Written by attorney Michael Ian Rott

How Long Should It Take to Settle My Workers' Compensation Claim?

It depends upon a number of factors. The top two are Liability and Damages (your injuries in this case). First, your employer or their insurance company has 90-days after you’ve notified them about your injury, to accept your claim. If your claim is not accepted within that time period, you will not receive temporary disability payments from the insurance company, and your case will be delayed until it is accepted. However, in the meantime you could be eligible for State Disability to pay these payments.

If your employer objects to a medical determination made by your treating physician, they have up to 20 days to do so, if you are represented by a lawyer. If you are not represented by a lawyer, then that time frame is extended to 30 days.

If your employer denies that your injury happened at work; whether or not you need to stay home from work to recover; whether or not your employer agrees upon an agreed evaluator, known as an “AME", and depending upon their availability, typically within 30-days after your physical or mental evaluation, a report should be ready to help move your case forward.

If however your employer will not agree to an AME, either of you have the right for you to be seen by a Panel Qualified Medical Evaluator, known as a “PQME". Typically the Division of Workers’ Compensation (“DWC") Medical Unit will send a list, known as a “Panel", of 3-QME’s to you and your employer within 15-working days of the request. However, if the Medical Unit does not issue a panel within 30 calendar days of receiving the request, in a case where you are represented by a lawyer, either party may seek an order from a Workers’ Compensation Administrative Law Judge to obtain a QME panel.

Both you and your employer have the right to strike 1 of the 3 names on the list within 10 days of assignment of the panel by the administrative director, and the remaining physician becomes your PQME. Just like an AME, once you have seen the PQME, he or she will have 30-days in which to complete your report, with some minor exceptions.

In cases however involving a Utilization Review (“UR") denial of medial treatment, your only option is to object within 30 days of this decision and request an Independent Medical Review (“IMR"). The IMR process applies to dates of injury on or after 1/1/13 and to all medical treatment requests made on or after 7/1/13.

The IMR is based solely upon the information given to the UR reviewer. Therefore, if you have additional information to supply thereafter, which was not supplied to the 1st UR physician, you may request a 2nd UR to consider this additional information. If the 2nd UR decision is still a denial of the medical treatment, once again your only option is to file a request for the IMR.

Reviews are to be completed within 30 days, with exceptions for expedite review in cases where the condition involves medical necessity.

Second, regarding your injuries, every claim and every injured worker are different. While the State of California continues to focus on statistics, we know that some of your injuries are more severe than others; and that your healing process could take longer than others.

This statistical data also breeds a constant denial of workers’ compensation benefits. It is therefore extremely important to hire a competent workers’ compensation lawyer right away. This is to ensure the best medical care under this system, and to pave the way for the quickest and smoothest path for your return to work.

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