16 Steps of a Workers Compensation Lawsuit in California

California employers are required to provide workers’ compensation insurance coverage for their employees to protect them when they are injured while working on the job or contract work-related illnesses or diseases. Injured employees are not required to prove that their employers were negligent to recover benefits. Under the workers’ compensation system, employees generally can’t file negligence lawsuits against their employers unless an exception applies. Filing a claim for workers’ compensation and collecting benefits when you have been injured is not always a straightforward process. In some cases, an employer or insurance carrier will dispute an injured employee’s claim for benefits. Here are 16 steps of a workers compensation lawsuit that you should know from a workers compensation lawyer in Santa Ana at the Fontes Law Group.

En español: 16 pasos de una demanda de compensación laboral en California

1. You are Injured or Learn That Your Medical Condition Was Caused By Your Job

The workers’ compensation claims process begins when you are injured at work or learn that your medical condition was caused by your job and work conditions. your injury might be an immediate one caused by a workplace accident or an injury that develops over time such as a repetitive stress injury. It might also be an occupational illness that was caused by your working conditions, including hearing loss or something else. If your injury happened because of your job, you have a viable claim for workers’ compensation. If you are injured at work and require emergency medical care, your employer should help you to get it.

2. Notify Your Employer

Under Cal. Lab. Code § 5400, you must notify your employer about your work-related injury in writing within 30 days. However, under Cal. Lab. Code § 5402, if you tell your supervisor about your injury or if your employer learns about it through another source, it is equivalent to providing the written notice. Under Cal. Lab. Code § 5403, failing to provide the required notice to your employer will not be a bar to your recovery unless the employer was harmed in some way or misled. However, it is best to notify your employer immediately about your injury in writing to protect your claim and to provide your employer with the opportunity to investigate it.

3. Complete the Claim Form

Once your employer learns about your injury, it should give you a claim form within one day. On this form, you will list important details about the incident, including the following information:

• Date and time when your injury occurred
• Address and location of where your injury happened
• Details about your injury and where on your body it occurred
• Social Security number

You will sign this form after you have completed the details. Make sure you are truthful on your claim form because knowingly making false statements on it to try to obtain workers’ compensation benefits is a felony in California.

Once you complete and sign the form, you will give it to your employer. Your employer will then need to complete the employer section, including the employer’s name, the date the employer learned about your injury, the date you received the claim form, the date you returned the form to your employer, the insurance company’s name and address, and the employer’s insurance policy number. Your employer will then sign this form.

4. Notices From the Insurer

Your employer will submit the completed claim form to its workers’ compensation insurance carrier. The insurance company will then send you notices about your rights and the workers’ compensation claims process. The notices will explain the procedure of beginning the process, an explanation of the different benefits that might be available, what will happen to your claim after filing, where you can go to obtain medical care, the function of your primary doctor, and your right to choose and change the treating doctor. The notices will also explain how you can get medical care while your claim is pending and explain the protection against discrimination you enjoy. Finally, it will explain that you have the right to disagree with decisions that might be made about your claim.

5. Selection of the Primary Treating Physician

If you chose a doctor in writing before you were injured, the doctor you pre-selected can serve as your primary treating physician. If you didn’t, you will have to choose a doctor from within your employer’s provider network, or your employer can choose a doctor for you.

6. Receive Initial Care

While your claim is being reviewed, the claims administrator at your employer’s insurance carrier will authorize up to $10,000 of initial care. This is in addition to any emergency medical care you had to receive.

7. Investigation of Your Claim

Once the insurer has received your claim form, it will have 90 days to investigate your claim and either accept or deny it. If the insurer has not decided within 90 days, your claim will be deemed accepted. During the investigation of your claim, the insurance company might depose you, subpoena your medical and employment records, and send you to a doctor for a medical evaluation.

8. Waiting for the Decision

After your claim is reviewed, the claims administrator will issue a decision to accept or deny your claim. If your claim is accepted, your workers’ compensation benefits will cover any additional medical care you need for your work-related injury. If your claim is denied, it means that the claims administrator doesn’t believe you are eligible for benefits. In this case, you will need to either appeal the decision or negotiate with the company to try to resolve your disagreement. If your claim is denied, it is best to get help from a qualified Riverside workers compensation lawyer because of the complexity of the process.

9. Continue Receiving Medical Care

If your claim is accepted, you will need to continue your medical care. Your doctor will recommend treatment to facilitate your recovery, and your employer will pay the costs. Your doctor will also send reports to the claims administrator about your ability to return to your job.

10. Determination of Disability Benefits Eligibility

The claims administrator will review your doctor’s reports to determine whether you are eligible for disability benefits either temporarily or permanently. These benefits replace a portion of your income while you are unable to work. If you can’t work for more than three days, you can receive temporary benefits. You won’t receive permanent disability benefits unless your doctor reports that you have reached your maximum medical improvement but are still unable to return to work.

11. Notice of Denial

If the insurer denies your claim, you will receive a notice in the mail. This notice will include information about why the company denied your claim. If you plan to appeal, you must do so within one year of the date of your denial notice under Cal. Lab. Code § 5405. Bring your notice of denial letter to your workers comp lawyer at the Fontes Law Group.

12. Utilization Review

If you have a dispute with the insurance insurer about your treatment, you might undergo a utilization review. This process involves the insurance carrier asking an independent doctor to review your proposed treatment plan. If you still have a dispute about a portion of your claim, your treatment, your injury, your disability benefits, or another aspect of your claim, you will need to bring the issue before a judge.

13. Application for Adjudication of Claim

To resolve a dispute with the insurer about your workers’ compensation claim, you will need to apply for adjudication of the claim with the Appeals Board. When you file your application, you will be given a case number.

14. Declaration of Readiness to Proceed

You will file a declaration of readiness to proceed to request a hearing. In this document, you will describe the issue that is the subject of the dispute between you and the insurer. You will then be given a notice of hearing that will tell you when you will appear and which administrative law judge will hear your case.

15. Pursuing a Settlement

You can try to resolve your workers’ compensation claim through a settlement or wait for the judge to issue a decision following the hearing. If you settle your case, you can either settle it for a flat sum to cover your future medical care or have the insurance company continue to pay for your treatment as it occurs. In either case, a judge must approve your settlement agreement.

In a stipulation with a request for an award, you and the insurer will agree on your disability benefits. The insurer will then continue to pay for your future medical care for your injury. In a compromise and release agreement, you will be paid a lump sum within 30 days of when the judge approves the agreement, and your case will be closed. If you need medical care in the future, it will be your responsibility.

16. Hearing

If you don’t resolve your dispute through a settlement, your case will go to a hearing before the assigned administrative law judge. You will likely be called to testify about your injury. Your attorney can help you to prepare for your hearing. After the hearing, the court will issue its decision about your claim. If the decision is unfavorable, you can file an appeal called a petition for reconsideration. A workers’ compensation appeal can take several years.

Talk to an Experienced Workers Comp Attorney

The workers’ compensation system in California is very complex and involves numerous steps. Insurers often aggressively defend against these claims to avoid paying injured employees or minimize how much they might have to pay. You should work with an experienced workers’ compensation lawyer at the Fontes Law Group instead of trying to handle your dispute with your employer’s insurance carrier on your own. We understand all of the processes involved and can guide you throughout your case. Contact us today to schedule a free consultation to learn more about your rights and legal options.