What employers should know about the system in California

CALIFORNIA WORKERS’ COMPENSATION

Insurance Company/Employer/Defendant

Applicant/Applicant ’s Att orney

Medical Providers/QME Doctors/Lien Claimants

Administrati ve Law Judges/I&A Offi cers/Raters/Support Staff

WHO IS INVOLVED IN THE PROCESS?

Up to 90 day delay period for investi gati on of claim that begins with employer date of knowledge

If accepted, the injured worker can collect benefi ts and begin treatment

If denied, there are possible appeals for the injured worker

Once the injured workers’ conditi on stabilizes, sett lement discussions can begin

BASIC CLAIMS PROCESS

Weekly benefi t meant to be parti al wage replacement

2/3rds of an Employee’s gross average weekly wage

Subject to maximum and minimum rates, updated annually

In most cases, 104 week limit over a 5 year period from the date of injury

TD ends when injured worker is released to work, reaches permanent and stati onary status, or reaches the 104 week cap

5 TYPES OF BENEFITSTEMPORARY DISABILITY (TD)

LC 4600 – Treatment reasonable and necessary to cure or relieve

Medical Provider Networks

Role of the Primary Treati ng Physician (PTP)

Role of QME/AME and the medical legal process Medical Treatment Uti lizati on Schedule

Uti lizati on Review and Independent Medical Review

5 TYPES OF BENEFITSMEDICAL

Weekly benefi t meant to compensate an injured worker for loss of ability to compete in the open labor market

Benefi t begins aft er the end of TD or when there is evidence of PD when no TD has been paid

Can be withheld unti l sett lement if the employee returns to work for the same employer

Percentage is based upon fi ndings of either the PTP, the QME, or a combinati on of the two

Based on the AMA guidelines, adjusted for age, occupati on, and type of injury

5 TYPES OF BENEFITSPERMANENT DISABILITY (PD)

Supplemental Job Displacement Benefi t (SJDB)Voucher

For an employee to be eligible for the voucher, there must be evidence of permanent disability AND no return to work with the employer

Certain elements are required to make a valid off er of work Amount used to vary, but all injuries aft er 1/1/13 now grant

a $6000 voucher

Return to Work Fund. Tied to eligibility for the voucher

5 TYPES OF BENEFITSRETURN TO WORK

Reduces costs on the claim (TD, SJDB, etc.)

Generally a bett er recovery result for the injured worker

Compensable consequence injuries are less likely

Supports a healthy culture in the work place

Preserves talent

RETURN TO WORK (CONT’D)

Payable to spouse, children, or other dependents if death results from an industrial injury or illness

Up to $10,000 for burial expenses

5 TYPES OF BENEFITSDEATH

Get insurance

Provide DWC 1 Claim Form within one day when you have noti ce or knowledge of industrial injury

Send completed DWC 1 Claim Form to insurance carrier within one day of receipt from employee

Post DWC-7 noti ce in a conspicuous locati on Provide workers’ compensati on pamphlet to new hires,

including pre-designati on form

EMPLOYER’S RESPONSIBILITIES

Conferences, trials, and other proceedings can occur before the Workers’ Compensati on Appeals Board (WCAB) throughout the case, but are not required

Two types of sett lement: C&R or Sti p

Findings and Award/Order may be necessary aft er liti gati on if no agreement can be reached

LITIGATION AND SETTLEMENT

Uninsured employers are sti ll responsible for work-related injuries

Exclusive Remedy rule does not apply to uninsured employers

Many Statutes of Limitati on arguments cannot be uti lized by the uninsured employer

It is i l legal and may subject employers to non-WCAB penalti es as well

UEBTF

Reimbursement/Civil Suit/Writ of Att achment

UNINSURED EMPLOYERS

Fraud – Special Investi gati ons Unit, District Att orney, Department of Insurance

Employer Discriminati on – Labor Code 132(a)

Serious and Willful Misconduct Peti ti on

Employee versus Independent Contractor arguments

OTHER ISSUES

WCAB Informati on and Assistance: (916) 928-3158 or htt p://www.dir.ca.gov

Division of Occupati onal Safety and Health (OSHA)

Insurance Commissioner ’s Offi ce

Workers’ Compensati on Insurance Rati ng Bureau (WCIRB.org)

RESOURCES

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