What is Workers' Compensation?
Designed to be a "no-fault" system, Workers' Compensation is a state-mandated benefit. The purpose of Workers' Compensation is to provide benefits and assistance to all workers who are either injured or develop a job-related illness as a result of their employment. Benefits may include:
· Medical costs
· Temporary disability
· Permanent disability
· Supplemental job displacement voucher
· Death benefits
What is a Work-Related Injury?
The California Labor Code definition of the term "injury" includes "any injury or disease arising out of employment and occurring in the course of employment." The injury may result from either trauma or disease. Injuries are categorized in three ways:
SPECIFIC– An injury to one or more parts of the body resulting from a specific incident.
CUMULATIVE – An injury resulting from repetitive traumatic activities over a period of time, such as exposure to chemicals or fumes which are injurious to an employee.
AGGRAVATION – A preexisting condition or non-work-related condition aggravated by an occupational injury or disease. The employer provides medical treatment until the employee returns to the pre-injury status of the preexisting condition
When a Claim is Accepted
Once a claim is accepted, if the employee has lost more than three days from work, the workers’ compensation insurance should authorize medical treatment and issues any temporary or permanent disability payments and medical payments related to the claim.
If the employee’s doctor provides disability for time off work, or the employer cannot accommodate restrictions provided by the doctor, the workers’ compensation insurance should mail a temporary disability check to the employee's home.
The check pays two-thirds of the employee's weekly salary up to a maximum amount determined by the State of California. A letter confirming that the claim has been approved will accompany the check.
By law, there is a three-day waiting period before the Workers' Compensation temporary disability payments begin. The employee's sick leave and other selected leave balances may be used to cover any lost time on the first three days the employee can not work after the date of injury. The three-day waiting period is waived if the employee is hospitalized or disabled for more than 14 days.
When an employee is working a reduced schedule due to a work-related injury or illness, the State of California uses a formula to pay employees for lost time from work. Based on the formula, the employee may or may not be paid by the workers’ compensation insurance.
Procedures for Pending Claims
A decision on a claim may be delayed by the workers’ compensation insurance. If more time is needed to make a decision, the workers’ compensation insurance will mail a letter to the employee's home stating the date a decision will be made. The employee may to apply for other Disability Benefits through EDD if the employee is losing time from work while the case is on delay.
Procedures for Denied Claims
If a claim is denied, the workers’ compensation insurance will mail a letter to the employee's home explaining why the claim has been denied.