What Types of Benefits Are Available Through the California Workers’ Compensation Scheme?

If you’ve been hurt on the job in California, you or your loved ones may be eligible to receive several different types of workers’ compensation benefits, including medical care, disability payments, retraining, and death benefits. Workers’ compensation is a no-fault system, which means that unlike a lawsuit, you don’t have to prove that someone did something wrong in order to receive benefits.

However, the insurance companies that are supposed to pay claims often make it very difficult to receive benefits, so you may need to be prepared for a legal battle to recover the benefits you should be receiving through the system. Here we review the types of benefits that may apply in your situation, depending on the severity of your injuries and other issues.

What Medical Benefits Can You Receive?

If you were hurt in a workplace accident or are suffering from an occupational illness such as asbestosis, then one of the things you need first is quality medical care. The workers’ compensation scheme is designed to provide that at no cost to workers.

What is Covered by Medical Benefits?

Types of treatment that may be covered include:

• Emergency care
• Hospitalization and surgery
• Doctor visits
• Tests and images such as X-rays
• Prescription medication
• Physical therapy

In addition, medical equipment and assistive devices may also be provided through workers’ compensation.

When Does Treatment Become “Medically Necessary?”

Insurance companies may try to avoid paying medical costs by insisting that recommended care is not medically necessary and therefore not covered. Insurers use a Utilization Review process to determine whether they believe treatment is medically necessary. If they deny or delay treatment, you can use the Independent Medical Review process to get the decision reconsidered.

Can You Receive Money to Make Up for Wages Lost While You are Unable to Work?

Workers in California may be able to receive disability benefit payments to replace wages lost when they are unable to work or can only work at a reduced capacity. These wage replacement benefits can be provided in four ways:

• Temporary total disability benefits
• Temporary partial disability benefits
• Permanent disability benefits
• Permanent total disability benefits

Temporary Disability Benefits

If you are approved for temporary disability benefits, you can receive up to 2/3 of the pre-tax wages you were earning at the time you got hurt. However, there are statutory maximums in place, so the amount you receive may not be a full 2/3 of your usual wage.

Workers who cannot work at all receive total disability benefits. If your injury doesn’t completely prevent you from working but it limits the hours you can work or the tasks you can perform, you may receive partial disability benefits to make up some of the difference between your usual wages and what you are able to earn while injured.

Temporary disability benefits usually end when the employee can return to work or when the doctor determines the worker has reached their maximum expected level of improvement. At that point, the worker is evaluated to determine whether they qualify for permanent benefits.

Permanent Disability Benefits

When doctors report that you have reached maximum medical improvement, they evaluate your condition to see whether permanent injuries continue to impair work abilities. They consider your condition to be “permanent and stationary,” so they write up a report that is referred to as a P&S report. The report addresses:

• Medical problems including pain and limitations on movement
• An opinion regarding what percentage of your problems stem from the workplace injury and what percentage are due to other factors
• Restrictions on the types of job tasks you can do
• Medical care you are likely to need in the future
• Your ability to do the same work you did in the past

Information from the report and other sources are used to set a “rating” for your level of disability, and the higher the number, the greater your level of disability is said to be. If you are rated at a full 100, you would be likely to qualify to receive permanent total disability benefits. However, this is extremely rare. Most workers are assigned a rating between 1 and 99, reflecting some ability to continue working. Then wage benefit payments are calculated and paid out for a set number of weeks. Permanent total disability benefits are paid for the life of the worker.

What If You Can’t Return to Your Former Job?

The California workers’ compensation scheme provides supplemental job displacement benefits that offer opportunities for retraining or skill development for workers who can’t return to their former jobs because of a workplace injury or illness. If you qualify, you receive a voucher that can be used to pay for certain education or training-related expenses.

What are Workers’ Compensation Death Benefits?

If an employee dies because of an on-the-job injury or illness, then family members may be able to receive payments to replace the financial support they would have received from the injured worker. A relative must be a dependent of the deceased worker to receive death benefits. Spouses and minor children are legally presumed to be dependents, and other relatives may qualify if they can show they relied on the deceased worker for financial support at the time of the injury.

FAQs About Workers’ Compensation Benefits in California

Can I get medical treatment while my workers’ comp claim is still being evaluated?

Yes, California law requires workers’ comp insurance companies to authorize treatment for up to $10,000 while your claim is being investigated.

What happens if they want me to try returning to work but I’m not sure I’m ready?

Returning to work, even on a part-time basis, can reduce your benefits, so if you disagree with the medical evaluation, you might want to discuss your concerns with your doctor or request another medical evaluation. You can also ask your employer for light-duty job tasks that strictly adhere to the medical restrictions described by your doctor.

Can I sue my employer if I don’t get workers’ compensation benefits?

Lawsuits may be possible in some situations, such as if your employer failed to carry the required workers’ compensation insurance. Generally, the workers’ compensation scheme prevents workers from suing employers for injuries, but it may be possible to sue a third party responsible for your illness or injury.

Get Help Receiving the Full Benefits You’re Entitled to Under the Workers’ Compensation Scheme in California

Employers and their insurance companies often fight workers’ compensation claims vigorously, making it hard for injured workers to get the benefits they need. It can be very helpful to work with an experienced attorney right from the start of the process to get your claim on the best track toward recovery.

For a free consultation to learn more about how the Law Offices of Benjamin Arsenian could help you receive full benefits for your workers’ compensation claim, call us at 714-200-4000 or contact us online now.