If you’ve been injured or became sick because of your job in California, you no doubt have a lot of questions, especially about the benefits available through workers’ compensation—and what you have to do to receive the benefits. This article addresses those basic benefit questions.
Once you report the injury to your employer and file a workers’ comp claim, your employer’s insurance company should begin paying benefits for your medical treatment. While your claim is being considered, the insurance company is legally responsible for up to $10,000 of your medical costs, even if it ultimately denies the claim. Also, if the insurer doesn’t reject your claim within 90 days after you file it, the law will assume that you’re entitled to benefits. (Cal. Labor Code § 5402 (2018).)
Under California workers’ compensation law, you’re entitled to payment for all medical treatment that’s “reasonably required to cure or relieve" the effects of the injury, with no deductible or out-of-pocket cost to the employee. This includes doctor's bills, hospital bills, prescription medicines, medical supplies and equipment, acupuncture treatment, and up to 24 sessions with a chiropractor or with a physical or occupational therapist. If your employer has set up a medical provider network (MPN) for workers’ comp treatment, you may have to go to a doctor within that network. There are exceptions to this rule, including when you need emergency treatment or you’ve already designated your regular primary care physician as your treating doctor. (Cal. Labor Code §§ 4600, 4600.3, 4604.5 (2018).)
Before you receive any treatment recommended by your doctor (other than emergency care), you may have to get authorization (through a process known as “utilization review”) to determine if it's medically necessary. For injuries that happened after January 1, 2018, the rules for pre-authorization are more lenient in the first 30 days after the injury. (Cal. Labor Code §§ 4600(d)(5), 4610 (2018).)
If your doctor says that you can’t do any part of your job for a while because of your work-related injury or illness, you’re entitled to temporary disability (TD). The payments won’t kick in until you’ve missed three days, unless you’re off work for more than 14 days or you're hospitalized. (Cal. Labor Code § 4652 (2018).)
TD benefits are meant to replace only some of your lost wages. During the time that you’re considered temporarily disabled and unable to perform the necessary functions of your job, you’ll generally receive two-thirds of your average weekly wages—although there are maximum and minimum amounts. Your average weekly wage is the pre-tax gross amount that you were earning at the time of the injury, including overtime, the market value of job perks, and wages from multiple jobs. (Cal. Labor Code §§ 4453(c)(2), 4454, 4653 (2018).)
Because the maximum and minimum temporary disability payments are linked to the statewide average weekly wage, they’re adjusted each year. For 2018, the maximum is $1215.27 per week, while the minimum is $182.29. However, these amounts will be different for people who were injured before 2018; for two years after the injury, you’re locked into the maximum TD payment that applied to your injury date. If you’re eligible to continue receiving TD payments after two years, the amount will bump up to any higher rate in effect.
If your doctor has said that you can work but only with limited hours, you can receive partial temporary disability payment. You’ll be entitled to two-thirds of your weekly wage loss, which is calculated as the difference between your average weekly wage (up to the maximum discussed above) and the amount you are earning for part-time work. (Cal. Labor Code § 4657 (2018).)
Temporary disability benefits may stop and start again—for instance, if you went back to work but then had a flare-up of pain or needed surgery. Whether you get these benefits continuously or intermittently, there’s limit on how long they’ll continue. Even if you haven’t fully recovered, you can’t receive temporary disability benefits for more than a total of 104 weeks within five years from the time you were first injured, unless you’re suffering from certain serious conditions like HIV, hepatitis B or C, or some forms of lung disease. (Cal. Labor Code § 4656 (2018).)
You may be entitled to permanent disability benefits if your doctors have determined that your injury or illness has left you with permanent limitations that affect your ability to work. This won’t happen until your treating doctor says that your medical condition is permanent and stationary—meaning that you aren’t expected to get better in the next year, with or without more treatment. Then you’ll be given a permanent disability rating (expressed in a percentage), taking into account your occupation and age, along with your impairments. (For more on how the rating process works and how it's used to determine how much you receive in benefits, see our article on permanent disability benefits in California workers’ comp cases.)
You may be eligible for a benefit called supplemental job displacement if your employer doesn't offer you regular, modified, or alternative work within 60 days after receiving a medical report that says your injury resulted in partial PD. This benefit consists of a voucher for up to $6,000, which you can use to pay for training or certain other expenses for getting the skills and certification needed to enter a new line of work. (For details, see our article on supplemental job displacement benefits in California.)
You’ll be entitled to a death benefit if you are a surviving dependent of an employee who died from a work-related injury. The amount of the death benefit depends on the number of survivors who are eligible to receive payments, as well as the date of the original injury. (For more on eligibility and how the benefits are calculated, see our article on workers’ comp death benefits in California.)
If your employer's insurance company refuses to pay any of the benefits described above, you have a right to challenge that decision. For details on how to do that, see our article on workers' comp appeals in California. And when the insurance company is late in paying benefits that are owed to you, you may be able to collect a penalty. However, the system for resolving disputes with insurance companies can be complex. An experienced workers' comp lawyer can help you navigate that system and get the benefits you deserve.