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In California, your employer is required to have workers’ compensation insurance to protect employees like yourself who get injured in the workplace (also known as an industrial injury). If you do suffer from an industrial injury, you are entitled to certain benefits that will help you while you recover.
If you suffered from an industrial injury, you are entitled to receive all the medical care that is reasonable to cure or relieve your injury or illness. The type of medical care can include medical, dental, surgical, psychiatric, hospital treatment, nursing care, physical therapy (PT), acupuncture and other types of medical care. However, laws passed in 2003 and 2004 have limited what type of care you are entitled to.
1. Chiropractic Visits and Physical Therapy Visits
You are now entitled to no more than 24 chiropractic and 24 physical therapy visits for each work-related injury if your industrial injury occurred on or after January 1, 2004. However, you may be entitled to more if the insurance company’s claim adjuster authorizes further visits in writing.
2. Any Treatments You Received Must Be “Appropriate and Necessary.”
Any treatments you receive must meet the standard of being “appropriate and necessary.” That standard is based on the “Occupational Medicine Practice Guidelines,” published by the American College of Occupational and Environmental Medicine (ACOEM). If the treatment does not meet the guidelines, your treatment will most likely be denied by the insurance company.
3. The Utilization Review (UR) Process
Any request for medical treatment also must go through the insurance company’s utilization review process for approval. Many times, your medical treatment can be denied at this stage, which will further delay the medical treatment you need to recover from an industrial injury. However, any approvals, modifications, or denials of medical treatment must be timely communicated. If the insurance company fails to timely communicate its decision regarding your request, you may still be entitled to treatment.
TEMPORARY DISABILITY (TD) BENEFITS
You are entitled to temporary disability (TD) benefits if your treating doctor determines you cannot do any kind of work as a result of your industrial injury. Your TD benefit rate is two-thirds of your average weekly salary, up to the legal maximum. Additionally, you are generally only entitled up to a maximum of 104 weeks depending on when you suffered from the industrial injury or if you meet certain exceptions.
PERMANENT DISABILITY (PD) BENEFITS
Another benefit you are entitled to if you suffered from an industrial injury are permanent disability (PD) benefits. In order to receive PD benefits, your treating doctor must first determine that you have reached “Maximal Medical Improvement” (MMI). You have reached MMI when you have fully recovered from your industrial injury or your treating doctor believes no future treatment will help you improve over the next year.
If you are fully recovered, you are not entitled to any PD benefits. However, for most this is not the case. Even after reaching MMI, most workers will still suffer from some form of PD. Your PD will be rated on a scale from 0.25% to 100%. Depending on the percentage of your PD, you will be entitled to a certain monetary amount.
SUPPLEMENTAL JOB DISPLACEMENT BENEFIT
If you are unable to return to your previous work due to your industrial injury, you may also be entitled to supplemental job displacement benefits. The insurance company provides you voucher, which is redeemable for up to $6,000. You can then use the vouchers to help you gain new skills to return to work.
When an industrial injury causes or contributes to the death of an employee, the deceased employee’s surviving dependents are entitled to recover death benefits. These benefits include that of:
- A fixed monetary amount that depends on the surviving dependents and when the injury occurred.
- Up to $10,000 in burial expenses.
- The deceased employee’s TD and PD benefits.
Unfortunately, most insurance companies will find multiple reasons to deny the benefits you are entitled to. Most insurance company may simply deny your claim, which will deny you of any benefits. Our firm has extensive experience litigating against these insurance companies to ensure you obtain the benefit you deserve. You can rely on us to protect your best interests and provide you with personalized care you need.
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