If you sustained an injury while on the job, you likely have several questions. Here are answers to some of the more common questions involving workers’ comp and related legal and claims processes.
There may be a need to secure a deposition from a Qualified Medical Evaluator (QME) or an Agreed Medical Evaluator (AME). This step is usually only necessary if there is a disagreement by you or your insurance company over the treating physician’s opinion. The QME and AME are entirely different doctors.
Certified by the Division of Workers’ Compensation Medical Unit, a QME is certified as being capable of performing medical and legal patient evaluations. An AME is a physician selected by the attorneys involved with the case. Either type of third party expert opinion may be sought if there are disputes about your injury, disability, or impairment. Disputes that may require a deposition from either a QME or AME may involve:
- A determination of whether or not the injury was likely caused by the work you do
- Whether treatment is necessary for your work-related injury
- Whether your condition or injury is considered temporary or permanent
- The permanent disability rating you received from the treating physician
- If it’s recommended that you remain off the job while you recover
A settlement of a worker’ comp claim or case could result in a lump sum payment. However, seeking a settlement means no more weekly benefits. In some situations, medical benefits may continue, but it’s also possible that an insurer may stop such payments if a settlement has been reached or accepted.
As for when you can settle, you are free to discuss settlement options at any time. However, most attorneys recommend waiting until you receive a medical evaluation before making this decision.
The settlement must be approved by the state workers’ compensation agency. Calculations for your settlement will be based on the amount of the workers’ comp benefit amounts you may have been entitled to receive and how likely it was that you would have received those benefits.
According to one survey, it took an average of nearly 16 months for workers’ comp cases to be resolved, either through a voluntary settlement or as a result of a hearing. The time it will take to settle your case will depend on the circumstances involved and the extent of your injury or injuries.
If your case requires a formal hearing in court before a workers’ compensation judge, the first step you’ll want to take is hiring a lawyer. You will also need documents that include medical evidence regarding your claim, unpaid medical bills, and any other documentation that supports your claim. Preparing for court can also involve:
- Calculating your damages — e.g., medical bills, lost wages, and other benefits
- Securing depositions from medical experts or bringing in expert witnesses, such as doctors, independent medical examiners, and vocational experts
- Asking co-workers who may have witnessed the incident to testify
- Presenting an accurate timeline of your injury — e.g., the date and time it occurred, when you reported the incident, what type of medical care you received, what symptoms you experienced, how those symptoms have progressed over time, etc.
Temporary total disability (TTD): This is an injury that’s serious enough to prevent you from doing your job, but it’s also one you are expected to recover from.
Temporary partial disability (TPD): With this type of an injury, you would only be temporarily limited with certain job duties.
Permanent disability (PD): This type of injury or disability is so severe that you’re not expected to recover enough to be able to return to work.
Partial permanent disability (PPD): With an injury of this nature, you can still work, but you are permanently limited with certain abilities. For example, a worker no longer able to stand for long periods of time may be retrained to do office work.
The Employment Development Department (EDD) is a California state agency that provides a variety of services for both existing employees and job seekers. The EDD manages several programs for unemployment and disability insurance.
A medical provider network (MPN) is a group of physicians and other medical professionals who specifically provide medical treatment for injured workers.
Denied claim: A denied claim is one that is not paid because it has been denied by an insurer after the initial documentation was submitted.
Delayed claim: A workers’ comp claim may be “delayed” for up to 90 days. This may be done if there is a need to investigate an alleged workplace incident. Other times, insurance providers use this tactic to tire a worker to the point where they opt to stop pursuing the claim.
Admitted claim: An admitted/accepted claim is one that is covered under an employer’s workers’ comp insurance according to the claims administrator.
California Labor Code Section 132(a) prohibits employers from discriminating against any employee who has filed a workers’ comp claim. A 132 claim refers to allegations that an employer has violated this particular code. An employee must prove that they were discriminated against in some way because they filed a worker’s comp claim. Discrimination related to a 132 issue may involve:
- Being terminated specifically because of having filed a claim
- Being demoted because of issues regarding a claim
- Purposely being moved to an undesirable shift or workplace location in order to pressure a worker into dropping a claim or settling one
Note: Simply being terminated while your claim is being investigated or processed does not automatically mean you have a valid 132 claim.