Basic Benefits

California Insurance Companies provide 5 types of basic benefits:

1. Medical Care

2. Temporary Disability

3. Permanent Disability

4. Supplemental Job Displacement

5. Death Benefits

 

MEDICAL CARE

Benefits that are paid for medical expenses to help you recover from a work-related injury or illness.

1. FACTS

• Your employer pays for medical care either through a workers’ compensation insurance policy or by being self-insured. The claims administrator pays the medical bills. You should never receive a medical bill, as long as you filed a claim form and your physician knows that the injury is work-related. It is illegal for a physician or medical facility to bill a worker if they know the injury is or may be work-related.

• California workers’ compensation law requires claims administrators to authorize and pay for medical care that is deemed “reasonable and necessary.”

• The medical treatment guidelines currently being used in California are the Occupational Medicine Practice Guidelines, Second Edition, published by the American College of Occupational and Environmental Medicine (ACOEM). The ACOEM guidelines are designed to help physicians give appropriate treatment. This includes advising and guiding the injured worker on how to remain active while recovering, and informing the employer about the kinds of changes at work that are needed to promote recovery. Such changes could involve different job assignments, reduced working hours, or other accommodations that are safe and appropriate for the particular injury. For more info on ACOEM

• If your doctor recommends treatment not in the ACOEM guidelines, the claims administrator is required to pay for the treatment if it follows other scientifically based guidelines that are generally recognized by the national medical community.

*Note: If your date of injury is in 2004 or later, you are limited to a total of 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits for your injury, unless the claims administrator authorizes additional visits in writing. Also, regardless of your date of injury, you may be subject to other limits on these visits based on the medical treatment guidelines of ACOEM.

2. WHEN MEDICAL TREATMENT BENEFITS BEGIN

• Emergency care: If it’s an emergency, your employer must make sure that you have access to emergency treatment right away, regardless of which doctor you see.

• For non-emergent care: The claims administrator is required to authorize treatment within one working day after you file a claim form. While the insurance company is investigating your claim, they must authorize necessary treatment up to $10,000. Once you are approved to receive benefits, your medical treatment will begin. Which doctor you see will depend on whether your employer has created a (a) medical provider network [MPN], (b) has a contract with a health care organization [HCO], or (c) whether you previously predesignated your personal physician.

1. If there is a medical provider network (MPN) - An MPN is a list of physicians and other health care providers selected by the employer or insurer to treat injured workers. MPNs must be approved by the state Division of Workers’ Compensation (DWC). An employer or insurer that creates an MPN must give written information about the MPN to every employee 30 days before the MPN is implemented, or when the employee is hired, or when the employee transfers into the MPN. This information must be provided again when a worker gets hurt on the job. If your employer or the insurer has created an MPN, in most cases you will first be treated by a doctor in the MPN after you are injured, unless you predesignated.

2. If there is a contract with a health care organization (HCO) - An HCO is an organization certified by the DWC that contracts with an employer or insurer to provide managed medical care for injured workers. Most employers and insurers do not have contracts with HCOs. An employer or insurer that has a contract with an HCO must give employees a form prepared by the state Division of Workers’ Compensation, DWC Form 1194, to allow them to choose whether to enroll in the HCO. This form must be given to new employees within 30 days after date of hire and to current employees at least once a year.
   
   If your employer or the insurer has a contract with an HCO, in most cases you will first be treated by a doctor in the HCO after you are injured, unless you predesignated.
   
   **If your employer or the insurer has not created an MPN and does not have a contract with an HCO, in most cases the claims administrator can choose the doctor who first treats you after you are injured, unless you predesignated.

3. If you predesignated your personal physician - Workers with employer-provided health insurance are allowed to predesignate their personal physician before injury. If you predesignated, you may see your personal physician right after you are injured. You can predesignate only if your employer offers a group health plan or group health insurance for medical conditions that are unrelated to work. If your employer does not offer this benefit, you do not have a right to predesignate.

• Workers Compensation is mandatory for California employers. Employers can buy insurance from an independent company or from the State Compensation Insurance Fund (SCIF). [For more info on SCIF]

• If your employer is not insured, employee will get compensated from the Uninsured Employers Benefits Trust Fund (UEBTF). UEBTF will then attempt to recover the money from the uninsured employer. [For more info on UEBTF, link to website: ]

• If you have started receiving benefits for medical treatment, you have 5 years from the day of injury to officially file a claim. If you are not receiving benefits, you have one year to file the claim.

• If you are collecting benefits from a relative who died in a work-related injury, you have one year from the day of death to file the claim.

• The insurance company must respond to you within 14 days of receiving your claim. At that point, they will begin making payments, deny your claim, or they will let you know that your claim is under investigation. If under investigation, the insurance company has 90 days to make a decision. While doing so, you are entitled to receive medical treatment of up to $10,000.

• If you are denied compensation, there is an appeals process you may go through. You can file a Declaration of Readiness and turn it into WCAB, which will schedule a hearing for you. The judge will settle the dispute. If dispute cannot be settled at the hearing, a trial will be scheduled.

• In CA, workers compensation attorneys are paid on a contingency basis only. Meaning, they will get a percentage of the benefits you receive. The percentage is usually 12%-15%. The judge must approve of the fee.

 

Standard procedure after a work-related injury

1. If emergency, seek medical attention immediately from any treatment facility available to you.

2. If not emergency, notify employer as soon as possible. Your employer will let you know if you need to be seen by a doctor in their medical provider network (MPN), or by your predesignated personal physician. The insurance company is required to create a Medical Provider Network (MPN). This is a network, or group of doctors who are preauthorized to treat your injury. While you are required to select and treat with one of these pre-approved doctors, you are allowed to switch to a different doctor within the MPN if you are not satisfied with the care you are receiving.

3. While at the doctor, notify him that the injury is work related to ensure the doctor fills out proper paperwork.

4. File a claim by filling out Form DWC-1 and an Application for Adjudication of Claim. In California, you have one year from the date of injury to file the claim. Describe your injury completely. Include every part of your body affected by the injury. Give the form to your employer. This is called “filing” the claim form. Do this right away to avoid possible problems

5. If injury developed over time, report it as soon as possible so as not to lose benefits.

6. Contact IIHC. We will find you the best medical and rehab resources. The doctors at our facilities are certified in completing and correctly filing claims forms. We also offer free attorney referrals. These experienced lawyers can:

• Expediting workers comp claims through the system

• Assess if there is cause to file a case against a third party, such as the manufacturer of the machine you were working on when you got hurt

• Negotiate the best compensation and settlement for your injuries

 

Related Topics:

• California Employees Rights

• California Laws

• Benefits (Compensation)

• Predesignating a Physician

• Filing a Claim

• Resolving Disputes

• Workers’ Compensation Facts

• California Workers Comp FAQs