Four Benefits That Injured Workers In California Should Know
Know the benefits that an injured worker in California is entitled to, understand the terminology and make sure you don't give up any benefits that you are legally entitled to receive. There are four types of benefits available to injured workers, outlined below.
Four Benefits in Worker's Compensation : (1) Temporary DisabilityThere are four benefits in worker's compensation, Temporary Disability or TD (wage loss), Medical Treatment for body parts injured at work, Permanent Disability as compensation for your injury, and last, Vocational Retraining if you are unable to return to your prior job and have a permanent disability rating as a result of your work injury.
(1) Temporary Disability, replaces your paycheck if you are unable to work for more than three days due to a work injury. Temporary Disability is calculated at 2/3rds of your income before taxes. Temporary Disability (TD) is not taxable to you. TD is paid by the insurance company who provided worker's compensation insurance to your job, not your employer. The longest time you can receive Temporary Disability in California is two years, a total of 104 weeks. A doctor has to certify that you cannot work every 45 days to the insurance company. The insurance company wants to avoid paying Temporary Disability, so they encourage your employer to take you back in a modified position. The modified position is based on what your doctor says you can do now, after your injury. If you accept a modified position, you go back to work and TD ends. Any right to TD is extinguished five years after your date of injury, whether or not you have received the full 104 weeks, and whether or not you can return to work.
Your worker's compensation doctor will make the decision on whether or not you are ready to return to your old job, with or without changes to that job. The worker's compensation doctor does not have to tell you that they are returning you to work. They also do not have to tell you in advance of finding you to be "Permanent and Stationary" (P&S). Your temporary disability payments will end immediately when any WC doctor treating you finds you "Permanent and Stationary." That means you will get a notice that your checks are ending. Sometimes, but not often, a small advance payment is made, at $290 per week.
Communicate with your doctor to make sure that you are not caught off guard. Many doctors will talk to you and tell you they will be "making you Permanent and Stationary" at the next visit. They are telling you to prepare yourself for having your temporary disability benefits cut off.
Many times, injured workers are deemed "Permanent and Stationary" much sooner than necessary. The doctors are being pressured to bring injured workers back to work as soon as possible. If you are found Permanent and Stationary, you can dispute this finding by asking for a Panel Qualified Medical Examiner (PQME - see below).
Four Benefits in Worker's Compensation: (2) Medical Treatment2. Medical Treatment is the second benefit injured workers are entitled to. The insurance company must authorize up to $10,000 of medical care for you after an injury is reported, up until they accept or deny your claim of injury. Injured workers can only treat within the insurance company's network list of doctors. If you go to your private insurance, WC will not pay for it or authorize any requested treatment.
The insurance carrier has up to 90 days to decide to accept or deny your claim of injury at work. If your claim is denied, apply for State Disability immediately.
During this waiting period of whether they will accept or deny the claim, medical care must be provided. Once the claim is denied, the insurance carrier can refuse to pay for any further medical treatment until the dispute over whether or not you were injured is resolved.
Four Benefits in Worker's Compensation : (3) Permanent DisabilityThe way a work injury dispute resolved is by getting a medical opinion of your case from an outside doctor who has been certified to evaluated injured workers and prepare assessments.
This outside doctor is sometimes called a Panel Qualified Medical Examiner (PQME). Either you or the insurance company can request a Panel Qualified Medical Evaluation (PQME) to get this outside doctor's opinion on your case. Once you have a Panel Qualified Medical Evaluator (PQME), you are pretty much stuck with that doctor for the life of your case. Choose carefully. You send in the form and will receive a list of three doctors' names. One of these is chosen, and they evaluate you in person and write a report to say whether or not you have permanent residual disability from your work injury.
In California, doctors have to use a formula to figure out how severely someone is injured. This formula is found in a book called the "American Medical Association's Guidelines for Assessing Permanent Impairment", or the "AMA Guides" for short. This book (AMA Guides) gives the directions to the doctor on how to evaluate various conditions using a formula. All medical reports must have objective evidence in order for a doctor to find that you have any level of permanent disability. You cannot get a permanent disability rating based only on pain complaints.
The doctor will review all your medical reports, MRIs, xrays, will evaluate you in person, ask you about your symptoms, then the doctor will prepare a report with numbers to put into a formula. We review the report to calculate the total disability according to the formula, to get a Permanent Disability Rating. The Permanent Disability Rating is the AMA Guides numbers, combined with your job title (occupation), age and what body part was injured. These combine to make a percentage. This is your percentage of disability. Then you go to a chart listed in the California Labor Code and find out the cash value of the percentage of disability. Each percentage number 2%, 10%, 25%, has a cash value. This is the 'Permanent Disability' part of your case.
The insurance carrier can disagree with the PQME doctor's opinion. They can take the doctor's deposition, obtain your prior medical records (yes, they are able to get your medical history) and try to reduce your award by arguing that either you weren't injured at all, or your injury was very minor, or that if there was an injury, you were already disabled because of (insert random excuse here - smoking, prior surgery, past motor vehicle accident). (You get the idea.)
Four Benefits in Worker's Compensation : (4) Vocational Rehabilitation4. Vocational Rehabilitation benefits are the last type of benefits available. Once you are Permanent and Stationary, the employer has to decide if they can bring you back to work. The employer can say that they do not have a job available within your work restrictions. It doesn't matter how long you have worked there, how much seniority you have, you can be let go. The employer can indicate that they have made a diligent search of available positions that you can do now, and there are no jobs available within your work restrictions. Yes, your employer can terminate your employment. (Many people on the internet seem to think a work injury stops an employer completely from firing you, that is incorrect.)
If you can't go back to your old job, and your employer doesn't have any modified job available, then you are eligible for vocational retraining. There are two parts to vocational retraining in California:
A $6,000 "Voucher" (or Coupon) for School / Classes / Certifications / Computer Equipment
(must use within two years)
B. A $5,000 cash payment from the State of California Supplemental Job Displacement Fund.
(must apply within one year)
You can locate a school or program who takes the voucher here: http://www.bppe.ca.gov/
The $6,000 is paid directly to the school on your behalf by the insurance company. You have two years from the date they send you the voucher notice. DO NOT DELAY IN USING THESE BENEFITS. You can use the voucher for certifications, licensing, going back to school for any reason (even astronomy!) The classes are not required to lead to a new job. It's an opportunity for you to improve your chances in the job market after a work injury.
Within that $6,000, you can get a $500 cash advance for anything, you can buy a laptop and request reimbursement out of the voucher monies (restrictions apply), and also purchase computer and printer equipment. A vocational rehabilitation counselor can help you research classes, but you do not have to use a counselor. The counselor's fees are capped at $600 (paid out of your $6,000 voucher).
You must use the voucher within two years of the date they send you a letter notifying you that you are eligible for a job retraining voucher. If you don't, it is gone.
The cash stipend of $5,000 is a 'bridge' from what it used to be to what it is now. There are no restrictions on what you spend this money on at all. Before the State of California reformed worker's compensation laws, injured workers would get $16,000 in vocational retraining. That was cut to $6,000 for all injuries after 1/1/13. The additional $5,000 is meant to bridge the gap between $16,000 and $6,000. This money comes from a State of California fund for injured workers, and once that fund is exhausted, no more injured workers will get the additional $5,000 cash stipend.
Again, you only have ONE YEAR to request the $5,000 cash stipend. Do not delay, there is no way to get the money after the deadline has passed.