After You Get Injured
More infomation every employee should know after sustaining a work-related injury includes:
Chiropractic Treatment is Covered by Workers' Compensation
Some patients have indicated that chiropractic is not part of their health plan (HMO, PPO, private insurance). Therefore, they believe that chiropractic care is not covered for their work-related injury. However, this is not the case. Your health plan is completely separate from the mandatory workers' compensation benefits provided to you by law (LC 3700). Injured workers may receive chiropractic, medical, surgical, acupuncture, or other health care treatments (LC 4600, 3209.3). All treatments for a work-related injury are covered and paid for by the workers' compensation insurance provider.
Exam by the insurance company doctor
The insurance company has the right to designate a particular doctor to examine you periodically. Even though you are required to attend the exam, you do not have to accept their treatment recommendations or return for care (LC 4050). Be sure to request a copy of the doctor's finding and review them with the doctor who is treating you. If you disagree with any of the findings, you or your doctor must object to them in writing. This will help set the record straight and avoid confusion in the future.
Maximum Medical Improvement (MMI)
After some period of treatment, you will reach your maximum medical improvement. If your condition has reached MMI and has retuned you to your pre-injury condition, the case can be closed. The insurance carrier is not responsible to heal all that ails you, but to bring you back to your condition prior to sustaining the work-related injury. If MMI is below your pre-injury condition, you will have sustained some level of "disability". If there has been no significant change in your condition over the last 2-3 months of treatment, then your condition is considered to have reached a plateau, and you are classified as Permanent and Stationary (P&S).
Permanent and Stationary (P&S)
When you have reached MMI and are Permanent and Stationary (P&S), the primary treating physician (PTP) must write a P&S report on your behalf (LC 4061.5). This report is critical since it will determine what benefits you will continue to receive, if any. The benefits can include permanent disability payments, future medical care, and vocational rehabilitation. Get a copy of the P&S report from your doctor. If you disagree with the findings, you have 30 days to request a qualified medical evaluation (QME).
Note: Many doctors are unfamiliar with the format, requirements, and intricacies of writing quality, ratable reports. This is not to your benefit. Seek out a doctor who works extensively with injured workers and has a good working relationship with applicant attorneys. If you like your doctor, have them refer you out for an exam and report. We write P&S reports for other doctors, and are available to discuss this service with your doctor (LC 4061.5).
Designate the P&S report
If your doctor does not write P&S reports or does not have the time, they can refer this responsibility to another doctor (LC 4061.5). Contact us for information on providing this service for your case.
Applicant Attorney
An applicant attorney is one who represents the injured worker. An attorney will review your case and determine if it warrants their expertise. Currently, applicant attorneys are paid based on a percentage of disability of the client, therefore, if your injury is unlikely to result in significant disability, you may find it difficult to retain an attorney. In these cases, the doctor's role in your case becomes even more important.
Disputed or Unaccepted Claims
If there is an issue at dispute, the insurance company may refuse to compensate for any of the above-mentioned benefits. At this stage, a qualified medical evaluation (QME) is preformed to determine if the injury is compensable or not. The doctor's report will determine if you will be receiving benefits for the alleged work injury. If you are not represented by an attorney, you will want to request a Panel QME. If your claim has been denied, you may select your own QME doctor to evaluate your claim (LC 4060 (d)).
Note: It is advisable to consult with a W/C attorney if your case has been denied or is on hold by the insurance company. The insurance company will pay for the services of your attorney if the attorney accepts your case.
Resolve Disputes Using the Workers' Compensation Appeals Board (WCAB)
The WCAB resolves many issues for the employer or the employee. If your claim is denied, or you are not getting your entitled benefits, you must appeal to the WCAB. This may take some time so contact them as soon as you experience problems.
For more information on this subject, visit the Division of Workers' Compensation website. Who controls your case makes all the difference in the benefits that you receive. Remember, you can always consult an attorney for assistance or contact the Information and Assistance office in your area.
Non-discrimination Policy
The state of California has a non-discrimination policy against employees who have filed, or have made know their intention to file a claim for compensation (LC 132a). An employee who feels they have been discriminated against may file a petition with the workers' compensation appeals board (LC 132a(4)).
Information and Assistance Office
The Divisions of Workers' Compensation makes information available to employees, employers, and other interested parties to assure the proper and timely furnishing of benefits and to assist in the resolution of disputes on an informal basis (LC 5450, 5451). Contact the Information and Assistance Office in your area for more in-depth assistance. Take charge of your case, ask lots of questions, and become informed.
Liberally Construed in the Injured Works Favor
The California Labor Code is liberally construed by the courts with the purpose of extending benefits for the protection of persons injured in the course of employment. (LC 3202) The injury has to be at least 51% attributed to the employment. There must be reasonable medical evidence that the injury occurred and arose out of employment (LC 3202.5).
If in doubt, file a claim. Let the doctor determine if your injury is work
related or not, they will have a better understanding of what is required
for an injury to be compensable.