Understanding The Workers’ Compensation Process

The Workers’ Compensation Appeals Board holds hearings in front of administrative law judges to determine the nature and extent of benefits you are entitled to. The workers’ compensation process can be long and involved and is often difficult for anyone with injuries. You may receive relatively small amounts of money from the insurance company (if at all) while your benefits are being determined.

Some of the typical events in the workers’ compensation process include the following:

1. Your work injury must be reported to your employer. You complete a “notice of claim” which is required to be provided by your employer to you after notice of your injury. By accepting the notice of claim from you, your employer does not “admit” your injury, but rather, it puts your employer on notice that your injury is being claimed.

2. Under California law, your employer may take up to 90 days to investigate and either accept or deny your claim. Your employer should not be able to automatically take advantage of this 90-day investigation period in every case; if your employer is well aware of an admitted industrial injury, penalties can apply if your benefits are delayed or denied. However, in a disputed claim, your employer can take up to 90 days to investigate your claim. During that time, your employer may be allowed to take your statement or have you examined by a physician, or obtain your medical records.

3. If your claim is accepted, you will select your treating physician and be provided with temporary disability benefits until the medical condition reaches permanent and stationary status (limited to 104 weeks). At that point, you will be evaluated for any permanent consequences from your injury.

4. If your permanent disability is disputed, you may be evaluated by a qualified or agreed upon medical examiner and your employer may also have you evaluated by a qualified medical examiner. Our attorneys will also attempt to negotiate with a physician known as “an agreed medical examiner.” That is a physician known to be fair to injured workers to evaluate the case, by agreement with the workers’ compensation insurance company.

5. If your dispute cannot be resolved, then a workers’ compensation judge may determine the issue after a hearing. Workers’ compensation judges sit as administrative law judges. Juries do not hear workers’ compensation cases.

6. If your employer or their insurance company denies your claim, then you can proceed to obtain medical evidence by obtaining reports from your treating physician and/or a qualified medical examiner. The insurance company may do the same and disputes again are determined by a workers’ compensation judge after a hearing.

7. Administrative hearings include the presentation of testimony by you, supporting witnesses, as well as hearing from employer or employee witnesses. Medical evidence is usually submitted by the submission of medical reports on behalf of you or on behalf of the insurance company. In a disputed case, our attorneys will help you obtain medical evidence either from your treating physician, an agreed medical examiner, or a qualified medical examiner to help present your claim in the strongest light.

8. After a decision is rendered by a workers’ compensation judge, either side has a right to appeal. This is done through the Workers’ Compensation Appeals Board. This board serves as a “court” comprising seven governor-appointees who will review the initial decision. Sometimes, certain cases can be taken a step further to the Court of Appeal or the California Supreme Court.

9. The question of attorney fees is answered by state law. The workers’ compensation judge typically sets a margin no higher than 15% of your recovery figure. Attorney fees are payable only upon the injured worker receiving an award from a judge or settlement.