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Disability Benefits for Work Injuries
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If you are injured on the job, you may be entitled to Workers’ Compensation benefits, regardless of fault. Below, we’ve outlined the benefits that are potentially available. Please remember that each case is specific. It’s important to speak with an attorney regarding your own situation.
1. Medical care
2. Temporary Disability
3. Permanent Disability
4. Vocational rehabilitation (for injuries before 2004)
5. Death benefits
Legislation that went into effect during 2004 substantially changed Workers' Compensation benefits and procedures. References to "new law" describe these changes.
1. Medical care
You are entitled to reasonable medical care needed to cure or relieve the effects of a work-related injury or illness. The new law attempts to restrict the definition of what is "necessary and reasonable care." In appropriate cases, the Workers' Compensation Appeals Board (WCAB) can award lifetime medical care for a work-related medical condition. Medical care can include doctors, hospitals, chiropractors, nurses, medicine, braces, canes, hearing aids, as well as treatment found to be necessary and reasonable care ordered by a doctor. Under California's Workers' Compensation law, "doctor" includes physicians and surgeons, psychologists, optometrists, dentists, podiatrists, acupuncturists and chiropractic practitioners licensed by California state law. Workers' Comp also includes reimbursement for transportation to and from medical treatment and pharmacies.
If you file a claim on or after April 19, 2004, your employer must provide medical care within 24 hours of the filing of the claim and pay up to $10,000 in treatment for the alleged condition - even if they have not accepted the claim - until the claim is rejected. Beginning in 2005, the manner in which employers provide treatment to injured workers has changed.
Medical Provider Networks
Under the new law, if an employer sets up a Medical Provider Network (MPN) to treat injured employees, a worker may be treated only by a doctor in such a network unless they pre-designate a doctor. If no MPN is set up, an employee can still change treating doctors to a doctor of his or her choice after 30 days after giving notice of an injury, unless the employer has a Health Care Organization (see below). The employer must send out specific notices before requiring treatment within the MPN. If your employer advises that treatment within the MPN is required, you should consult with an attorney to see if such notices were sent and if the MPN is certified.
Health Care Organizations
An HCO is like an HMO for treatment of industrial injuries. Although certain requirements must be met, if your employer contracts with an HCO, you may be required to be treated by the employer's HCO for up to six months before you can change treating doctors - unless you have pre-designated a treating doctor. If your employer claims you are covered by an HCO, you should consult an attorney to see if the proper requirements have been met.
Pre-designating your doctor
You may advise your employer in writing before an injury that, if hurt on the job, you wish to be treated by your personal physician. The new law imposes additional restrictions on pre-designation. The doctor must agree to be the treating physician. It is a good idea for the doctor to sign the pre-designation form. He or she must be the employee's regular physician, with an existing medical record and history of care. Employees may not be able to pre-designate a physician if their employer does not provide group medical coverage. Employees should complete a pre-designation form and make two copies (one for their records and one for their doctor's files) stamped with the date they file it with their supervisor. Pre-designated physicians may refer employees to appropriate specialists and therapists or for other treatment. A pre-designation form is available here.
New limits on medical treatment
The new law caps chiropractic care and physical therapy to 24 visits each for injuries after Jan. 1, 2004, and occupational therapy is also limited to 24 visits for injuries after April 19, 2004. The Labor Code now defines "reasonable and necessary" treatment based on approved guidelines, such as the American College of Occupational Medicine (ACOM) practice guidelines.
The attorney's role in your medical care
An attorney can give you experienced guidance on your choices and availability of medical treatment and evaluation. Laws concerning rights for treatment and disability benefits are quite complex. It is now more important than ever to seek skilled legal advice to ensure that your rights are protected. Employees represented by an attorney have different rights than unrepresented workers. It is in your best interest to see an attorney before choosing a doctor from a State Panel to evaluate your disability. If you choose from a State Panel, your future Workers' Compensation rights and benefits may be adversely affected.
2. Temporary Disability
You are entitled to Temporary Disability (T.D.) benefits if you are unable to perform your job duties while recovering from a work-related injury or illness. Benefits begin on the fourth day you are absent from the job due to a work-related injury or illness. There is no compensation for the first three days unless you miss 14 days of work or are hospitalized overnight.
T.D. benefit rates are two-thirds of your average weekly salary, up to the legal maximum. The first payment is to be paid no later than 14 days after your employer is made aware of the injury and accepts liability. Additional payments must be made at least twice a month. These benefits are non-taxable.
For injuries before 2004, T.D. payments are made until you return to work, or until your condition reaches a point of maximum recovery, or becomes "Permanent and Stationary," with no time limit. T.D. benefits for injuries on or after Jan. 1, 2004, with very few exceptions, are no longer payable after two years from the date of the first payment.
3. Permanent Disability
If you suffered a work-related injury or illness before 2005 that resulted in permanent symptoms, loss of function, work restrictions, or a decreased ability to compete in the labor market, you may qualify for Permanent Disability benefits. Under the old system, these weekly payments were based on a person's loss of ability to compete in the open labor market.
The new law has radically changed how Permanent Disability (P.D.) benefits are calculated for injuries some injuries prior to Jan. 1, 2005, and all injuries after Jan. 1, 2005. Benefits for such claims are based on a book entitled American Medical Association Guidelines, 5th Edition (AMA Guides). The book purports to provide an "objective basis" for evaluating loss of overall body function. Disability caused by subjective symptoms (pain) without objective findings may no longer be compensated.
P.D. benefits for many disabilities have also been significantly reduced, although the new law also requires some modification of the AMA Guides rating by loss of earning considerations. The new guidelines may also apply to injuries before 2005 if a doctor did not declare the injured worker "permanent and stationary" prior to that date, or if the employee has not returned to work after a period of Temporary Disability before 2005.
The P.D. rating establishes the amount of the award and the length of time benefits will be paid. Employees may still be eligible to receive this benefit even after returning to work. These benefits are non-taxable.
When an employer has more than 50 employees, the new law allows for an increase in P.D. benefits by 15% if the injury happened on or after Jan. 1, 2005, and the injured worker was not offered a return to work. For all employers, benefits decrease by 15% for injured workers who are offered a return to work for 12 months. If terminated during those 12 months, the injured worker is entitled to his or her full P.D. award.
Employees must now disclose previous disabilities upon request, and employers are liable only for the portion of Permanent Disability caused by the workplace injury. Any prior Permanent Disability award is now presumed to exist at the time of a subsequent injury. Successive awards may never exceed 100% for multiple injuries to any one region of the body.
4. Vocational rehabilitation
Vocational rehabilitation may be available for injuries or illnesses that occurred before 2004. Rehabilitation has been abolished for injuries on or after Jan. 1, 2004, although you may be eligible for Supplemental Job Displacement benefits. These non-transferable vouchers - up to $10,000, depending on the level of Permanent Disability - may only be used for education-related training at state-approved schools.
5. Death benefits
If an employee dies on the job from a job-related injury, or from a heart attack, cancer, stroke or other disease found to be caused or aggravated by work, the surviving spouse, minor children or other dependents may be entitled to receive benefits. Dependents who are good-faith members of the household also may be eligible for benefits, even if not legally married. For example, the family of an employee with three or more dependents may be entitled to benefits of $160,000 or more. These benefits doubled in 2006.
If the job-related injury was not the main cause of the death, but contributed to the cause of death, a dependent spouse and children still may be entitled to full death benefits. Even survivors only partially dependent on support of the deceased worker may be eligible for this benefit. There is also an allowance for reimbursement of burial expenses.
A $250,000 benefit is now owed to the estate of safety officers without dependents who die from job-related injuries that occur on or after Jan. 1, 2003.
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