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  • On the Job Injury
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Todd R. Tatro Attorney at Law
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Workers’ Compensation Claims Process Explained

When you’ve been injured on the job, you need relief – relief from the pain you are experiencing due to your injuries, and from the disruption in your life that your injuries are causing. You also need relief from the stress of your financial worries now that you’re out of work, and need to know that you will be able to take care of your family during this difficult time.

If you have been injured while working in the course and scope of your employment, this relief usually comes in the form of workers’ compensation benefits provided under California’s workers’ compensation laws. When you’ve been injured at work, these laws are there to provide you with the benefits needed for the medical care that you require, and to help provide the financial assistance you need to care for your family.

How The Process Works

Every state in the United States is required to provide workers’ compensation benefits to their employees. While each state may differ in its laws, every employer in the State of California must provide workers’ compensation benefits to their employees who are injured while working in the course and scope of their employment.

Although in California some employers such as State or other governmental entities may be legally uninsured for the provision of workers’ compensation benefits and larger employers in many instances might be permissibly self-insured, most employers either pay into a California’s workers’ compensation insurance fund or have private insurance coverage or funds that serve the purpose of providing this coverage. When an injury occurs to an employee while in the course and scope of their employment, this insurance coverage is there to pay for things such as medical treatment needed to cure or relieve the effects of the industrial injuries and to replace a percentage of lost wages in the form of temporary disability benefits up to set statutory maximum levels.  In some cases, additional benefits may also be available for things like vocational rehabilitation, permanent disability, or even death benefits to an employee’s survivors if the injuries suffered resulted in the employee’s death.

It should be kept in mind that even where your employer has failed to take the necessary steps to provide their employees with workers’ compensation coverage, you may still be entitled to receive workers’ compensation benefits the California Uninsured Employers Benefits Trust Fund.  The California Uninsured Employers Benefits Trust Fund (also referred to as UEBTF or UEF) was established to protect employees where their employer failed to secure the payment of workers’ compensation coverage and fail to pay the compensation required under the laws to the person entitled thereto.  The UEBTF will normally provide the workers compensation benefits to which the employee of the uninsured employer is entitled, and then seek to recover those benefits from the employer.  

In addition, along with the potential availability of UEBTF benefits, the employee of the unlawfully uninsured employer may also have a separate civil action against this employer.  Under current law, Labor Code section 3706 provides that if an employer fails to secure the payment of compensation, any injured employee or his dependents may bring an action at law against such employer for damages as if this division did not apply.    

Eligibility For Workers’ Compensation Benefits

California workers’ compensation laws are different from those laws that govern personal injury cases. Under workers’ compensation law, you are only required to demonstrate that you are an employee who was injured in the course and scope of your employment. You are not required to show that your employer was negligent. In short, if you were employed in California and have suffered injuries while working, you are generally entitled to recover workers’ compensation benefits, provided that your injury was not caused by one of several exceptions to coverage. (A couple of examples of these exceptions would for instance if your injury was due to your intoxication or intentionally self inflicted.) This isn’t to say that recovering benefits even where you might be clearly entitled to such is easy, though. The process of recovering compensation for your on the job injuries can be complicated and in most instances can take quite a long time.  Also, many claims are initially  delayed or denied, which complicates the situation even further and results in additional delays, even if you are ultimately successful in getting your case accepted.

Obtaining Worker’s Compensation Benefits For Your Injuries

First and foremost, when you’re injured on the job, if possible you need to immediately report your injury to your employer and seek out any needed medical treatment for your injuries as soon as you can. It’s very important to notify your doctor that you were injured while working. Most doctors will ask this question when you come in with injuries, because they too, are aware of the importance of noting this in your records. If you put off reporting your injury and seeking treatment from a doctor, you could seriously damage your ability to file a workers’ comp claim, because it might be assumed that you were not injured on the job, or that your injuries were not serious enough to have warranted seeking medical attention without delay.

Once you’ve been treated by a doctor for your injuries, the next step will be to inform your employer if you have not already done so that you’ve been injured at work. Under California law, your employer must provide a workers’ comp claim form (also called a DWC 1) within 24 hours of this notification. This particular form is considered the official start of your claim for workers’ compensation benefits, and therefore, it’s very important that you fill it out completely, honestly, and to the best of your ability. Especially important is the section that will ask you to describe your injuries. List all body parts that have been injured, and explain the injuries in detail to the best of your ability.  Again, you need to be as complete and as accurate as possible in completing this form and in listing your injuries and any body parts or systems affected.

When you’ve completed the form, return it immediately to your employer in person, or by certified mail, so that you have proof of delivery. Your employer will fill out some information on the form also, and they have 24 hours in which to submit the completed form to their insurer. They will also return a completed copy to you for your records.  It is important that you keep this document in a safe place to show not only that you filed it, but because you will also need it when filing an Application for Adjudication with the Workers’ Compensation Appeals Board.  

As referenced above, the next legal form to fill out and timely file in the process is an an Application for Adjudication of Claim. Once this application is completed and timely filed with the Workers’ Compensation Appeals Board, such document would constitute your official filing and opening of a workers’ compensation case before them.  This too is an important form to complete and file since it confers jurisdiction on the Board when timely filed and also serve to toll the applicable Statute of Limitations on your case. Submit this form in person to the district office of the Workers’ Compensation Appeals Board that is nearest you.  It is also important that you make sure to obtain and keep a conformed copy of the filing in a safe place to prove when and where the Application was timely filed so that you can try to eliminate any problems down the road if it were to get lost or misfiled by the Board.

At the time of filing the Application for Adjudication and a copy of your completed DWC 1 Claim form with the Board, you will also need to complete and submit with those documents a signed declaration under penalty of perjury pursuant to Labor Code 4906 (h). This is a sworn statement is to confirm that you have not violated Labor Code 139.3 and essentially have not asked or given your doctor any form of consideration to prepare and/or submit fraudulent records regarding your injuries to the Division of Workers’ Compensation.

Actions After A Claim Has Been Filed

As we’ve previously discussed, this is a complicated process that must be completed in the proper sequence in order for your claim for compensation to be accepted and for benefits to be provided. It greatly pays to have an expert in workers’ compensation law on your side to handle the process and ensure that everything happens when it’s supposed to happen, and exactly how it’s supposed to happen. Attorney Todd Tatro is a certified specialist in Workers’ Compensation Law and he and his staff can help you with your claim every step of the way.  By hiring Mr. Tatro to represent you, you are effectively taking the technical burden off your shoulders and leveling the playing field with your employer and their insurance carrier or representative to help get the benefits to which you are entitled.  Hiring an attorney to represent you allows you to concentrate and place your focus on healing, rather than the litigation process.

In summarizing the initial issues involved in a claim, once your claim form has been completed and officially filed with your employer, their workers’ comp insurer or third party administrator must respond within 14 days. Their response will usually happen one of three ways:

  1. The insurer will begin providing benefits, including making temporary disability benefits payments to you if you were taken off work due to your industrial injuries;
  2. The insurer will deny your claim; or
  3. The insurer will postpone or delay a decision on your claim pending an investigation. If this occurs, they have 90 days from the receipt of the claim form within which to make their decision to accept or deny your claim. However, while the investigation occurs, they still are obligated by law to authorize the provision of all medical treatment consistent with Labor Code 5307.27 for the alleged injury that happened while you were at work, up to a maximum of $10,000.

It often happens that a delayed claim for workers’ compensation benefits is eventually denied. One of the most common reasons for denial is that the claim was either not reported on time, or not filed on time. In California, you have 30 days from the date of your injuries to file your claim. Another very common reason for a denial of benefits is that the employer:

  • Disputes that an accident occurred; or
  • Disputes that the injuries that occurred were a result of the industrial accident.

If the claim is denied for one of the above reasons, you or your attorney will be required to gather evidence supporting your claim, including but not limited to witness accounts of the accident, or a physician statement that the injuries you’ve sustained happened at work. Denial of a claim can happen for a number of reasons because denying your claim means that your employer doesn’t have to pay out insurance benefits. This doesn’t mean that you should give up. What it means is that you need an experienced workers’ compensation attorney in your corner, fighting for your right as an employee to receive compensation.

Workers’ compensation attorney Todd Tatro invites you to contact his office by phone at (559) 431-0123, or via his contact page, to set up a free, confidential consultation. Mr. Tatro will assess your situation, and if an agreement is reached to represent you, set up your claim filing properly and work to try and ensure that you receive the greatest compensation available for your workplace injuries.