A Basic Guide to Filing Workers’ Compensation Claim in California

All employers in California are required to carry workers’ compensation insurance. Employers with no workers’ comp insurance policy may face criminal and civil penalties. When you file a workers’ comp claim, you have to deal with your employer’s workers’ comp insurer. If there is a dispute regarding any aspect of your claim, the Workers’ Compensation Appeals Board will resolve the disagreement. Dealing with workplace injuries or illnesses can be stressful and confusing. Read on to learn how and when to file a workers’ compensation claim in California.

Steps to Filing a Claim

Knowing California’s workers’ compensation process can help you access the medical care and benefits you deserve. Workers’ compensation insurance provides benefits if you suffer from a work-related injury or illness. However, to avail of the benefits, you’re required to file your claim on time. The process of filing a claim entails the following steps:

  • Reporting the injury
  • Filing a claim with the employer
  • Filing for adjudication of your claim with WCAB (Workers’ Compensation Appeals Board)

When the Clock Starts Ticking: Date of Injury

Generally, there are two types of workplace injuries. These include specific injury and cumulative trauma. Specific injuries result from one incident that causes you to seek medical treatment or miss work, like falling off a ladder or hurting your back as you lift a heavy load. Conversely, cumulative trauma refers to physical or mental injuries that occur over time. The deadline for reporting the injury starts on the day you’re injured. With specific injuries, the date of reporting the injury is clear. However, with cumulative trauma injuries or occupational diseases, such as lung disease caused by exposure to harmful chemicals, the date of reporting can be unclear. In such situations, you should file your claim when the following happens:

  • When you first see a doctor or miss work due to illness or injury
  • When you know that the illness or injury is linked to your work – usually because your doctor has explained it to you

How to Report an Injury at Work

If you’re injured at work, you should immediately seek medical treatment. In case the injury requires emergency care, you can seek medical care anywhere. Otherwise, you can choose a doctor from your employer’s MPN (Medical Provider Network). Make sure that you inform the treating doctor that your illness or injury is work-related. You should also report the illness or injury to your employer as soon as possible. If you fail to give written notice to your employer within 30 days, you can lose your claim for workers’ comp benefits. However, there are exceptions, like when your employer is already aware of the injury.

Filing a Workers’ Comp Claim

Once you’ve reported the injury or illness, your employer should provide you with a claim form – Form DWC-1 – and information on your eligibility for benefits and your rights. Your employer is also required to give you information on what you need to do to get your benefits as well as other details about the claim process.

If you don’t get a DWC-1 from the employer, you can get it online from California Workers’ Compensation site. You should then fill out the employee’s part of the form. Ensure that you list all your injuries. Once you’re done, you should either give the Form DWC-1 to the employer in person or send it by certified or first-class mail.

After the Claim: The Insurance Company’s Response

After you’ve presented the claim form, the employer’s insurance company is required to pay for your medical treatment while it’s reviewing the validity of your claim. While your employer reviews your claim, the insurance company is liable for up to $10,000 of your medical expenses. Generally, if the insurance company doesn’t deny a claim in 90 days, the claim is considered approved. If you’re forced to miss work due to a workplace illness or injury, the insurer should start paying you temporary disability benefits within 14 days after it’s been notified of your temporary disability.

Application for Adjudication of Claim

Insurance companies often undertake a utilization review or med-legal examination. During the review, an independent doctor reviews the proposed treatment plan. You may disagree with the insurer about some aspects of your claim, including the nature of the illness or injury, your disability, your medical treatment, or any other element of your case.

To resolve any disagreement, you need to file your Application for Adjudication of Claim with the Appeals Board. Once you’ve applied, you should file a Declaration of Readiness to Proceed form, which allows you to ask for a hearing. You will then get a Notice of Hearing, which will inform you about the judge who will hear the case and when to appear. Generally, you’re required to file your Application for Adjudication form within a year after:

  • The date of illness or injury
  • The last day you received medical benefits
  • The day when the workers’ compensation benefits end

When You Miss the Deadlines

If you fail to make your claim or your application for adjudication in time, you should consult a workers’ compensation attorney. The law regarding workers’ compensation is complex, and you may be excused for failing to meet a deadline under certain circumstances. A lawyer can also help you appeal in case your claim is denied for any reason.

Contact CF&P Insurance Brokers

If you need a workers’ compensation policy that will adequately protect you and your employees, contact our workers’ comp experts at CF&P Insurance Brokers. As an independent insurance agency, we will help you get customized and cost-effective workers’ compensation insurance. Call us today to learn more!

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