Worker's Compensation: FAQs

Workers’ Compensation Questions:

Below are the questions and answers we typically receive on most of our cases. Please take a moment to review these for a more immediate response to your questions/ concerns.

Question: Can I count on my employer to follow the rules when I report a work related injury?

  • Answer: Many employers do not understand or even know their obligations to their employees who get hurt at work. Some employers are fearful that if you make a claim, it will somehow hurt them. After you have informed your employer that you were hurt at work, he/she is required to provide you with a claim form so he/she can formally report the injury his/her workers’ compensation insurance company. In addition, your employer is required to provide you with a copy of the claim form identifying who the insurance company is so you may contact it if necessary. If your employer fails to provide a claim form, you may obtain one online at www.dir.ca.gov, or from your local district office of the Workers’ Compensation Appeals Board.

Question: I have heard that many employers suspect that their injured employee is somehow attempting to defraud them?

  • Answer: It is unfortunate, but true, that many employers incorrectly suspect their employees of filing false workers’ compensation claims. Nevertheless, if you have suffered a legitimate work related injury, demand from you employer a claim form and immediately seek the medical care you need. If you believe your employer or the insurance company is treating you inappropriately, call us right away.

Question: My employer’s insurance company has advised me they are going to delay my case for 90 days in order to conduct an investigation. Can they do this?

  • Answer: Yes, the insurance company has a legal right to reasonably delay and investigate any claim it receives. However, during the course of the investigation the insurance company must keep you informed of its progress.

Question: If the insurance company delays my claim for 90 days, how will I pay my bills?

  • Answer: We recommend you go the employment development department (EDD) and apply for state disability insurance benefits (SDI) immediately. In fact, we recommend that you apply for SDI benefits even if the insurance company IS paying you disability benefits. Call us and we can tell you why.

Question: If the insurance company delays my claim for 90 days, how will I be able to get medical care?

  • Answer: Even if the insurance carrier delays your claim for 90 days, it must still provide the medical care you need as a result of your injury. In fact, it must continue providing your medical care until your claim is denied, or until the insurance company has spent $10,000.00 on your care, whichever happens first.

Question: The insurance company has told me that they have a right to choose the doctor I must treat with for my work related injury, and that I have no say in the matter. Is this true?

  • Answer: Not exactly. The insurance company is required to create a Medical Provider Network (MPN). This is a network, or group of doctors who are pre-authorized to treat your injury. While you are required to select and treat with one of these pre-approved doctors, you are allowed to switch to a different doctor within the MPN if you are not satisfied with the care you are receiving.

Question: The insurance company has accepted my claim, but my doctor tells me they will not authorize the treatment she wants me to have. What can I do to get the treatment I need?

  • Answer: Insurance companies often delay and deny medical care which is recommended by the treating doctor. If you are in need of treatment being denied by the insurance company, it may be possible to request an expedited hearing before a workers’ compensation judge, and have the judge order the insurance company to authorize your care.  Contact us right away so we can determine whether or not that is an option in your case.

Question: The insurance company says I have to see a Qualified Medical Examiner (QME) to help resolve my case. Is this true?

  • Answer: Perhaps. If either you or the insurance company is not satisfied with what your treating doctor is saying about your medical condition, either of you may request from the state medical unit a list of QME doctors. If you receive the list of QME doctors, you have only 10 days to select a doctor from the list and schedule an appointment with her. If you fail to do this within those 10 days, then the insurance company will select the QME doctor for you. Remember, the insurance company knows these doctors and will select a doctor who will be favorable to it, NOT FAVORABLE TO YOU!
  • YOU SHOULD CALL US FOR AN APPOINTMENT TO ANALYZE YOUR CASE BEFORE YOU SEE ANY QME DOCTOR. YOU ARE ONLY ALLOWED ONE QME FOR YOU CASE. IF YOU SELECT THE WRONG DOCTOR, YOU MAY SERIOUSLY DAMAGE YOUR CASE!!

Question: How much will it cost me to hire an attorney?

  • Answer: Attorney fees in most workers’ compensation cases are limited to 9% – 15% of the amount the attorney obtains for you by way of a settlement, or by an award from a judge. The fees are contingent on some form of recovery. In other words, if the attorney does not obtain a settlement or award for you, there will not be any fee awarded to the attorney. In some cases it may be possible to make the insurance company pay your attorney’s fee. Ask us how.

Question: What advice do you have, which can help me with my case?

  • Answer: We always advise our clients to do the following: Never give a recorded statement or allow yourself to be interviewed by anyone from the insurance company without your attorney present. You have an absolute right to have your attorney present at any interview by an investigator or attorney, and to have the insurance company pay your attorney for attending. Keep all correspondence you receive from the insurance company (including the envelope), and copies of everything you send to the insurance company. Always follow your doctor’s medical advice and ask her to provide you copies of everything she provides to the insurance company. Keep a record of the mileage you drive in order to obtain medical care. The insurance company is required to reimburse you for all the miles you drive to obtain medical care. CONTACT OUR OFFICE IMMEDIATELY IF ANY OF THE FOLLOWING EVENTS OCCUR: If your employer refuses to give you a claim form. If your employer asks you not to report your injury to the insurance company. If your employer takes adverse action against you because you got hurt at work. If you receive a list of QME doctors.

Remember, worker compensation claims can be very complicated and confusing for both inured workers and employers. An uninformed injured worker can make mistakes which can have serious and negative effects on your case. Please see us before making any decisions about your workers’ compensation case

NOTE: Making a false or fraudulent workers’ compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000.00 or double the volume of the fraud, whichever is greater, or both imprisonment and fine.

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