Pocket Guide to Workers’ Compensation in California (2nd ed., 2014)

The Pocket Guide to Workers’ Compensation in California gives an overview of workers’ compensation law and procedure. It provides a brief history of the law and a summary of citations to applicable statutes, regulations, and precedent cases. The guide includes pertinent resources, a glossary, and an index of terms.

The guide covers:

• • Stages of a compensation claim
  • Benefits
  • Rights and obligations
  • Labor-management carve-outs
  • Rights of employees whose employers are illegally uninsured
  • How workers’ compensation law relates to disability rights laws, job-protected leave laws, and public benefits

The guide is a valuable reference and training tool, and helpful to anyone who needs to understand the workers’ comp process in both the public and private sectors in California.

Table of Contents

1. Scope and Operation of the Workers’ Compensation System (Page 1)
   1. Introduction (Page 1)
   2. California workers’ compensation laws apply to most injuries and illnesses caused by employment (Page 2)
   3. Injured workers may not sue the employer in court, and benefits are limited (Page 3)
   4. Employers are required to have insurance (Page 4)
   5. Coverage of post-termination claims is limited (Page 4)
   6. Coverage of psychiatric injuries is limited (Page 5)
   7. Sleep dysfunction and sexual dysfunction claims also limited (Page 6)
   8. Five categories of benefits are paid (Page 6)
   9. Administrative law judges adjudicate disputes (Page 7)
2. Preliminary Rights and Responsibilities (Page 8)
   1. Employers and workers can prevent injuries and illnesses (Page 8)
   2. Some workers may predesignate their personal physician (Page 8)
   3. Employers and unions may create labor-management carve-outs (Page 10)
3. Requesting Benefits After Injury (Page 11)
   1. The injured worker should inform the employer and get emergency treatment if needed (Page 11)
   2. Filing a claim form preserves the injured worker’s rights (Page 12)
   3. Employees of illegally uninsured employers may sue the employer and apply for Uninsured Employers Benefits Trust Fund benefits (Page 14)
   4. Presumptions of compensability apply to public safety officers (Page 15)
4. Medical Care (Page 15)
   1. Employers and providers may not collect payment from an injured worker for medical care (Page 17)
   2. Scientifically based medical treatment guidelines govern care (Page 17)
   3. Claims administrators must promptly authorize treatment (Page 18)
   4. The primary treating physician has a role in determining benefits (Page 19)
   5. How the initial primary treating physician is selected depends on whether the worker predesignated and whether there is a medical provider network (MPN) or health care organization (HCO) (Page 19)
   6. The injured worker’s rights to switch primary treating physicians depend on whether the worker is being treated in an MPN or HCO and whether the worker predesignated (Page 21)
   7. Disputes over out-of-network medical treatment (Page 22)
5. Resolving Problems with Medical Care and Medical Reports (Page 24)
   1. An injured worker may discuss concerns with a treating physician or switch physicians (Page 24)
   2. Steps to dispute a treating physician’s opinion about necessary care depend on whether the injured worker is being treated in an MPN or HCO (Page 24)
   3. Decisions to authorize care are made in a utilization review (UR) process, followed by an Independent Medical Review (IMR) appeal process (Page 25)
   4. The injured worker has the right to challenge a decision denying treatment (Page 26)
   5. The injured worker and the claims administrator may dispute a treating physician’s opinion on matters other than treatment (Page 27)
   6. A medical evaluation is required to dispute an opinion by a treating physician or a decision to deny care (Page 28)
6. Temporary Disability Benefits (Page 30)
   1. Temporary disability (TD) benefits are paid to injured workers who are disabled while recovering (Page 30)
   2. Payment amounts depend on lost wages (Page 31)
   3. TD benefits are paid on a schedule (Page 31)
   4. Penalties are payable for delays (Page 32)
   5. When TD payments end is based on the worker’s medical condition, return to work, or duration of payments (Page 32)
7. Working After Injury (Page 34)
   1. Workers’ compensation law prohibits discrimination against workers with job injuries (Page 34)
   2. The treating physician determines work capacities and restrictions (Page 35)
   3. The employer may reduce its liability for certain benefits by offering work (Page 35)
   4. Actions taken in a workers’ compensation claim do not eliminate rights and obligations under disability rights laws (Page 37)
8. Permanent Disability Benefits (Page 40)
   1. Permanent disability (PD) benefits are paid to workers who will always be limited in their ability to work (Page 40)
   2. Benefits depend in part on a medical report (Page 41)
   3. The worker’s disability is given a permanent disability rating (Page 41)
   4. Payment amounts depend on ratings of the disability, date of injury, pre-injury wages, and whether the employer offers work (Page 43)
   5. PD benefits are paid on a schedule (Page 43)
   6. Penalties are payable for delays (Page 44)
   7. PD benefits are commonly settled (Page 44)
9. Supplemental Job Displacement Benefits (Page 46)
   1. A supplemental job displacement benefit (SJDB) is a voucher that promises to pay for educational retraining or skill enhancement (Page 46)
   2. Benefit amounts depend on the worker’s permanent disability rating (Page 47)
   3. Voucher expiration date (Page 47)
10. Sources of Further Information and Help (Page 48)
    1. California agencies (Page 48)
    2. Reference materials (Page 49)
11. Glossary (Page 50)
12. Index (Page 61)