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What Every Injured Worker Needs To Know

 

  • Understanding What An Injury Is

  • When Should You See A Doctor

  • Knowing Your Rights

  • What Does Your Workers Compensation Cover?

  • When Do You Need To Seek The Advise Of An Attorney?

  • Dealing With The Insurance Company

  • What You Can Expect From Your Employer

  • How Much Will An Attorney Cost

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Workers' Compensation

 

State laws vary as to the exact compensation available, but as an injured worker you may be entitled to:

  • Temporary total disability while you can’t work at all (usually 2/3 of your previous actual earnings)

  • Payment of your medical bills

  • Permanent partial disability

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Your employer’s Workers’ Compensation insurance may be responsible for job displacement benefits, so that you can work at some meaningful job that is geared to your current abilities.

 

If there are permanent restrictions, your employer is generally responsible to offer you a modified position, if there is one available within the restrictions of what you can now do. If there are no such jobs, there is no guarantee of future employment with your employer.

 

Workers’ Compensation is your exclusive remedy, which means that you can’t sue your employer, but are only entitled to benefits under California Workers’ Compensation laws.

 

In some cases, however, you can file a lawsuit against another party other than your employer.

 

The Administrative Process

 

The Workers' Compensation Appeals Board, not the courts, usually decides whether your worker’s comp claim for benefits should be granted.  The administrative decision will be based on what’s in your worker’s comp file with the agency, and the evidence presented at an administrative hearing. Make sure you provide your lawyer with all the medical information you have, so that your lawyer knows everything you do about your medical condition.

 

If your lawyer asks you to round up information or paperwork, make it a priority to get it done as soon as possible. Your lawyer wouldn’t be asking for the information if he or she didn’t see it as important. Keep copies of everything you send to your lawyer, and all the hearing paperwork. Be prepared for a long wait while your workers’ comp claim is processing. It is not unusual for claims to take years to resolve.

 

An "Industrial Accident" is any accident that happens to you while you are on the job. When you become injured, you shouldimmediately seek medical attention. Avoid "putting it off until tomorrow" to see if you'll feel any better. There could be serious underlying injuries that may not manifest that quickly, and you could cause further injury to yourself by delaying medical attention. 

You have the right to see a doctor, without charge to you, for any accident at the workplace, regardless of how trivial it may seem. Your employer will issue you a form to fill out and return; do this as soon as possible! 

 

In most cases, Workers' Compensation covers your medical treatments until your treating physician releases you to go back to work doing your normal job. However, there a times when your medical coverage is covered even while you are back to work. These issues are better dealt with on an individual basis with your attorney.

 

When you're injured, you should seek the advise of an attorney as soon as possible. When you try to represent yourself, the insurance company is required by their company to offer you the absolute minimum settlement possible, if any at all. In order to protect your rights under the workers compensation laws, you should seek legal advise before signing anything that would, in effect, give up your rights to medical treatment or monetary compensation.

 

Your employer, regardless of how much he may genuinely care for you as an employee, knows that the longer you are off work, the more it costs him. He or she will want you back on the job as soon as possible; either at your regular job, or some type of modified position. Be aware that if you are brought back in a modified position, the employer only has to pay you 85% of your pre-injury wage. Workers' compensation pays the difference.

 

Unlike civil cases or criminal cases, there are no "up-front" fees to be paid to an attorney. The costs incurred by the law firm handling your case are deducted from your settlement and a modest amount of 12% to 15% that the attorney receives is dictated by the workers' compensation board. 

 

Answers to your questions about Panel QME's and Agreed Medical Examiners

 

This fact sheet will help you understand your rights and responsibilities when requesting a panel qualified medical evaluator (PQME) or agreed medical evaluator (AME) exam. PQMEs are independent physicians certified by the state Division of Workers' Compensation (DWC) Medical Unit to do medical evaluations. PQMEs and AMEs examine injured workers to determine the benefits they will receive.

 

Q: Do I need to fill out the claim form (DWC 1) my employer gave me?

 

A: Yes, if you want to make sure you qualify for all benefits. Your employer must give you a DWC 1 claim form within one day of knowing you were injured. Filling out the claim form opens your workers' comp case. State law also lays out benefits beyond the basics you may qualify for once you file the claim form with your employer. Those benefits include, but are not limited to:

  • A presumption that your injury or illness was caused by work if your claim is not accepted or denied within 90 days of giving the completed claim form to your employer

  • Up to $10,000 in treatment under medical treatment guidelines while the claims administrator considers your claim

  • An increase in your disability payments if they're late

  • A way to resolve any disagreements that might come up between you and the claims administrator over whether your injury or illness happened on the job, the medical treatment you receive and whether you will receive permanent disability benefits.

  • If you do not file the claim form within a year of your injury you may not be able get benefits.

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Q: What if my employer didn't give me the DWC 1 claim form?

 

A: Ask your employer for the form or call the claims administrator to get it. The claims administrator is the person or entity handling your employer's claims. The name, address and phone number of this person should be posted at your workplace in the same area where other workplace information, like the minimum wage, is posted. You can also get the form from the DWC Web site at www.dir.ca.gov/dwc/. Click on "forms."

 

Q: I've been to the doctor. Why do I need to see a PQME?

 

A: You and/or the claims administrator might disagree with what the doctor says. There could be other disagreements over medical issues in your claim. A doctor has to address those disagreements. You might disagree over:

  • Whether or not your injury was caused by your work

  • Whether or not you need treatment for your injury

  • What type of treatment is appropriate

  • Whether or not you need to stay home from work to recover

  • A permanent disability rating

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Q: What qualifications do PQMEs have?

 

A: The DWC Medical Unit certifies PQMEs in different medical specialties. A PQME must be a physician licensed to practice in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists or acupuncturists.

 

Q: Who makes the decision about going to a PQME?

 

A: Either you or your attorney (if you have one) or the claims administrator can request a QME exam. You might request a QME exam if:

 

1. Your claim is delayed or denied and you need a medical exam to find out if the claim is payable

2. You need to find out if you are permanently disabled in some way or if you'll need future medical treatment

3. You disagree with what your doctor says about your medical condition

4. If you disagree with the results of utilization review.

 

The DWC Medical Unit will provide whoever makes the request with a list (called a panel) of three QMEs. One physician from the list is chosen to examine you and make a report on your condition. Each QME panel is randomly generated and the physicians listed are specialists of the type requested. Once a QME is chosen for your claim, all medical disputes must go to that QME. 

 

Q: What's the difference between a QME and an AME?

 

A: If you have an attorney, your attorney and the claims administrator may agree on a doctor without going through the state system used to pick a QME. The doctor your attorney and the claims administrator agree on is called an agreed medical evaluator (AME). A QME is picked from a list of state-certified doctors issued by the DWC Medical Unit. QME lists are generated randomly.

 

Q: How do I request a QME exam?

 

A: Complete the "Request for Qualified Medical Evaluator" form and submit it to the DWC Medical Unit. See Information & Assistance (I&A) guide 2 for help with this form.

 

NOTE: If your employer says there's a problem with your claim and sends you a "Request for Qualified Medical Evaluator" form, you have 10 days from when you get the form to complete and submit the form to the DWC Medical Unit. If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the kind of doctor you'll see.

 

Q: What difference does it make who submits the form to request the PQME?

 

A: Whoever submits the request form picks the specialty of the doctor that does the exam. The DWC Medical Unit will issue a panel of three doctors in that specialty. The doctors are selected randomly and will be as close as possible to your home address. See I&A guide 2 for more information. When you receive the panel, you will also receive a letter that explains how to set up the QME appointment and how to provide the QME with important information about yourself.

 

Q: Is there anything I can do if I disagree with what the QME says?

 

A: Yes, but you have a limited amount of time to decide if you agree with the PQME's report or if you need more information. When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options.

 

If you don't have an attorney, first call the claims administrator. If that doesn't help, contact an I&A officer at your local Workers' Compensation Appeals Board office. The I&A officer can help you figure out what's best in your case. See below for contact information.

If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement.

 

Q: I'm in a medical provider network (MPN). Does this process apply to me?

 

A: There are two tracks for resolving a medical dispute if you're in an MPN, depending on the situation. If your MPN doctor requests treatment that you agree with and that treatment gets denied under utilization review (UR), you have the right to be evaluated by a PQME. The claims administrator must advise you of this right. However, if you disagree with your MPN doctor about your diagnosis or treatment, you do NOT go to a PQME you have other options. First, you can change to another physician on the MPN list. You can also ask for a 2nd and 3rd opinion from a different MPN doctor. If you still disagree, you can have an independent medical review (IMR) to resolve the dispute. See the information on your MPN provided by your employer.

 

Q: I still have questions. Who do I contact?

 

A: If you have questions about requesting a PQME panel, contact the DWC Medical Unit.

 

Reach them by phone at 1-800-794-6900 or by writing to:

 

Division of Workers' Compensation Medical Unit

P O Box 71010

Oakland CA 94612

 

If you need an Information & Assistance (I&A) guide or other help, call an I&A office or attend a workshop for injured workers. The local I&A phone numbers are attached to this fact sheet. You can also get information on local workshops and download the guides from the Web at www.dir.ca.gov/dwc/.

 

The information contained in this fact sheet is general in nature and is not intended as a substitute for legal advice. Changes in the law or the specific facts of your case may result in legal interpretations different than those presented here.