Workers’ compensation is a form of insurance California law requires employers to purchase for the protection of their employees. Generally speaking, these protections come into play when an employee is injured on the job.
Instead of having to sue their employer to recover their injury-related costs—a process which can take months or years and have numerous roadblocks to recovery—workers’ compensation removes several of those roadblocks and speeds up the process.
This article will explain when an employee can receive workers’ compensation benefits, the workers’ compensation process, what workers’ compensation benefits cover, and whether you have a case. This is not meant to be an exhaustive guide to workers’ compensation law in California, but to provide a general overview of how it works.
When are you entitled to Workers’ Compensation?
Only certain injuries qualify for workers’ compensation benefits. To qualify, the following must be true:
- At the time of injury, both employer and employee must be subject to workers’ compensation laws;1
- At the time of injury, the employee must be performing service related to his or her employment;2
- The employment must have contributed to causing the injury;3
- The injury was not caused by the injured employee’s intoxication;4
- The injury was not intentionally self-inflicted;5
- The employee didn’t commit suicide;6
- The injury wasn’t caused by a fight started by the employee;7
- The injury wasn’t caused by the employee’s commission of a felony;8
- The injury wasn’t caused by voluntary participation in a non-work-related off-duty recreational, social, or athletic activity;9 and
- The compensation claim was not filed after notice of termination or layoff, unless certain conditions apply and except for certain psychiatric injuries.10
If any of these requirements aren’t met, you probably won’t be entitled to workers’ compensation benefits. But these requirements are not as simple might might think.
For example, in one case, death benefits were denied to an employee’s widow because the employee committed suicide. However, on appeal it was found that the employment’s stress was a cause of that suicide and death benefits were awarded.11
The point is: if you think your injury doesn’t satisfy one of these requirements, you might be surprised. This is one of many reasons consulting with an attorney is invaluable for your workers’ compensation claim.
Workers’ Compensation Procedure
Time is of the essence for a workers’ compensation claim. If an employee suffers a work-related injury and misses any work or suffers a work-related death, written notice of the injury or death must be sent to the employer by the employee or dependent within 30 days.12
Within one business day of receiving the notice the employer must provide you with a claim form and notice of potential eligibility for benefits.13 This form will inform the employee how the claims process works, where the employee can receive medical care, how to get medical care while the claim is pending, the employee’s right to an attorney, and more.
A completed claim form must be submitted to the employer by the employee or dependent.14 Within 90 days of the claim being submitted, it will be accepted or rejected. If it is not rejected within this time, it will be presumed accepted.15 Within one day of receiving claim, the employer must provide medical treatment to the employee even while the claim is under decision.16
If the claim is denied, you must be notified within 14 days. If you feel your injuries do qualify for workers’ compensation coverage, you can appeal to the Workers’ Compensation Appeal Board. At this point, legal representation becomes very important. Any mistake can be devastating to your claim.
Available Benefits in Workers’ Compensation Cases
Workers’ compensation benefits include:
An injured employee can also recover medical-legal expenses when their claims are contested21 and receive increased compensation when their employer or the workers’ compensation insurance company acts improperly.22
Medical Treatment Benefits
If your injuries qualify for workers’ compensation coverage you will be entitled to all care ‘reasonably required’ to cure or relieve” your injuries.23 This includes, but is not limited to:
- Medical care;
- Surgical care, including cosmetic surgery;24
- Chiropractic care, physical therapy, and occupational therapy;25
- Hospital care; and
The starting point for medical care is with the primary treating physician.26 This PTP is responsible for evaluating the employee’s injuries, coordinating any necessary treatment with other medical providers, determining what benefits the employee is entitled to, and providing this information to the employer.27
Wage Loss Benefits
Some injuries covered by workers’ compensation leave employees “disabled” and unable to work. If you are in this position, you’ll likely worry about bills and expenses. You might be entitled to receive what is known as disability indemnity. This entitles you to payment while you remain unable to work, with certain exceptions.28
It is impossible to say how much your payments will be and for how long you will be entitled to them without the specific facts of your injury and medical treatment. Generally speaking, there are four types of disability that apply to workers’ compensation:
- Temporary Partial Disability: Employee able to work with temporary limitations.29
- Temporary Total Disability: Employee temporarily unable to work at all.30
- Permanent Partial Disability: Employee able to work with permanent limitations.
- Permanent Total Disability: Employee permanently unable to work at all.
Payment is due 14 days after your employer has learned of your disability.31 These payments can last up to 104 weeks in a 5-year period in the case of a temporary disability32 and for the rest of your life if your disability becomes permanent and total.33
The Supplemental Job Displacement Benefit
The Supplemental Job Displacement Benefit (SJDB) is a voucher covering the expenses of education or training for a new job. SJDB is available for employees who:
- Suffer a permanent disability;
- Are not offered modified work from their employer; and
- Do not return to work within 60 days after their temporary disability ends; or
- Are seasonal employees, unable to return within 60 days because the season has ended and do not return the next season.34
These benefits are designed to help a permanently disabled employee find employment that accommodates their special needs by easing the financial burden of transition.
In the tragic event that a work-related injury result in death, the employee’s family is entitled to receive death benefits and reasonable burial expenses from the employer.35 A claim for these benefits must be made within 1 year of the death and 240 weeks from the injury.36
Penalties in Workers’ Compensation Cases
Sometimes an employer or insurer will act improperly during the workers’ compensation process. When this happens, the law provides penalties to punish the conduct and benefit the employee. Some types of improper employer conduct include, but are not limited to:
- Delaying payment of compensation;37
- Willfully failing to obtain insurance;38
- Willfully failing to guard against injury;39
- Discriminating against an injured employee.40
Protecting your rights, especially against an employer acting improperly, can be difficult. Recognizing violations, knowing what to look for, and proof can be overwhelming. Luckily, for some violations (delayed payment, for example), attorney’s fees will be covered.41
Having a knowledgeable attorney not only makes the process easier, but also increases your chances of winning. With the cost possibly being covered by your employer, it’s a no-brainer.
Do You Have a Good Workers’ Compensation Case?
Now that you have learned the basics of workers’ compensation, you may be wondering whether you have a decent claim or whether your employer or its insurer has acted improperly. In either case, you might be entitled to compensation.
Some factors lawyers consider are:
- Whether your injury fits the criteria discussed above,
- Whether your employer delayed your compensation,
- Whether treatment recommended by your primary treating physician was denied, and
- Whether you were discriminated against because of your injury.
- Lab. Code, § 3600, subd. (a)(1); Lab. Code, §§ 3300-3302; Lab. Code, §§ 3350-3368.
- Lab. Code, §3600, subd. (a)(2).
- Lab. Code, §3600, subd. (a)(3); see Maher v. WCAB (1988) 33 Cal.3d 729, 734 fn. 3.
- Lab. Code, § 3600, subd. (a)(4).
- Lab. Code, § 3600, subd. (a)(5).
- Lab. Code, § 3600, subd. (a)(6).
- Lab. Code, § 3600, subd. (a)(7).
- Lab. Code, § 3600, subd. (a)(8).
- Lab. Code, § 3600, subd. (a)(9).
- Lab. Code, § 3600, subd. (a)(10).
- Burnight v. Industrial Accident Commission (1960) 181 Cal.App.2d 816.
- Lab. Code, § 5400.
- Lab. Code, § 5401, subd. (a).
- Lab. Code, § 5401, subd. (c).
- Lab. Code, § 5402, subd. (b).
- Lab. Code, § 5402, subd. (c).
- Lab. Code, § 4600, subd. (a).
- See Lab. Code, §§ 4650-4657, 4661-4661.5.
- Lab. Code, §§ 4658.5-4658.6.
- Lab. Code, §§ 3600, 4701.
- Lab. Code, § 4620, subd. (a); Cal. Code Regs., tit. 8, § 10451.1, subd. (b).
- See, e.g., Lab. Code, §§ 132a, 3700.5, 4650, 4553-4554, 5814; see also Dept. of Corrections v. WCAB (1971) 5 Cal.3d 885, 889.
- Lab. Code, § 4600, subd. (a).
- Cano v. WCAB (2000) 81 Cal.4th 225.
- Lab. Code, § 4604.5, subd. (c)(1).
- Lab. Code, § 4061.5.
- Cal. Code Regs., tit. 8, § 9785, subd. (c); Cal. Code Regs., tit. 8, § 9785, subds. (a)(4), (d).
- Pacific Employers Ins. Co. v. IAC (Stroer) (1959) 52 Cal.2d. 417, 420; see Lab. Code, §4657. [measuring loss in wages due to disability as difference between injured employee’s average weekly earnings and earnings “which the injured worker will probably be able to earn during the disability”]. An employee who refuses reasonable alternative or modified work without giving a good reason may be estopped from claiming temporary disability benefits. (Vittone v WCAB (2001) 66 CCC 435.)
- Lab. Code, §4654.
- Lab. Code, §4653.
- Lab. Code, § 4650, subd. (a).
- Lab. Code, § 4656, subd. (c)(2).
- Lab. Code, § 4659, subd. (b).
- Lab. Code, § 4658.5, subd. (b); Cal. Code Regs., § 10133.56, subds. (a)–(b).
- Lab. Code, §§ 3600, 4701.
- Lab. Code, § 5406, subds. (a)-(b).
- Lab. Code, §§ 4650, 4661.5, 5814.
- Lab. Code, § 4554.
- Lab. Code, § 4553.
- Lab. Code, § 132a.
- Lab. Code, § 5814.5.