The fact sheets provide answers to frequently asked questions about issues affecting your benefits. The guides will help you fill out forms you may need to get a problem with your claim resolved at the local DWC district office. How can I find out who provides workers' compensation coverage for my employer or another business in California?
In California all employers are required to either purchase a workers' compensation insurance policy from a licensed insurer authorized to write policies in California or become self insured. The DWC does not provide workers' compensation insurance for employers and does not maintain information about employers and their respective insurers. To find out which insurer provides workers' compensation insurance for a specific employer, visit the California Workers' Compensation Coverage website.
The roster of self-insured employers can be found on the Self Insurance Plans Web page. More information about workers' compensation can be found on the DWC's Web page for injured workers. I know that independent contractors aren't covered under workers' compensation.
How do I know if I really am an independent contractor? There is no set definition of this term. Labor law enforcement agencies and the courts look at several factors when deciding if someone is an employee or an independent contractor.
Some employers misclassify employees as an independent contractor to avoid workers' compensation and other payroll responsibilities. Just because an employer says you are an independent contractor and doesn't need to cover you under a workers' compensation policy, doesn't make it true. A true independent contractor has control over how their work is done. You probably are not an independent contractor when the person paying you:. What happens to an injured worker's personal information that is requested on various DWC forms?
Is it kept confidential? The division uses this information solely to administer its duties in workers' compensation claims. For example, if an injured worker provides their Social Security number in whole or in part , DWC will use it as an identifier to ensure that documents are matched to the correct workers' comp case.
Unless authorized by law to do so, DWC cannot disclose the residence addresses of injured workers or their Social Security number. Note that some case file information can be found by using the public information case search tool on the DWC's website.
What personal information can be found in a public information search? The search tool shows limited case data, such as an injured worker's name, case number, case status, court location, employer name, a description of events in the case, and associated dates.
It may list the parts of the body that were injured, but it does not include medical records or any case documents. The information provided in this search tool relates solely to cases in DWC's adjudication unit and is intended to help move cases through the court system efficiently. Any person requesting access to this information is required to identify themselves, state the reason for making the request and is instructed not to disclose the information to any person who is not entitled.
Injured workers should be aware that, once an Application for Adjudication of Claim is filed, case file information, including case documents, may be disclosed under the California Public Records Act.
Even in this circumstance, an injured worker's address and Social Security number are not revealed to the requestor by the DWC. What are my employer's responsibilities under workers' compensation laws? Can my employer take part of my check to pay for workers' compensation insurance? Workers' compensation insurance is part of the cost of doing business.
An employer cannot ask you to help pay for the insurance premium. Your employer must post the notice to employees poster in a conspicuous place at the work site. This poster provides you with information on workers' compensation coverage and where to get medical care for work injuries. What happens if my employer is uninsured and I'm hurt on the job?
If you have a work-related injury or illness and your employer is not insured, your employer is responsible for paying all bills related to your injury or illness. Workers' compensation benefits are only the exclusive remedy for injuries suffered on the job when your employer is properly insured. If your employer is illegally uninsured and you have a work-related injury or illness, you can file a civil action against your employer in addition to filing a workers' compensation claim.
The UEBTF is a special unit within the Division of Workers' Compensation that may pay benefits to injured workers who get hurt or ill while working for an illegally uninsured employer.
The UEBTF pursues reimbursement of expenditures from the responsible employer through all available avenues, including filing liens against their property.
Where can I report an employer for not carrying workers' compensation insurance? You may report an uninsured employer to the nearest office of the Division of Labor Standards Enforcement.
The offices are also listed in the state government section of the white pages of your local telephone directory under industrial relations, labor standards enforcement.
Doctors in California's workers' compensation system are required to provide evidence-based medical treatment. That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses.
Those treatments are laid out in a set of guidelines that provide details on which treatments are effective for certain injuries, as well as how often the treatment should be given frequency , the extent of the treatment intensity , and for how long duration , among other things. To comply with the evidence-based medical treatment requirement, the state of California has adopted a medical treatment utilization schedule MTUS.
The DWC has a committee that continuously evaluates new medical evidence about treatments and incorporates that evidence into its guidelines. They may. Treatment guidelines are considered correct even in cases that settled before the guidelines were added to workers' compensation law in Your claims administrator may continue to pay for medical care you're accustomed to for your injury. If your medical treatment has been denied you can request an expedited hearing before a workers' compensation administrative law judge to get the situation resolved.
The claims administrator hasn't accepted or denied my claim yet, but I need medical care for my injury now. What can I do? The claims administrator is required to authorize medical treatment within one working day after you file a claim form with your employer, even while your claim is being investigated. If the claims administrator does not authorize treatment right away, speak with your supervisor, someone else in management or the claims administrator about the law requiring immediate medical treatment.
Ask for treatment to be authorized now, while waiting for a decision on your claim. If your date of injury is in or later, you are limited to a total of 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits, unless the claims administrator authorizes additional visits or you have recently had surgery and need postsurgical physical medicine. For as long as it's medically necessary.
However, some treatments are limited by law and the medical treatment you receive must be evidence-based. The MTUS lays out treatments scientifically proven to cure or relieve work-related injuries and illnesses.
It also deals with how often the treatment is given and for how long, among other things. If the treatment your doctor wants to provide goes beyond what is recommended by the MTUS, your doctor must use other evidence to show the treatment is necessary and will be effective.
Additionally, your doctor's treatment plan may be reviewed by a third party hired by the claims administrator. This process is called utilization review UR. All claims administrators are required by law to have a UR program. They use UR to decide whether or not to approve treatment recommended by your doctor.
UR is the program claims administrators use to make sure the treatment you receive is medically necessary. All claims administrators are required by law to have a utilization review program.
This program will be used to decide whether or not to approve medical treatment recommended by your doctor. The state has rules about how UR must be conducted. If you believe the UR company reviewing your doctor's plan is not following those rules you can file a complaint with the DWC.
Find more information about utilization review in the factsheet. If my doctor's request for treatment is not approved, what can I do? There are specific timelines you must meet or you will lose important rights. As of July 1, , medical treatment disputes for all dates of injury will be resolved by physicians through the process of independent medical review IMR. If UR denies or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR.
Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process. What happens if I was treated and the claims administrator won't pay for it?
Do I have to pay? You most likely will not have to pay. This is a problem your doctor and the claims administrator need to work out. A medical provider network MPN is a group of health care providers set up by your employer's insurance company and approved by DWC's administrative director to treat workers injured on the job.
Each MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. If your employer is in an MPN your workers' compensation medical needs will be taken care of by doctors in the network unless you were eligible to predesignate your personal doctor and did so before your injury happened. A health care organization HCO is an organization certified by the DWC to provide managed medical care to injured workers.
Your primary treating physician PTP is the physician with the overall responsibility for treatment of your injury or illness. Generally your employer selects the PTP you will see for the first 30 days, however, in specified conditions, you may be treated by your predesignated physician or medical group. If a physician says you still need treatment after 30 days, you may be able to switch to the physician of your choice.
This is a process you can use to tell your employer you want your personal physician to treat you for a work injury. You can predesignate your personal doctor of medicine M.
The DWC has a form for predesignating a personal physician on the forms page of its website. I would like to be treated by my personal chiropractor or acupuncturist. How does that work? If your employer or your employer's insurer does not have a MPN, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness.
There is a form you can use called the notice of personal chiropractor or personal acupuncturist. After your claims administrator has initiated your treatment with another doctor during the first 30 day period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. If you were injured on or after Jan. Once you have received 24 chiropractic visits if you still require medical treatment, you will have to select a new physician who is not a chiropractor.
The 24 visit cap does not apply to injuries that occurred before Jan. Also, the cap does not apply if your employer authorizes additional visits in writing. Additionally, the cap does not apply to visits for certain postsurgical physical medicine and rehabilitation services.
You can also ask for a 2nd and 3rd opinion from different MPN doctors. If you still disagree, you can have an IMR to resolve the dispute. See the information on your MPN provided by your employer. What if I disagree with the MPN doctor's opinion regarding my ability to return to work, whether I'm permanently disabled, or if I need future medical treatment? If you disagree with your MPN doctor on any issues other than diagnosis or treatment, you must request a qualified medical examiner QME.
You, your treating doctor, your employer and your attorney if you have one should review your job description and discuss the changes needed in your job. For example, your employer might give you a reduced work schedule or have you spend less time on certain tasks. If you disagree with your treating doctor, you must promptly write to the claims administrator about the disagreement or you may lose important rights. I don't have an attorney and I have a disagreement about what my doctor report says about my injury.
What should I do? You may request a medical evaluation with a physician called a qualified medical evaluator or QME:. If you are represented, your attorney and the claims administrator may agree on a doctor to examine you.
Ask your treating physician to help if you don't know what kind of doctor should look at your injury. QME lists are randomly selected and do not represent your employer or the insurance company. You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked and the date of your appointment.
If you don't do this within 10 days, the insurance company will have the right to pick the doctor you'll see and make the appointment. What if the claims administrator has sent me a QME panel request form?
You might need to see a QME if the insurance company disagrees with something in your claim. In that case, the insurance company will give you the form to request a QME. If you don't send the form within 10 days of receiving it, the insurance company will have the right to request the QME list and select the kind of doctor you'll see. You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked, and the date of your appointment.
A QME must be a physician licensed to practice in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists, dentists, optometrists, podiatrists or acupuncturists. If you have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a QME. The doctor they agree on is called an agreed medical evaluator AME. If they cannot agree, they must ask for a QME panel list. There could be other disagreements over medical issues in your claim.
A doctor has to address those disagreements. You might disagree over:. Yes, but you have a limited amount of time to decide if you agree with the QME's report or if you need more information. When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options.
If you don't have an attorney, and you believe there are factual errors in the QME's report, you can request factual correction of the report by making a request within 30 days of receipt of the report.
Upon receipt of a request for factual correction of the report, the QME is required to file a supplemental report with the DEU and state whether factual correction is necessary to ensure accuracy of the report and, if so, whether the factual corrections change the opinions of the QME stated in the comprehensive medical report.
If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement. Temporary disability TD benefits are payments you get if you lose wages because your injury prevents you from doing your usual job while recovering. There are two types of TD benefits. If you cannot work at all while recovering, you receive temporary total disability TTD benefits.
If you can't work your full schedule while recovering, you receive temporary partial disability benefit TPD payments. As a general rule, TD pays two-thirds of the gross pre-tax wages you lose while you are recovering from a job injury. However, you cannot receive more than the maximum weekly amount set by law. Your wages are figured out by using all forms of income you receive from work: wages, food, lodging, tips, commissions, overtime and bonuses. Wages can also include earnings from work you did at other jobs at the time you were injured.
Give proof of these earnings to the claims administrator. The claims administrator will consider all forms of income when calculating your TD benefits.
These are paid to the surviving children, spouse, or dependents of the person that passed away due to work-related injury or illness. Death benefits paid will vary by the number of dependents and other factors. Each benefit type is calculated differently. For medical care benefits, the injury victim would be entitled to the full amount of care that is reasonably required to cure or relieve the effects of the illness or injury. There should be no out-of-pocket expenses or deductibles charged to the employee.
Each treatment is individual, and workers comp should cover anything that is determined to be medically necessary. This is even if your claim ends up being denied. Temporary and permanent disability benefits are not as direct to calculate. This is because it must calculate the time off or the inability to work. Temporary benefits are intended to replace some of your missed wages or income.
The minimum and maximum temporary disability payments are determined by the state weekly wage averages. Skip to main content. Contact Us Careers. Search this site. Business Insurance. Small Business.
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