California Workers’ Compensation Laws – Benefits and How to Apply

Anyone facing injury on the job in California may find themselves unsure of how they’re going to survive financially. Fortunately, California workers’ compensation law offers protection for hurt employees through the state’s no-fault system.

Depending on the injury, CA workers’ comp benefits may cover medical care, lost wages, physical therapy, disability payments, and more.

But how exactly does workers’ compensation insurance work, who qualifies, and how can you receive workers’ compensation benefits? Read on about workers’ compensation laws in California and when you need a workers’ comp attorney to analyze your case.

Is Workers’ Comp Mandatory in California?

Per California Labor Code §3700, employers with at least one employee must provide workers’ compensation benefits.

To satisfy this law, employers will typically take out a workers’ comp insurance policy covering anyone working for them. However, larger companies and sole proprietors may also have the option to self-insure for CA workers’ comp.

The bottom line, however, is that employers in California have legal requirements to provide workers’ compensation protections for their employees.

These protections range depending on the workers’ condition, from temporary wages to permanent benefits that last one’s whole life.

Types of Benefits in California Workers’ Compensation Law

Specific workers’ compensation benefits are available to California workers depending on the circumstances surrounding a work-related injury or illness.

In CA workers’ compensation claims, there are five basic types of benefits potentially obtainable after a workplace injury:

• Medical care
• Temporary disability benefits
• Permanent disability benefits
• Supplemental job displacement benefits
• Death benefits

Note that workers’ compensation only pays for losses directly resulting from your injury. Most of the time this means medical bills, but there are other conditions that may extend your workers’ compensation payments.

Medical Treatment Costs

Medical care for an illness or injury can cost upwards to $40,000 on-average, excluding lost time from work and property damage from the accident.

That’s why it’s important that workers’ comp, at the very least, cover an injured workers’ medical bills.

Medical benefits pay for not only hospital and doctor’s visits, but may also include:

• Surgery
• Hospitalization
• Prescription drugs
• Diagnostic tests (X-ray, MRI, CT scan)
• Blood work
• Physical therapy
• Chiropractic treatment
• Assistive devices (wheelchairs, crutches)

Basically, if it’s a medical expenditure that’s necessary for your recovery from a work-related illness or injury, it will be coverable. This also includes transportation to and from appointments at the IRS mileage rate of 67-cents/mile.

IMPORTANT: It’s illegal for a physician or medical professional to bill you if your injury was work-related.

The type of medical treatment you’re entitled to must follow California’s Medical Treatment Utilization Schedule (MTUS). These sets of regulations dictate what treatment is considered reasonable for specific forms of work injuries.

The MTUS also contains a drug formulary to help doctors cure or mitigate work-related injuries addressed by California workers’ comp law.

However, keep in mind that in the case of injury, you will need to use employer-arranged medical providers. This is true for the first 30 days from the reported injury date, unless you previously predesignated your own physician.

Temporary Disability Benefits

Temporary disability benefits are tax-free payments to help replace lost wages resulting from a work-related injury or illness. These occur when a worker cannot return to work within three days of their injury, or if they were hospitalized.

Payment amounts are two-thirds of the employee’s weekly salary, up to the state’s current set maximum. Temporary disability benefits may continue up to two years from the date of the injury (technically 104 weeks within five years).

However, you may qualify for 240 weeks of coverage if you suffer one or more of the following conditions:

• HIV
• Amputation
• Severe burns
• Hepatitis B or C
• Chronic lung disease
• Certain eye conditions (like partial or total blindness)

There are two types of temporary disability benefits available in California for injured workers:

1. When unavailable to work at all, you may receive temporary total disability (TTD) payments.
2. If your employer offers another job role while you recover, you may receive temporary partial disability (TPD) if your post-injury wages are below a set limit.

Permanent Disability Benefits

If your work-related injury or illness becomes permanent, then you may qualify for and transition to permanent disability (PD) benefits.

Keep in mind that you don’t have to be totally disabled to receive these benefits as there is also a category for permanent partial disability. This occurs when you can still work, but in a permanently-reduced capacity due to an injury.

These benefits come into play when a worker reaches their maximal medical improvement, where no further recovery is possible.

The amount an employee receives for partial or total disability stems from a formula that considers:

• Extent of the physical injury or disfigurement
• Age of the employee at the time of the injury
• Occupation (and how this injury affects the ability to perform said job)
• Date of the injury

California workers’ comp may not cover losses unrelated to work-induced injuries, and it may not recover all lost income from the accident.

If your permanent disability benefits do not adequately cover your losses, bring your case to a California workers’ comp attorney. A specialist can help you handle disputes between you and your employer’s insurance company.

Supplemental Job Displacement Benefits

This benefit — available for post-2004 California injury claims — is a voucher for education-related retraining and/or skill enhancement. It’s available to injured workers with permanent disabilities who cannot fully recover or return to work for their employer.

Its purpose is to help the worker switch to a career that matches their new level of functionality post-injury.

In California, this non-transferable voucher may be worth up to $6,000 to cover tuition fees, supplies, and books related to your career change.

Death Benefits

These benefits offer next-of-kin protections if an employee passed away due to a work-related injury or illness. In this situation, the payments go to the employee’s spouse, children or other dependents. It includes burial benefits.

How to Report a Workers’ Compensation Claim in California

The first thing to do if your workplace injury requires immediate attention is acquire emergency care. Tell the doctor it’s a work-related injury afterwards and ask for detailed receipts when in a more stable state.

If your injury or illness doesn’t require instant medical assistance, then your initial step will be reporting to your employer. Here’s how you should file a CA workers’ comp claim.

1. Notify your supervisor of your injury or illness immediately. If the condition develops gradually, report it as soon as you recognize your job caused the accident. If you fail to report within 30 days, you may lose your right to CA workers’ compensation.
2. File a claim form. Your employer should supply you with the form within 24 hours of you notifying them of your work-related condition. If they don’t, you can download Form DWC1 yourself. Be sure to sign and date the form, and keep a copy for yourself before submitting to your employer.
3. Wait while your employer notifies their insurance. Your employer must complete the “employer” section of your DWC1 form and submit it to their insurance company. Generally, the insurance company has 14 days to mail you a letter updating you on the status of your claim.
4. Expect a final decision. A claims adjuster will review your claim and determine whether you qualify for workers’ compensation benefits.

However, note that within one day of filing a claim form, your employer must authorize appropriate medical treatment. While your employer is deciding whether to accept/reject your claim, you may receive up to $10,000 in medical treatment.

Workers’ Compensation 90-Day Rule in California

California workers’ compensation law requires that an employee must receive notice of claim approval or rejection within 90 days. If you don’t receive a denial letter within 90 days, then the state automatically approves your claim.

For questions while you’re waiting, a great resource is the Department of Workers’ Comp Information Services Center. If you call 1-800-736-7401, you can speak to a live representative during regular business hours.

California Workers’ Comp Laws for Employers

California workers’ compensation laws function in a no-fault system. What that means is that workers cannot sue their employers in court, but in return employers must provide insurance. And that coverage cannot come from deductions from an employee’s paycheck.

Ultimately this agreement means that workers will have protection if they’re hurt on the job. And this system means employers have a way of managing this quickly and effectively.

From a legal standpoint, however, what California employers absolutely must do before an employee’s injury or illness occurs is:

1. Acquire workers’ compensation insurance. California businesses can buy coverage from licensed private insurance companies or the state fund for workers compensation. The other option is to qualify to become self-insured in California.
2. Provide a workers’ compensation pamphlet. When hiring a new employee, a California employer must provide them with a workers’ compensation pamphlet. This should clearly explain the employee’s rights and responsibilities in case of injury or illness.
3. Post a workers’ compensation poster. It should be someplace where it’s visible for all employees to see.

Penalties for Violating California Workers’ Comp Laws

Any employer who doesn’t have workers’ comp coverage risks violating CA Labor Code §3700.5. The penalties for skipping insurance and not adhering to the rules are not worth it since they include:

• $10,000 fine for the first offense/$50,000 for subsequent offenses
• One-year prison sentence
• State penalty of up to $100,000

There are a few scenarios where an employer doesn’t have to provide coverage. But in most cases, workers’ compensation is simply a requirement for doing business in the state of California.

Who is Not Eligible for Workers’ Compensation in California?

In almost all cases, an employee working for a company will have workers’ comp coverage in California. However, the caveat is that you must actually be an employee (not an independent contractor).

Additionally, employers do not have a requirement to provide coverage for individuals on Cal. Lab. Code § 3352. In California, that may include:

• Company executives and directors who own the company
• Sole proprietors with no employees (except roofers, who must carry self-insurance)
• Agricultural workers (on farms with less than five employees)
• Domestic workers (who work less than 52 hours in 90 days)
• Volunteers (though some non-profits will offer coverage anyway)
• Federal employees (they have to file through the U.S. Department of Labor per the Federal Employees Compensation Act)

Also ineligible are workers whose injuries are not work related. Remember, that for coverage to kick in, the injury or illness must directly result from a person’s employment.

What Injuries are Not Covered Under Workers’ Comp in California?

Injuries that happen at work but that are not work-related may not receive approval for workers’ comp claims. The determination will hinge on if the accident happens during the course and scope of employment for an employee.

What that rule does is exempt claims that may happen at work but reject injuries that are:

• Self-inflicted or intentional
• Due to horseplay or fighting
• Injuries from under the influence of drugs or alcohol
• Violations of company policy

Also note that purposely attempting to sustain an injury at work for workers’ comp benefits is a felony under California workers’ compensation law.

Additionally, California enforces a “going and coming rule.” This means injuries an employee might sustain while commuting to and from work does not qualify for workers’ compensation. Keep this in mind when filing your claim.

Workers’ Compensation Settlements in California

Once a workers’ comp claim reaches approval, there may be a settlement awarded after the employee reaches maximum medical improvement.

Usually the insurer will make a compensation offer to the employee in the form of a lump sum or a structured-payment schedule. It’s up to the worker to decide if the offer is acceptable or if they wish to negotiate for different terms.

This is where having a workers’ comp lawyer becomes crucial to the success of your claim. They can accurately tell if the insurance’s offer adequately covers present and future losses. If not, an attorney can fight to dispute and raise your settlement amount.

Payouts for workers’ comp claims typically take one of two forms: “stipulated findings and award,” or “compromise and release.”

Stipulated Findings and Award

In a stipulated findings and award settlement, the employee and insurer come to an agreement about continuing benefits. This usually comes into play when the injury results in permanent disability that necessitates ongoing care.

The employer pays for continuing benefits under this type of settlement. The worker may also reopen the claim if their condition worsens within 5 years of the date of injury. Typically, a judge will have to sign off on this type of agreement.

Compromise and Release

A compromise and release settlement is basically an agreement between an employee and the insurance company to close the case. The injured-worker agrees to accept a one-time, lump sum payment that fully resolves the workers’ comp claim.

When accepting this type of settlement, the employee cannot reopen the claim at a later date.

How to Dispute a California Workers’ Comp Claim

If you receive a rejection of your claim and wish to contest the decision, you’ll need to file an Application for Adjudication of the Claim.

Disputing means you’ll need to appeal your case in front of a workers’ compensation administrative law judge (WCJ). This appearance will take place at one of California’s 23 Division of Workers’ Compensation offices plus satellites.

While you may choose to represent yourself in court, CA workers’ comp law can be very confusing. Statistics show that individuals who acquire legal representation are much more successful in their appeals.

File a California Workers’ Comp Claim With an Attorney

Even though employees have one year from their injury date to file a workers’ compensation claim, it’s always better not to wait. That’s because if your claim doesn’t receive approval right away, it can take time to navigate the system.

While you’re recovering from a work-related injury, you don’t want to delay any benefits you’re owed.

The good news is that workers’ comp attorneys work on a contingency basis. So you won’t have to pay anything out-of-pocket for legal services if you qualify for a claim.

Let us help connect you with a lawyer in your area today! We can help you get the coverage you need so you can start healing and hopefully get back to work.