Here are some frequently asked questions about workers' comp claims and benefits for California employees who’ve suffered work-related injuries or illnesses.
Among the eligibility requirements for workers’ comp benefits, your injury or illness must be work related. California law says that workers’ comp covers employees’ injuries “arising out of and in the course of the employment” (Cal. Labor Code § 3600 (2020)). Generally, that means that you were injured or became ill while you were doing your job and because of your job.
Workers’ Compensation in California for COVID-19
Under California's normal rules for occupational diseases, you can’t get workers’ comp for an infectious illness unless your job involves a special risk of exposure that’s greater than the risk in the general public, and you can provide medical evidence that you contracted the disease because of a specific exposure or incident at work. In response to the coronavirus pandemic, however, the California legislature enacted laws that make it easier for some employees to qualify for workers’ comp when they test positive for COVID-19 within 14 days after working at their employer's workplace. The laws apply to certain healthcare workers and first responders, as well as other employees working at certain job sites where there's been an outbreak of the disease. (Learn more in our article on getting workers' comp benefits in California for COVID-19.)
Generally, you should give your employer written notice of the injury within 30 days after you were hurt. You also need to file an official workers’ comp claim by filling out the employee’s portion of the claim form (which your employer should give you) and returning it to your employer. If you turn in the form within 30 days after the injury, it will also serve as the written notice.
There are special rules for determining when the 30-day period starts if you’ve developed a work-related medical condition over time (such as a repetitive stress injury or an occupational disease). For more information on that, as well as details on the claims process and what happens if you miss the 30-day deadline, see our article on how to file a workers’ comp claim in California.
If your claim is approved, you’re entitled to receive payment for:
When an employee dies from a workplace injury or illness, surviving dependents may be eligible for payments known as death benefits.
For more details on these and other benefits available to injured employees in the state, see our article on workers’ comp benefits in California.
When you’re first injured at work or become ill because of working conditions, you probably won’t be able to choose any doctor you want to see for treatment. Typically, the insurance company will have you go to a doctor or health care group; if it has established a medical provider network for workers’ comp treatment, you’ll usually need to select a doctor within that network. There are some exceptions to this rule, including when you’ve given your employer written notice—before you were injured—that you wanted your personal primary care physician to treat you for any work-related injury or illness. Even if you haven’t been able to choose your initial treating physician, you might be able to switch doctors after a period of time. To learn more about the rules for predesignating your personal physician and making a switch, see our article on how to select and change treating doctors in your California workers’ comp case.
Every employer in California is legally required to have workers’ comp insurance, either through an insurance company or an approved self-insurance program (available to large employers and government agencies that can show they have enough money to pay any potential workers’ comp claims). If your employer has broken the law by not having insurance, you have the right to sue your employer in civil court. In that case, you may be able to collect for your pain and suffering (which is allowed in personal injury lawsuits but not in workers' comp cases), in addition to your medical expenses and lost wages. (Cal. Labor Code §§ 3700, 3706 (2020).)
Even if you file a lawsuit against an uninsured employer, you may still file a workers’ comp claim in California. That way, if you’re awarded benefits in that case and the employer doesn’t pay, you can collect from a fund the state has set up for this purpose, called the Uninsured Employers Benefits Trust Fund. (California Labor Code §§ 3715, 3716 (2020).)
In most cases, your employer’s insurance company must respond to your claim within 90 days after you turn it in. (The time period for responding is shorter if you qualify for one of the presumptions for COVID-19 claims, discussed above.) If you don’t hear anything by the deadline, the law assumes that your claim is accepted. In the meantime, while your claim is being investigated, the insurer is legally responsible for up to $10,000 in medical expenses—even if it ultimately denies the claim. (Cal. Labor Code §§ 3212.87, 3212.88, 5402 (2020).)
If the claims adjuster sends you a letter denying your claim, you have the right to challenge that decision by filing an application for adjudication of claim. For details about the appeals process, see our article on what to do when your California workers' comp claim is denied.
Once you’ve received a denial letter, you should strongly consider speaking with a workers’ comp lawyer. Unfortunately, insurance companies routinely deny valid claims, and they know how to use the system for their financial advantage. A California attorney who’s experienced in workers’ comp can help protect your rights and tilt the scales in your favor. To learn more, see our page on finding and hiring a workers’ comp lawyer.
You might be able to collect Social Security Disability Insurance (SSDI) benefits in addition to workers' comp benefits, depending on the nature of your injury and whether you meet the other eligibility requirements. But your benefits could be reduced if the amount you receive from both workers' comp and SSDI is over a certain amount. See our page on qualifying for SSDI to learn more.
In general, you can't receive California State Disability Insurance (CASDI) for a work-related injury. However, you may be able to get interim benefits from CASDI when your employer's insurance company denies or delays paying your benefits. If you're later able to collect workers' comp benefits, CASDI will have a legal right to reimbursement for what it paid.