California Workers' Compensation Claims: Eligibility, Filing and Appeals
The California workers’ compensation program, like all other states’ workers’ comp systems, is regulated and operated by the state, not the federal government. This article gives you a clear overview of how the workers' comp laws work in California.
Workers' Comp Basics in California
In a nutshell, California employers must provide workers’ compensation benefits to employees by paying for workers’ compensation insurance from one of the many licensed insurers in the state, or from the State Compensation Insurance Fund (SCIF). All employers must purchase workers’ compensation insurance, regardless of the number of employees. When a worker suffers a work-related accident or becomes ill due to conditions on the job, the insurance company pays for the employee’s medical treatment, lost wages, and possibly compensation for a permanent impairment.
If a worker is injured and the employer was not properly insured, California’s Uninsured Employer’s Benefit Trust Fund (UEBTF) will step into the place of the insurance company to pay worker’s compensation insurance benefits. The UEBTF will then attempt to recover the money from the illegally uninsured employer.
Common Work-Related Injuries
The most common workers’ comp injuries in California are from car (or truck) accidents, falls, and lifting or moving objects. Almost all injuries and illnesses arising at work and related to the job are eligible for workers’ compensation benefits. This includes injuries caused by a one-time accident, cumulative injuries (injuries caused by doing the same motion over and over), and illnesses arising out of the job environment or work tasks. For information on injuries that happen off the jobsite and injuries that may have been the employee’s fault, see our article on which particular injuries and workers are covered by workers’ comp.
How to File a California Workers Compensation Claim
You should notify your employer as soon as you are injured or know that a work-related illness has developed. Unless you have a medical emergency, do this before seeking medical treatment, as your employer may refer you to a physician who is part of its medical provider network.
After you have obtained treatment, fill out DWC (Division of Workers’ Compensation) Form 1 and give it to your employer, who will in turn give it to its workers’ compensation insurance company. You will also need to file an Application for Adjudication of Claim within one year of your injury to officially file your worker’s comp claim.
There are several other forms you need to file with the Application for Adjudication of Claim—for more information, see our article on filing a worker’s comp claim in California (this article also covers how and when the insurance company must reply to your claim).
Collecting Workers' Compensation Benefits in California
California workers’ compensation insurance pays for all medical expenses related to the injury, as long as the medical expenses are authorized. At least at first, you may have to select a doctor within the medical provider network.
Temporary disability benefits are also available if you are unable to work for a period of time. Temporary disability pays two-thirds of your average weekly wage while you are temporarily disabled, up to a weekly maximum. The weekly maximum was $987 for 2010 and 2011. There may be up to a 90-day delay in your first payment while your claim is pending approval.
If your ability to work has been permanently impaired, partially or totally, you will also be eligible for permanent disability benefits. Permanent disability payments are based on the percentage of the impairment you suffered as a result of the work-related injury. Workers' compensation benefits are not taxable.
For more information on workers’ compensation benefits and payments, see our article on how workers’ comp payments are calculated in California.
Workers' Compensation Claim Denials
Your employer’s insurance company might deny your claim if it believes that:
- there is insufficient evidence of an injury
- your injury isn’t work-related
- your injury is due to another job
- you don’t need medical treatment, or
- you can return to work.
Appealing a California Workers' Compensation Denial
If you disagree with your employer or insurer about a benefits decision, including the denial of your claim, you can file a Declaration of Readiness to Proceed with the Worker’ Compensation Appeals Board (WCAB). You must also serve this form on your employer’s insurance company and include a proof of service form. The Appeals Board will hold a hearing and make a determination on your claim. For further information, see the article on appealing a denial of a California workers’ comp claim.
California Workers' Compensation Appeals Board Locations
San Diego office:
7575 Metropolitan Dr., Ste. 202
San Diego, CA 92108