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The following laws are taken from the Labor Code. The most common question we get is about denial of treatment but for a good discussion of frequently asked questions you can also follow this link: https://www.dir.ca.gov/dwc/WCFaqIW.html#Basics
Labor Code 4610 - Utilization Review.
Utilization Review is the process by which the insurance companies deny medical treatment. When your doctor wants to provide some form of treatment he will send a Request for Authorization to the insurance company. The insurance company is supposed to be on a strict time limit to respond and will send the RFA over to a Utilization Review Company. This is a company hired by the insurance company to review the request under Medical Guidelines to determine whether the requested treatment is reasonable under the circumstances. As you might imagine, many forms of treatment are denied.
If you received a letter in the mail denying treatment this came through UR. There are then time limits for appealing the UR decision to the Independent Medical Review. We work to make sure these deadlines are not missed and will drag insurance companies to court to get the judge to Order the insurance company to comply with the law and provide requested treatment.
Labor Code Section 5401 - Employer must provide injured worker a claim form
Your employer must provide you a workers compensation claim form within one day. Once you are injured, you must give written notice to your employer as soon as possible. The claim form is a legal document, and has legal implications. California Labor Code says you may get nothing if you were fired, and then you filed a claim.
Many times an employer does not act in compliance with the law. Beach Cities Legal Center will help you fill out all claim forms, attend all hearings and conferences, and answer all your questions about the workers compensation insurance system.
Labor Code 5402 - Employer has 90 days to accept or deny your claim.
Your employer has 90 days from the time you submit your claim form to decide whether to deny or accept your claim. Denial of your workers compensation claim would get you no benefits, and you would need to decide to file an appeal. Many employers deny a claim, and hope the injured worker will not try to appeal the denial.
An unfortunate result of this 90 day time frame to investigate, is that insurance companies can put a claim on delay for 90 days. During this time they can basically deny benefits without consequences. Thankfully, there are things that can be done to counter act this as 90 days is a very long time to be left injured, unable to work, and without money.
Labor Code 3600 - Employee gets benefits even if totally at fault.
Workers are entitled to most benefits even if the worker was totally at fault for the injury. Your employer may try to say you are not an employee, but an independent contractor, and thus not entitled to any benefits. We see this all the time and have successfully shown injured workers called contractors are actually employees, and should get workers compensation benefits.
Labor Code 4650 - Temporary disability benefits.
An injured worker may receive money, known as temporary disability benefits, which is calculated at 2/3 of a worker's regular salary. This can be received for up to 2 years. However, in order to receive these payments a Primary Treating Physician must state that you are unable to work, or that you have restrictions that your employer cannot provide. That is why it is important to treat with a physician that is sympathetic to injured workers and not looking to make friends with insurance companies. If you are being treated by a doctor that was selected by your employer or the insurance company it is probably best to move care elsewhere as soon as possible, for various reasons.
There are many times where the injured worker is denied Temporary Disability money, or where the insurance company underpays the injured worker. Temporary Disability benefits stop when a doctor states that you are Permanent and Stationary. This is a turning point in the life of a case. However, many times a doctor will state that someone is Permanent and Stationary even though more treatment, even surgery, is required. You may need to get second opinions from a Panel Qualified Medical Evaluator and even ask for supplemental reports to use as evidence in Court.
Once a doctor states that a worker is unable to work the insurance company has 14 days to start paying. Penalties may be owed if they do not make timely payment.
Labor Code 4656 - Permanent disability benefits.
Permanent Disability benefits begin when the treating physician states that the employee is Permanent and Stationary. This stops the TD payments and begins PD payments. Unfortunately, the Permanent Disability payments will be deducted from any final settlement amount where the TD payments typically are not. As such, it is important to keep receiving TD rather than PD. Insurance companies want to switch you oever as quickly as possible.
Permanent Disability is usually paid in a lump sum payment upon settlement of the case, and is calculated using a complex system of percentages of body impairments. The work comp lawyer has enormous input into this money calculation. It is a complicated process that should not be left to anyone that has not undergone specific training in rating the AMA Guides doctors use to prescribe impairment. Our work comp attorney has years of training and experience to ensure the doctors utilize the AMA Guides correctly and will ask the tough follow up questions to keep the doctors on point.
Labor Code 4600 - Medical care and procedures for injured worker.
The workers' compensation insurance must provide for all medical treatment, medications, procedures and therapy necessary to the injured worker. You have the right to select a doctor, and we will help you select the correct doctor. It is increasingly difficult to set appointments with medical providers as insurance companies withhold authorization needed to schedule an appointment. We frequently pursue penalties for delaying care pursuant to Labor Code 5814 and failed payments per 4650.
There are many more laws in the Labor Code that are important. Call and ask a friendly attorney:
Work Comp Lawyer
Torrance, CA 90504
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