1. Your heath plan and your workers’ compensation benefits are not the same thing. Your personal health plan, if any, has
nothing to do with your workers’ compensation benefits. These are separate and distinct insurance coverages.
2. Workers’ Compensation is a no fault system. Regardless of fault, you are entitled to benefits if you have a work
related injury. There are always exceptions, but for the most part, if you were hurt at work you are entitled to receive
workers’ compensation benefits.
3. There are specific predetermined and defined benefits. The benefits you are entitled to are predetermined and
fixed. They include; medical treatment, vocational rehabilitation (depending on date of injury), total temporary disability, permanent disability and
death benefits.
4. The California Workers’ Compensation system is very complex. There are thousands of rules and regulations that
govern how the system works. Like our legal system, if you don’t know the rules, you are at a significant disadvantage,
and as the injured worker you have the most to lose or gain. These rules are outlined in the California Labor Code, which can be
viewed at www.leginfo.ca.gov. If you
are not familiar with the workers’ compensation system, you will want to work with a doctor that you trust who will look
out for your medical interests. It may also be advantageous to you to retain the services of an attorney who specializes
in this area of law.
5. Learn your rights. Nobody thinks that they are going to get hurt at work, yet in California alone, over 700,000
workers file for Workers’ Compensation (WC) every year. There are many others workers who get injured but never file a
claim. Tens of thousands of injured workers will end up with some level of disability and many require long-term, even
lifetime care. If you have been hurt at work, learn as much as you can. An excellent resource is the Internet.
6. Document everything and get copies of your records. In the Workers’ Compensation system, as in the legal system,
“If it wasn’t written down, it didn’t happen.” If you have a claim, you should start a file and track everything regarding
your case. Keep a log of all your conversations with adjusters, lawyers, and doctors, and send them follow-up letters
outlining the important issues. Track your benefits to ensure that you are receiving appropriate coverage. If your claim
ends up in the Workers’ Compensation Appeals Boards, (WCAB, the WC court), these records support you in your claim. You
will also want to carefully review any reports written regarding your injury, especially if the insurance company sends
you out for an evaluation. These reports will have a major impact on your claim, so you want to verify that the
information accurately reflects your case.
7. Your employer’s medical provider may not be the best place for treatment. Usually injured workers are sent for
treatment to medical facilities contracted by the insurance company. These medical facilities do not always have the
patient’s best interest in mind. Their goal is to contain costs and limit benefits and if they do a good job, their
contract will be renewed for another year. If not, they could lose that contract. Also, more employers are joining a type
of HMO called an MCO (Managed Care Organization). The goal of the MCO is much like that of an HMO - to contain costs and
limit benefits - however the MCO may control your care for up to one year! There are ways to select your own doctor for
treatment or change to a new treating doctor, but this may not be possible if you have joined the MCO.
8. The insurance company is not your friend. Often, after an employee has filed a claim for a work injury,
the claims adjuster is the only contact and advisor for the employee. This is like asking the coach of the other team for
advice on how to win against them. The job of the adjuster is to control costs, limit benefits and most importantly close
claims. Every open claim is a liability to the insurance company. The less benefits you receive, the greater the profit
for the insurance company. If you rely solely on the advice of your claims adjuster, it is likely that you will not be
receiving all of your benefits. Remember, it is your responsibility to make sure all your benefits are received, not the
insurance company who has to pay for them.
9. Under the present system, applicants' attorneys (attorneys for injured workers) are paid based on your disability.
In the Workers’ Compensation system, the attorney that represents an injured worker is paid based on a percentage of your
disability. It is often difficult to get representation if your injury results in minor or no disability. The insurance
companies know this and often deny valid claims, knowing the injured worker will not be able to secure the services of an
attorney. I recommend getting an attorney if you can, otherwise you are left at a disadvantage. If not, find a doctor who
works with applicant attorneys and knows the system.
10. Find a doctor that specializes in workers’ compensation. The California workers’ compensation system is
medically driven. This means that the doctors who treat and/or evaluate you will have a major impact on your case. If you
do not have an attorney, then the doctor who treats you will guide you through the system. If that doctor or medical
facility has a contract with the insurance company, they may not be inclined to provide you with or inform you of all your
benefits. If your doctor does not regularly treat injured worker’s, they may not be aware of all the laws, and will
therefore be unable to guide you through the workers’ compensation system correctly.
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