This page provides answers to the following questions:
- I had an accident at work. How do I file a workers compensation claim in my state?
- Should my employer have workers compensation insurance? How do I know I am covered?
- What are the conditions that enable me or prevent me from claiming benefits under my state's law?
- What benefits might I be eligible to receive?
- How much time do I have to file my claim? What are the stages of the claim process? What should I expect?
- If I'm not happy with the determination, how do I appeal?
1. I had an accident at work. How do I file a workers compensation claim in my state?
If you are injured at work, you must first report the injury to your employer by telling your supervisor as soon as possible. This includes recent injuries and injuries/illnesses that have developed over time as a result of your job. It is important you notify your employer about your injuries promptly, aiming to inform your employer within thirty (30) days. Failing to do so may cause problems or delays in the claims process.
Next, seek emergency treatment if necessary. Your employer may specify a physician or care center where you should seek treatment. Notify the physician that this is a job-related injury or illness.
It is also important to fill out a claim form, DWC form 1, and give it to your employer once you have completed it. Your employer must give or mail you a claim form within one working day after learning about your injury/illness. If your employer does not, you may visit the forms page of the California Department of Industrial Relations Agency Division of Workers' Compensation site to download one. You should fill out this form within one year of your injury; otherwise, you may not be able to receive benefits.
2. Should my employer have workers compensation insurance? How do I know if I am covered?
In California, all employers are required to either purchase a workers' compensation insurance policy from a licensed insurer, authorized to write policies in California, or become self-insured. The Division of Workers' Compensation does not provide insurance to employers and does not maintain information about employers and their insurance providers. If you are uncertain about the insurance program available at your place of employment, you may contact the Workers' Compensation Insurance Rating Bureau.
3. What are the conditions that enable me or prevent me from claiming benefits under my state's law?
The conditions that will either enable you or prevent you from receiving benefits under California's workers' compensation system will depend on the nature of your claim. A more detailed look into temporary disability benefits and permanent disability benefits through the respective links can provide you with more information about what to expect
4. What benefits might I be eligible to receive?
In California, six basic benefits are provided through workers' compensation insurance:
- Medical Care
- Temporary disability benefits
- Permanent disability benefits
- Supplemental job displacement benefits
- Vocational rehabilitation
- Death benefits
The kinds of benefits you are capable of receiving and how they are to be calculated will depend on the nature of your claim. Some other benefits may be available outside of your employer's insurance program, including:
- Benefits paid by state and federal governments,
- Disability Insurance, unemployment insurance, and Social Security Disability Insurance.
- Benefits offered by employers and unions
- Payments if your injury was caused by someone other than your employer
5. How much time do I have to file my claim? What are the stages of the claims process? What should I expect?
Filling out a DWC 1 Form initiates the claim process. Once this begins, you, your employer, and a claims administrator become involved with your injury claim to determine whether you are entitled to receive any benefits. A claims administrator is assigned to your place of work. Usually, his/her name will be posted at your workplace in the same area where other workplace information is posted.
Next, Utilization Review (UR) will determine if medical treatment is necessary. A UR program determines whether the medical treatment outlined by your treating physician should be approved. The California's Medical Treatment Utilization Schedule outlines medical treatment for work-related injuries and illnesses, specifying the treatments, efficacy, duration and extent of treatments that are recommended for injured workers.
If you and/or the claims administrator disagree over the results and conclusions made by the treating physician, you may expect to be examined by a second doctor, an Agreed Medical Evaluator (AME) or Qualified Medical Evaluator (QME) during the claim process. You may decide to request a QME examination if:
- Your claim is delayed or denied and you need a medical exam to see if your claim is payable
- You need to know if you are permanently disabled or you will need further medical treatment
- You disagree with what your doctor says about your condition
- You disagree with the finding of the utilization review.
- You, your employer, or your attorney (should you seek one) may request a QME examination.
6. If I am not happy with the determination, how do I appeal?
If you disagree with the claim's administrator's decision, you must act within specific timelines in order to maintain your rights. You must appeal a decision in writing within twenty (20) days of receiving it. Your claims administrator will most likely file a QME panel request to initiate a QME review. If the claims administrator continues to deny your claim after the QME process, you will need to see a worker's compensation judge to resolve the disagreement. This can be accomplished by filing a declaration of readiness to proceed with an expedited hearing before a judge. If you do not already have an existing case open, you will need to file an application for an adjudication claim; this opens a case for you. It is advised that you work with a lawyer familiar with workers compensation law to pursue an appeal, if you are not working with one already, as it is a specialized field of law with short time deadlines which, if missed, may jeopardize your ability to receive compensation.