Wheeler & Beaton - A Professional Law Corporation

Question: What is Workers' Compensation?
Answer: Workers' Compensation is a "no fault" insurance program in California which partially covers an injured worker's losses due to work related injuries or diseases.
Question: Why do so many people tell me Workers' Compensation cases take such a long time to resolve?
Answer: Most cases can not settle until the treating doctor or doctors have decided that the work injury has reached a point of maximum medical improvement, otherwise known to be the permanent and stationary point. Workers Compensation Judges will often refuse to approve a settlement until they have been assured that the doctors have reached that conclusion. In a case with multiple injuries, it may take months or even years before the injured worker has received full and appropriate treatment.
Question: Is it true the insurance company can take up to 90 days from the time a claim of injury is made to decide whether or not to admit or deny liability?
Answer: By current state law the employer and it's insurance carrier have up to 90 days from the date that the injury is reported, to decide whether to admit or deny responsibility for treatment and weekly payment. When such delays occur, the injured workers attorney, if he is represented, cannot arrange for medical consultations until the 90 days have passed.
Question: Is it important to select my own primary treating physician?
Answer: In certain circumstances the opinion of your primary treating physician is presumed to be correct - as to the level of your permanent disability and the type of care you are to receive in the future. Thus, any injured worker should choose to treat with a physician he or she believes to be both caring and competent. A favorable opinion from the treating physician, helps to speed the final result in most cases. Most injured works can select their own treating doctor, not simply the one to which the employer or the insurance company refer's them, anytime more than 30 days after the date of injury. However, you will need to request your particular insurance carrier's MPN list of physicians from which to choose.
Question: How do I select my primary treating physician?
Answer: Start by contacting a Doctor of your choice. Then, satisfy yourself the Doctor is both available and willing to treat your condition. Be sure to ask them to let you know if they have problems getting approval. If you have an attorney, have your attorney demand the change of treating doctor in writing.
Question: What if the Workers' Compensation carrier refuses or delays my treatment?
Answer: In most situations, simple written communication and clarification can help get to the bottom of authorization issues. Make sure your primary treating physician has put his request (either for referral or a particular type of service) in writing and that a copy of any such request is sent to the attention of the claims adjuster and/or your attorney. Once notification to the carrier has been documented, you may have grounds to request a hearing before the Appeals Board, along with a request for a penalty if the delay is unreasonable, but only if all of the above has been satisfied.
Question: Should I talk to claims adjusters and/or private investigators if contacted?
Answer: If represented by an attorney, you should not converse with either the claims adjuster, their investigators or attorneys. To do so may cause a potential compromise of your case.
Question: How much will I get when my case is Settled?
Answer: There is no way to give an accurate advance estimate of a Workers Compensation settlement. The amount you will receive depends on may factors, including the disability level assigned by the evaluating doctors, the insurance carrier anticipation of your likely future medical needs and your decision whether to except weekly payment with a guarantee of future medical care or, in the alternative, to give up the weekly payments and medical care in exchange for a lump sum settlement. Each case is different. You should never presume you know the value of a settlement offer based upon another injured workers result.
Question: Do I get a lump sum when my case is resolved?
Answer: Lump sum settlements in Workers' Compensation, known as a "Compromise and Release" Settlement under California Law, are typically available only where the injured worker gives up his right to life-time medical care. Also, both parties must agree to such a settlement. The Judge cannot order the Insurance Company to pay you a lump sum.
Question: What is an award for Medical Care?

Answer: A Workers' Compensation Judge can award lifetime medical care for a part of the body injured in a specific incident at work or aggravated by wear and tear on a job over a period of time. All such awards are subject to the prevision that the care must be considered "reasonable and necessary" . That phrase gives the insurance carrier the right to question any recommendation by your treating doctor. You may have to take your case back to a Workers Compensation Judge to enforce the award if the insurance carrier questions it at a later date.

Question: How much TTD will I get?
Answer: New laws provide for 2 years of Temporary Total Disability for an injury occurring on or after 1/1/2004.
Question: Should I apply for SDI?
Answer: If you are not receiving Workers' Compensation benefits, you should apply for SDI (State Disability Insurance). You may be denied, but you will lose the right to apply if you do not do so.
Question: What is UR?
Answer: With the recent changes in the Workers Compensation System, UR (Utilization Review) has come into play. Utilization Review is usually done by an outside company contracted by the Insurance Carrier. Itís function is similar to a substandard HMO, whereas all treatment, testing and medications requested by the doctors must go to Utilization Review for approval before treatment can be done, or payment will not be made.

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California Workers Compensation System http://www.dir.ca.gov/DWC/basics.htm
Social Security / Disability Programs