Initiating a Workers’ Compensation Case

Workers’ Compensation law like most other areas of law is complicated. However, when you have been injured or developed an illness at work, simplicity would be helpful in an otherwise stressful situation. Unfortunately, no legal discipline is user friendly. There are so many trappings, but one way to avoid the pitfalls is to know the basics. Here is some general information as how to navigate the initial processing of a claim.   

1. Reporting your injury:
   1. Report your injury or illness to your supervisor. Report it as soon as possible. The injury or illness must be reported within 30 days of learning of the illness or injury. Failing to do so may result in you losing your right to receive workers’ compensation benefits. (Labor Code Section 5400).
      1. Note: You can obtain emergency medical treatment.
      2. Note: It is best to report your injury or illness in writing, when possible.  Written notice must include your name, the time and place of the claimed injury, and the nature of your injury.  
2. File a claim. The claim form must be mailed or given to you by your employer within one working day of learning of your injury.  
   1. Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility: https://www.dir.ca.gov/dwc/DWCForm1.pdf 
      1. Only complete the employee section. Your employer will complete the employer section. 
      2. Keep a copy for yourself.  
      3. Follow instructions as to how to return the form to your employer.  
3. What Happens after you filed a claim:  
   1. Your employer will forward the completed claim form to their workers’ compensation insurance carrier. The insurance company will initiate an investigation. The insurance company has 14 days to provide you an update on the status of your claim. They will also provide general information about your rights, the procedures following the submission of your claim, and where you can receive treatment. If you do not hear from them, you may call them for an update.  
      1. Note: If your employer does not deny the claim within 90 days, your injury is presumed covered. (Labor Code Section 5402).  
   2. Your employer must authorize appropriate medical treatment within one day of filing the claim form. While the claim is investigated you may receive up to $10,000 in medical treatment.  
   3. Emergency treatment must be made available right away.  
4. Potential Outcomes: 
   1. Your claim is accepted: Certain benefits are triggered such as medical treatment and disability benefits. 
   2. Your claim is denied: This means the claims adjustor does not believe your injury or illness is covered by workers’ compensation. If you disagree with this decision, you have a right to challenge this decision. However, there are deadlines, and some are short. 
      1. Note: There are several procedural steps that must be completed before your case is heard before a Workers’ Compensation Administrative Law Judge (ALJ).  
   3. Your claim is accepted, but there is a disagreement about treatment or injury: You may request an evaluation by a qualified medical evaluation (QME).  
5. Returning to Work: This will be assessed by your primary treating physician, employer, claims adjustor, and your attorney, if you have one. Once you return to work, your work may be modified if you are no longer able to perform at the same level as before the injury and/or illness.  
6. Resolving your case: All settlements must be reviewed by a Workers’ Compensation Administrative Law Judge.  
   1. Stipulations with Request for Awards (Stips): This includes an agreement on the amount of temporary or permanent disability payments you will receive. It also includes an agreement regarding medical treatment.  
   2. Compromise and Release (C&R): This includes a one-time payment to resolve your claim. It is important to note that if the agreed amount includes medical care, future medical care will be your responsibility.  
   3. A judicial order is rendered: If an out of court settlement cannot be reached, your case will be heard by an Administrative Law Judge and an order will be issued.  

Workers’ Compensation law is very procedure driven so it is important to ensure all deadlines are met. It is also important to remember that workers’ compensation cases are heard by Workers’ Compensation Appeals Board, which is different than superior court. The issues in dispute are whether your injury or illness arose out of or in the course of employment and the extent of your injury/illness.  Types of injuries include specific injury (e.g., one fall), cumulative trauma (e.g., continual motions that lead to injury, such as carpal tunnel); injuries may be physical and/or psychological.  

The California Department of Industrial Relations is a good place to start: https://www.dir.ca.gov/. The Department of Industrial Relations also has an information and assistance unit, which provides information and assistance to interested parties, including employees, concerning rights, benefits, and obligations under the California workers’ compensation laws: https://www.dir.ca.gov/dwc/IandA.html.