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Understanding California’s workers compensation system begins by becoming familiar with the terms an injured worker might encounter

workers compensation systemPursuing a California worker’s compensation claim is easier when the injured employee understands the process. In the first part of a two-part series, we explain ten of the twenty most common terms used in California workers’ compensation law. A Santa Rosa workers’ comp lawyer can answer any additional questions that an injured employee might have.

Alternative work. Injured workers who have a permanent disability that prevents them from returning to their former job might be offered alternative work. A job offer for alternative work must generally pay at least 85% of the injured worker’s former wages and benefits, must be within a reasonable commuting distance from their last place of employment, and must last for at least 12 months. The job duties must also be consistent with the injured worker’s permanent work restrictions. Employers have an incentive to offer alternative work as a way to avoid paying supplemental job displacement benefits (or vocational rehabilitation benefits for injuries occurring before 2004).

Agreed Medical Evaluator (AME). When the injured worker’s Santa Rosa workers compensation attorney and the claims administrator cannot agree on the extent of a permanent disability, they may decide to resolve the dispute by agreeing upon a physician who will perform a one-time medical examination of the injured worker. The physician selected to perform the examination is called an agreed medical evaluator.

Claims administrator. A claims administrator is the person who handles a workers compensation benefits claim on behalf of the employer or the employer’s insurance company. A claims administrator might also be known as a claims adjuster. The claims administrator is required to provide injured workers with certain information after they make a claim for benefits. The claims administrator also investigates the claim, pays medical expenses related to the work injury, pays temporary disability benefits, and if the injured worker suffers from a permanent impairment, pays permanent disability benefits. The injured worker’s Santa Rosa workers compensation attorney will generally negotiate with the claims administrator to settle the claim for benefits.

Compromise and Release. The most common way to settle a dispute about workers compensation benefits is called a compromise and release. Rather than receiving permanent disability benefits in installment payments, the injured worker agrees to accept a lump sum payment. Since the injured worker also agrees to be responsible for any future injury-related healthcare costs, they usually receive a larger monetary award than they would receive if they were to be paid permanent disability benefits in installment payments.

Date of Injury. The date of injury is one factor that determines an injured worker’s entitlement to benefits. Deadlines for making claims are also measured from that date. When an injury is caused by a work-related accident, the date of injury is the date of the accident. When an injury develops over time (such as an occupational disease or a repetitive stress injury), the date of injury is the date the employee knew or should have known that the injury was caused by work.

Disability. For the purpose of workers compensation law, a disability is an impairment of the body or mind that affects the injured worker’s life. A disability can be temporary or permanent. A disability that prevents all work is a total disability, while a disability that allows the employee to perform some work is a partial disability.

Employee. Only employees are entitled to workers compensation benefits. However, whether a worker is an employee is determined by a legal test, not by the label assigned by the business that hired the worker. As a general rule, a worker who performs labor or services exclusively for one business at a location and time chosen by the business, whose work performance is controlled by that business, and whose work is closely supervised will generally be regarded as an employee even if the business classifies the worker as an independent contractor. An injured worker who is denied workers’ compensation benefits because the worker has been labeled as an independent contractor should ask for legal advice from a Santa Rosa workers’ compensation lawyer.

Impairment Rating. When an injured worker’s physician writes a permanent and stationary report, the doctor will assign an impairment rating. Impairment ratings are based on the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, and are intended to objectively rate the degree to which the employee’s ability to engage in the normal activities of daily living are impaired. That impairment rating is then used as a key factor in determining a permanent disability rating. The AMA Guides can be controversial if they suggest little or no impairment for someone whose condition causes ongoing symptoms and other issues. Fortunately, a Santa Rosa workers’ compensation lawyer can help injured workers challenge an unrealistic impairment rating.

Maximum Medical Improvement. An injury has reached Maximum Medical Improvement when it has stabilized but not completely healed, and further improvement is unlikely. When a doctor determines that MMI has been reached, the injured worker should expect temporary disability benefits to end and will be in a position to seek permanent disability benefits.

Modified Work. Before an injured worker’s medical condition reaches Maximum Medical Improvement, the treating physician may decide that the injured worker is able to return to work, with restrictions. If the physician imposes work restrictions, the employer may choose to modify the injured worker’s former job in a way that satisfies those restrictions. Offering modified work is a way for employers to avoid providing the injured worker with temporary disability benefits, and in some cases a Supplemental Job Displacement Benefit, or voucher.

Help with Workers’ Comp Claims. To learn more about how California’s workers compensation system works, call Kneisler & Schondel at (707) 542-5132. You can also ask a question by submitting our online contact form.