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California Workers’ Compensation FAQs

Most people go through life without having a serious workplace accident or contracting an illness on the job, or if they do, workplace injuries and illnesses are hopefully few and far between. One consequence of this fact is that very few employees are experts on California workers’ compensation law, the claims process, or what to do in the event of a denial. The employer’s workers’ comp insurance carrier, however, deals with claims every day and knows everything there is to know about the law and process. Knowledge is power, so below are answers to some frequently asked questions employees have about workers’ comp. To truly level the playing field, though, get yourself an experienced and successful California workers’ compensation attorney who knows as much or more as the insurance company lawyers on the other side.

Get answers to common questions below, and contact Invictus Law, P.C. in Orange and Ontario for answers to your specific questions and help with your claim in Orange County or the Inland Empire.

Q. What kind of workers’ comp benefits can I receive?

A. The major types of workers’ comp benefits in California are medical treatment and disability payments. Medical treatment benefits should cover the full cost of doctor’s bills and related medical expenses for the duration of your injury or disability. Disability payments equal roughly two-thirds of your regular wages while you are temporarily disabled from working, for as long as two years. If your disability is permanent, you’ll receive a disability rating and permanent disability benefits based on that rating.

Benefits are also available for job retraining if you are unable to return to the same type of work. A surviving spouse or other family members are also entitled to death benefits in the case of a fatal workplace accident or illness.

Q. Can I choose my own doctor?

A. Sometimes yes and sometimes no. Your employer actually has the authority to choose your doctor for your first appointment. After that first appointment, some workers can select a different doctor within the employer’s Medical Provider Network. Other workers can select any doctor they want after 30 days of medical treatment, so long as the doctor accepts workers’ compensation insurance. Your specific rights to choose a different doctor depends on the type of employer you are working for.

Q. What is a QME?

A. QME stands for Qualified Medical Evaluator. If ordered by the insurance company, you will be required to undergo an examination from a QME. A panel of three qualified medical evaluators are provided to you, and you are allowed to choose your evaluator from the panel. You have ten days to choose, or the claims administrator will choose for you. Physicians on the panel are paid by the insurer, and the insurer may end up denying benefits based on the evaluator’s findings. If those findings differ from the opinion of your own doctor, your attorney may need to take the case to the California Workers’ Compensation Appeals Board (WCAB) to make sure you get the appropriate care and treatment, and that the costs are covered by workers’ comp.

Q. What is an AME?

A. An AME is an Agreed Medical Evaluator. An AME is selected jointly and agreed upon by your attorney and the claims administrator. The findings of an AME are binding on both the employer and employee, in contrast with the findings of a QME, which are not binding but are given the same weight as the primary physician’s findings. You have to have an attorney in order to get an AME; make sure your lawyer has years of experience in California workers’ compensation so that she or he will know which physicians are competent to address a dispute regarding your particular issue.

Q. Can my employer deny benefits for an on-the-job injury by claiming I was “goofing off” when I got hurt?

A. Possibly. California law allows an employer to deny a claim based on “serious and willful misconduct,” which could include being drunk or high on the job or engaging in horseplay or recklessness that results in injury. Whatever the conduct, it must meet the legal definition of “serious and willful misconduct” to meet the grounds for a denial of a claim. Don’t just take your employer’s word as the final say on the matter. Your attorney can make your case to the workers’ compensation judge or WCAB that the alleged conduct did not rise to the level of “serious and willful misconduct” or was not responsible for the injury.

Q. Can I sue my employer if the company is responsible for my injury?

A. In most cases, workers’ compensation benefits are your sole source of compensation for an on-the-job injury, regardless of who was to blame. However, if the accident was caused by the employer’s willful and intentional actions, such as disabling safety equipment to speed up production, you may have a civil case against your employer. Invictus Law, P.C. can help you with these claims, as well as third-party liability claims when an outside party is responsible for the injury.

Q. Does workers’ comp cover undocumented immigrants?

A. California workers’ compensation law specifically includes “aliens” in the definition of employees eligible for workers’ comp benefits.

Q. Am I covered by workers’ comp if I work for a small business or a family business?

A. Even if you are the only employee at the business, your boss is required to carry workers’ compensation insurance coverage for you. Only a few specific exceptions to this requirement exist in California, including if you are working for a member of your immediate family, or if your type of employment is specifically excluded from coverage in the California Labor Code. Some employers may exclude you by saying you are an independent contractor and not an employee, but they may be illegally misclassifying you, so talk to an experienced workers’ compensation attorney if you’re hurt on the job and unsure about your employment status.

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