. Dispensario de Vieques Sra. Carmen M. Ramos Cruz Oficinista 2 Calle Luis Muñoz Rivera # 99 Vieques, P.R. 00765 (787) 741-5442 (787) 741-0540 Fax Hospital Industrial Lcda. Jane Vega de Díaz Directora Ejecutiva (Al lado del Hospital Oncológico) Centro Médico Bo. Monacillos, Río Piedras, P.R. PO Box 365028 San Juan, P.R. 00936-5028 (787) 754-2525 (787) 767-3968 Fax

ESTADO LIBRE ASOCIADO DE PUERTO RICO COMISION INDUSTRIAL DE PUERTO RICO

SECRETARIA

Lesionado: Caso CI: Caso F.S.E: Patrono: Núm. Hosp. Ind: Seg. Soc: Asegurador: Seg. Soc. Patronal: Corp. Fondo del Seguro del Estado Núm. Póliza:

ESCRITO DE APELACION

Comparece el apelante de epígrafe, por derecho propio y muy respetuosamente, EXPONE, ALEGA, Y SOLICITA:

1. Que el Administrador del Fondo del Seguro del Estado emitió decisión el, notificada el, sobre.

2. Que no estoy conforme con dicha decisión, por las siguientes razones:

EN VIRTUD DE LO ANTERIORMENTE EXPUESTO, solicitó de la Honorable Comisión Industrial, que previo a los trámites de Ley pertinentes, REVOQUE la decisión emitida por el Administrador y en su lugar, ordene la vista y/o remedio que en derecho corresponda.

Certifico: Que en esta misma fecha he remitido al Administrador del Fondo del Seguro del Estado copia fiel y exacta del presente Escrito.

En, Puerto Rico el. ______________________ ______________________ Testigo de marca Firma del Apelante

INFORMACION ADICIONAL SOBRE EL CASO

Sexo: Edad:

Fecha de Nacimiento:

Preparación Académica:

Ocupación:

Fecha del Accidente:

Ingreso:

Lugar donde ocurrió:

Nombre del Pariente más cercano:

Dirección:

Teléfono:

Parte del cuerpo afectada:

Razón del Radicación

Dirección Residencial ( Física ) Dirección Postal Tel. ( residencia ) : Tel. ( empleo o patrono ) :

INSTRUCCIONES

1. INDIQUE CON MARCA DE COTEJO LA IMFORMACION A OFRECER. 2. DETALLE LA MISMA SEGUN SEA EL CASO.

PARA FACILITAR LOS PROCESOS DE SU CASO, ES NESESARIO QUE COMPLETE LA IMFORMACION QUE SE SOLICITA. ESTA ES PARA USO OFICIAL DE LA AGENCIA.

Testigo Beneficiario

Tutor Patrono

Edad

Parentesco

Dirección

Residencial

Dirección

Postal

Workers’ Compensation Claim Form (DWC 1) & Notice of Potential EligibilityFormulario de Reclamo de Compensación para Trabajadores (DWC 1) y Notificación de Posible Elegibilidad

If you are injured or become ill, either physically or mentally,because of your job, including injuries resulting from a workplacecrime, you may be entitled to workers’ compensation benefits.Attached is the form for filing a workers’ compensation claim withyour employer. You should read all of the information below.Keep this sheet and all other papers for your records. You may beeligible for some or all of the benefits listed depending on the natureof your claim. If required you will be notified by the claimsadministrator, who is responsible for handling your claim, about youreligibility for benefits.

To file a claim, complete the “Employee” section of the form, keepone copy and give the rest to your employer. Your employer willthen complete the “Employer” section, give you a dated copy, keepone copy and send one to the claims administrator. Benefits can’tstart until the claims administrator knows of the injury, so completethe form as soon as possible.

Medical Care: Your claims administrator will pay all reasonable andnecessary medical care for your work injury or illness. Medicalbenefits may include treatment by a doctor, hospital services,physical therapy, lab tests, x-rays, and medicines. Your claimsadministrator will pay the costs directly so you should never see abill. For injuries occurring on or after 1/1/04, there is a limit onsome medical services.

The Primary Treating Physician (PTP) is the doctor with theoverall responsibility for treatment of your injury or illness.Generally your employer selects the PTP you will see for the first 30days, however, in specified conditions, you may be treated by yourpredesignated doctor. If a doctor says you still need treatment after30 days, you may be able to switch to the doctor of your choice.Special rules apply if your employer offers a Health CareOrganization (HCO) or after 1/1/05, has a medical provider network.Contact your employer for more information. If your employer hasnot put up a poster describing your rights to workers’ compensation,you may choose your own doctor immediately.

Within one working day after an employee files a claim form, theemployer shall authorize the provision of all treatment, consistentwith the applicable treating guidelines, for the alleged injury andshall continue to provide treatment until the date that liability for theclaim is accepted or rejected. Until the date the claim is accepted orrejected, liability for medical treatment shall be limited to tenthousand dollars ($10,000).

Disclosure of Medical Records: After you make a claim forworkers' compensation benefits, your medical records will not havethe same privacy that you usually expect. If you don’t agree tovoluntarily release medical records, a workers’ compensation judgemay decide what records will be released. If you request privacy, thejudge may "seal" (keep private) certain medical records.

Payment for Temporary Disability (Lost Wages): If you can'twork while you are recovering from a job injury or illness, you willreceive temporary disability payments. These payments may changeor stop when your doctor says you are able to return to work. Thesebenefits are tax-free. Temporary disability payments are two-thirds ofyour average weekly pay, within minimums and maximums set bystate law. Payments are not made for the first three days you are offthe job unless you are hospitalized overnight or cannot work for morethan 14 days.

Si Ud. se lesiona o se enferma, ya sea física o mentalmente, debido a sutrabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo,es posible que Ud. tenga derecho a beneficios de compensación paratrabajadores. Se adjunta el formulario para presentar un reclamo decompensación para trabajadores con su empleador. Ud. debe leer toda lainformación a continuación. Guarde esta hoja y todos los demásdocumentos para sus archivos. Es posible que usted reúna los requisitospara todos los beneficios, o parte de éstos, que se enumeran, dependiendo dela índole de su reclamo. Si se requiere, el/la administrador(a) de reclamos,quien es responsable del manejo de su reclamo, le notificará a usted, loreferente a su elegibilidad para beneficios.

Para presentar un reclamo, complete la sección del formulario designadapara el “Empleado”, guarde una copia, y déle el resto a su empleador.Entonces, su empleador completará la sección designada para el“Empleador”, le dará a Ud. una copia fechada, guardará una copia, y enviaráuna al/a la administrador(a) de reclamos. Los beneficios no puedencomenzar hasta, que el/la administrador(a) de reclamos se entere de lalesión, así que complete el formulario lo antes posible.

Atención Médica: Su administrador(a) de reclamos pagará toda la atenciónmédica razonable y necesaria, para su lesión o enfermedad relacionada conel trabajo. Es posible que los beneficios médicos incluyan el tratamiento porparte de un médico, los servicios de hospital, la terapia física, los análisis delaboratorio y las medicinas. Su administrador(a) de reclamos pagarádirectamente los costos, de manera que usted nunca verá un cobro. Paralesiones que ocurren en o después de 1/1/04, hay un límite de visitas paraciertos servicios médicos.

El Médico Primario que le Atiende-Primary Treating Physician PTP esel médico con toda la responsabilidad para dar el tratamiento para su lesióno enfermedad. Generalmente, su empleador selecciona al PTP que Ud. verádurante los primeros 30 días. Sin embargo, en condiciones específicas, esposible que usted pueda ser tratado por su médico pre-designado. Si eldoctor dice que usted aún necesita tratamiento después de 30 días, es posibleque Ud. pueda cambiar al médico de su preferencia. Hay reglas especialesque son aplicables cuando su empleador ofrece una Organización delCuidado Médico (HCO) o depués de 1/1/05 tiene un Sistema de Proveedoresde Atención Médica. Hable con su empleador para más información. Si suempleador no ha colocado un poster describiendo sus derechos para lacompensación para trabajadores, Ud. puede seleccionar a su propio médicoinmediatamente.

El empleador autorizará todo tratamiento médico consistente con lasdirectivas de tratamiento applicables a la lesión o enfermedad, durante elprimer día laboral después que el empleado efectúa un reclamo parabeneficios de compensación, y continuará proveyendo este tratamiento hastala fecha en que el reclamo sea aceptado o rechazado. Hasta la fecha en queel reclamo sea aceptado o rechazado, el tratamiento médico será limitado adiez mil dólares ($10,000).

Divulgación de Expedientes Médicos: Después de que Ud. presente unreclamo para beneficios de compensación para los trabajadores, susexpedientes médicos no tendrán la misma privacidad que usted normalmenteespera. Si Ud. no está de acuerdo en divulgar voluntariamente losexpedientes médicos, un(a) juez de compensación para trabajadoresposiblemente decida qué expedientes se revelarán. Si Ud. solicitaprivacidad, es posible que el/la juez “selle” (mantenga privados) ciertosexpedientes médicos.

Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puedetrabajar, mientras se está recuperando de una lesión o enfermedadrelacionada con el trabajo, Ud. recibirá pagos por incapacidad temporal. Esposible que estos pagos cambien o paren, cuando su médico diga que Ud.está en condiciones de regresar a trabajar. Estos beneficios son libres de

Workers’ Compensation Claim Form (DWC 1) & Notice of Potential EligibilityFormulario de Reclamo de Compensación para Trabajadores (DWC 1) y Notificación de Posible Elegibilidad

Return to Work: To help you to return to work as soon as possible,you should actively communicate with your treating doctor, claimsadministrator, and employer about the kinds of work you can dowhile recovering. They may coordinate efforts to return you tomodified duty or other work that is medically appropriate. Thismodified or other duty may be temporary or may be extendeddepending on the nature of your injury or illness.

Payment for Permanent Disability: If a doctor says your injury orillness results in a permanent disability, you may receive additionalpayments. The amount will depend on the type of injury, your age,occupation, and date of injury.

Vocational Rehabilitation (VR): If a doctor says your injury orillness prevents you from returning to the same type of job and youremployer doesn’t offer modified or alternative work, you mayqualify for VR. If you qualify, your claims administrator will pay thecosts, up to a maximum set by state law. VR is a benefit for injuriesthat occurred prior to 2004.

Supplemental Job Displacement Benefit (SJDB): If you do notreturn to work within 60 days after your temporary disability ends,and your employer does not offer modified or alternative work, youmay qualify for a nontransferable voucher payable to a school forretraining and/or skill enhancement. If you qualify, the claimsadministrator will pay the costs up to the maximum set by state lawbased on your percentage of permanent disability. SJDB is a benefitfor injuries occurring on or after 1/1/04.

Death Benefits: If the injury or illness causes death, payments maybe made to relatives or household members who were financiallydependent on the deceased worker.

It is illegal for your employer to punish or fire you for having a jobinjury or illness, for filing a claim, or testifying in another person'sworkers' compensation case (Labor Code 132a). If proven, you mayreceive lost wages, job reinstatement, increased benefits, and costsand expenses up to limits set by the state.

You have the right to disagree with decisions affecting your claim. Ifyou have a disagreement, contact your claims administrator first tosee if you can resolve it. If you are not receiving benefits, you maybe able to get State Disability Insurance (SDI) benefits. Call StateEmployment Development Department at (800) 480-3287.

You can obtain free information from an information and assistanceofficer of the State Division of Workers' Compensation, or you canhear recorded information and a list of local offices by calling (800)736-7401. You may also go to the DWC web site at www.dir.ca.gov.Link to Workers’ Compensation.

You can consult with an attorney. Most attorneys offer one freeconsultation. If you decide to hire an attorney, his or her fee will betaken out of some of your benefits. For names of workers'compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their web site at www.californiaspecialist.org.

impuestos. Los pagos por incapacidad temporal son dos tercios de su pagosemanal promedio, con cantidades mínimas y máximas establecidas por lasleyes estatales. Los pagos no se hacen durante los primeros tres días en queUd. no trabaje, a menos que Ud. sea hospitalizado(a) de noche, o no puedatrabajar durante más de 14 días.

Regreso al Trabajo: Para ayudarle a regresar a trabajar lo antes posible,Ud. debe comunicarse de manera activa con el médico que le atienda, el/laadministrador(a) de reclamos y el empleador, con respecto a las clases detrabajo que Ud. puede hacer mientras se recupera. Es posible que elloscoordinen esfuerzos para regresarle a un trabajo modificado, o a otro trabajo,que sea apropiado desde el punto de vista médico. Este trabajo modificado,u otro trabajo, podría extenderse o no temporalmente, dependiendo de laíndole de su lesión o enfermedad.

Pago por Incapacidad Permanente: Si el doctor dice que su lesión oenfermedad resulta en una incapacidad permanente, es posible que Ud.reciba pagos adicionales. La cantidad dependerá de la clase de lesión, suedad, su ocupación y la fecha de la lesión.

Rehabilitación Vocacional: Si el doctor dice que su lesión o enfermedad nole permite regresar a la misma clase de trabajo, y su empleador no le ofrecetrabajo modificado o alterno, es posible que usted reúna los requisitos pararehabilitación vocacional. Si Ud. reúne los requisitos, su administrador(a)de reclamos pagará los costos, hasta un máximo establecido por las leyesestatales. Este es un beneficio para lesiones que ocurrieron antes de 2004.

Beneficio Suplementario por Desplazamiento de Trabajo: Si Ud. novuelve al trabajo en un plazo de 60 días después que los pagos porincapcidad temporal terminan, y su empleador no ofrece un trabajomodificado o alterno, es posible que usted reúne los requisitos para recibirun vale no-transferible pagadero a una escuela para recibir un nuevoentrenamiento y/o mejorar su habilidad. Si Ud. reúne los requisitios, eladministrador(a) de reclamos pagará los costos hasta un máximo establecidopor las leyes estatales basado en su porcentaje del incapicidad permanente.Este es un beneficio para lesiones que ocurren en o después de 1/1/04.

Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, esposible que los pagos se hagan a los parientes o a las personas que vivan enel hogar, que dependían económicamente del/de la trabajador(a) difunto(a).

Es ilegal que su empleador le castigue o despida, por sufrir una lesión oenfermedad en el trabajo, por presentar un reclamo o por atestiguar en elcaso de compensación para trabajadores de otra persona. (El Codigo Laboralsección 132a). Si es probado, puede ser que usted reciba pagos por perdidade sueldos, reposición del trabajo, aumento de beneficios, y gastos hasta unlímite establecido por el estado.

Ud. tiene derecho a estar en desacuerdo con las decisiones queafecten su reclamo. Si Ud. tiene un desacuerdo, primero comuníquese consu administrador(a) de reclamos, para ver si usted puede resolverlo. Si ustedno está recibiendo beneficios, es posible que Ud. pueda obtener beneficiosde Seguro Estatal de Incapacidad (SDI). Llame al Departamento Estatal delDesarrollo del Empleo (EDD) al (800) 480-3287.

Ud. puede obtener información gratis, de un oficial de informacióny asistencia, de la División estatal de Compensación al Trabajador (Divisionof Workers’ Compensation – DWC), o puede escuchar información grabada,así como una lista de oficinas locales, llamando al (800) 736-7401. Ud.también puede ir al sitio electrónico en el Internet de la DWC enwww.dir.ca.gov. Enlácese a la sección de Compensación para Trabajadores.

Ud. puede consultar con un(a) abogado(a). La mayoría de los abogadosofrecen una consulta gratis. Si Ud. decide contratar a un(a) abogado(a), sushonorarios se tomarán de sus beneficios. Para obtener nombres de abogadosde compensación para trabajadores, llame a la Asociación Estatal deAbogados de California (State Bar) al (415) 538-2120, ó vaya a su sitioelectrónico en el Internet en www.californiaspecialist.org.

State of California Department of Industrial Relations DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION CLAIM FORM (DWC 1) Employee: Complete the “Employee” section and give the form to your employer. Keep a copy and mark it “Employee’s Temporary Receipt” until you receive the signed and dated copy from your em -ployer. You may call the Division of Workers’ Compensation and hear recorded information at (800) 736-7401. An explanation of work-ers' compensation benefits is included as the cover sheet of this form. You should also have received a pamphlet from your employer de-scribing workers’ compensation benefits and the procedures to obtain them.

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation bene-fits or payments is guilty of a felony.

Estado de California Departamento de Relaciones Industriales

DIVISION DE COMPENSACIÓN AL TRABAJADOR

PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL TRABAJADOR (DWC 1)

Empleado: Complete la sección “Empleado” y entregue la forma a su empleador. Quédese con la copia designada “Recibo Temporal del Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador. Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736- 7401 para oir información gravada. En la hoja cubierta de esta forma esta la explicatión de los beneficios de compensación al trabjador. Ud. también debería haber recibido de su empleador un folleto describiendo los benficios de compensación al trabajador lesionado y los procedimientos para obtenerlos.

Toda aquella persona que a propósito haga o cause que se produzca cualquier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores lesionados es culpable de un crimen mayor “felonia”.

Employee—complete this section and see note above Empleado—complete esta sección y note la notación arriba.

1. Name. Nombre. _____________________________________________Today’s Date. Fecha de Hoy. ___________________________________

2. Home Address. Dirección Residencial. _______________________________________________________________________________________

3. City. Ciudad. _______________________________________ State. Estado. __________________ Zip. Código Postal. ___________________

4. Date of Injury. Fecha de la lesión (accidente). ________________________ Time of Injury. Hora en que ocurrió. _________a.m. ________p.m.

5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _________________________________________

_______________________________________________________________________________________________________________________

6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. _______________________________________________

_______________________________________________________________________________________________________________________

7. Social Security Number. Número de Seguro Social del Empleado. _______________________________________________________________

8. Signature of employee. Firma del empleado. _________________________________________________________________________________

Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.

9. Name of employer. Nombre del empleador. ___________________________________________________________________________________

10. Address. Dirección. _____________________________________________________________________________________________________

11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. _____________________________

12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. _________________________________________

13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. _______________________________________

14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros.

_______________________________________________________________________________________________________________________

15. Insurance Policy Number. El número de la póliza de Seguro. _____________________________________________________________________

16. Signature of employer representative. Firma del representante del empleador. _______________________________________________________

17. Title. Título. _____________________________________ 18. Telephone. Teléfono. _______________________________________________

Employer: You are required to date this form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the claim within one working day of receipt of the form from the employee. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY

Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su com-pañía de seguros, administrador de reclamos, o dependiente/representante de recla-mos y al empleado que hayan presentado esta petición dentro del plazo de un día hábil desde el momento de haber sido recibida la forma del empleado.

EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD

❑ Employer copy/Copia del Empleador ❑ Employee copy/ Copia del Empleado ❑ Claims Administrator/Administrador de Reclamos ❑ Temporary Receipt/Recibo del Empleado

7/1/04 Rev.

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