If you get injured at work, you will probably have many questions. You may not be sure of the severity of your injury, how long or complicated the healing process will be, or when you can return to your regular duties. That can mean falling behind on your bills and not getting all the medical care you need, all while hoping you can get back to work at some point.
The most important thing you can do during that time, from the standpoint of protecting yourself financially and legally, is to know your health care rights for workers’ compensation insurance. Here is what to consider when making your case and filing for these benefits, so you can have the best chance of receiving all that is due to you.
Understanding Your Choice of Doctor
If you pre-designated a doctor, you could see them for treatment after your injury. However, if you did not have a predesignated health care professional, you will have to see one approved by the Division of Workers’ Compensation and selected by your employer.
This doctor must come from the Medical Provider Network (MPN) or Health Care Organization (HCO) your employer selected, but not all employers have taken this step. If your employer chooses no HCO or MPN, your doctor will be set by the claims administrator for your case. You must see that doctor for the first 30 days, and then you can choose your doctor, as long as they are reasonably close to your current location.
This Guide Applies to California Workers’ Compensation Law
California has some of the most detailed and employee-friendly workers’ compensation regulations in the U.S.
Everything discussed in this article is based on California Labor Code and DWC (Division of Workers’ Compensation) procedures. Always consult your attorney or official resources if you’re in another state.
For official resources, visit the California DWC website.
What Are Your Employer’s Legal Responsibilities?
Your employer plays a critical role in your workers’ comp process. Under California law, they must:
- Provide you with a DWC-1 claim form within one working day of learning about your injury.
- Inform their workers’ comp insurance carrier within 5 days.
- Authorize up to $10,000 in medical care while your claim is being reviewed.
- Post required notices and provide access to the MPN (Medical Provider Network).
- Not retaliate against you for filing a claim.
Failing to comply can result in penalties and even criminal liability.
What Happens After You Report Your Injury?
Once you report your injury to your employer:
- You should receive a DWC-1 Claim Form.
- You begin receiving medical treatment, either immediately authorized or pending claim investigation.
- Your employer’s insurance must decide to accept or deny the claim within 90 days.
- You may be scheduled for an evaluation with a QME (Qualified Medical Evaluator) or AME (Agreed Medical Evaluator) if disputes arise.
Options for Alternative Care
Alternative medical professionals, such as acupuncturists and chiropractors, could become your primary care provider after 30 days only if you had already designated them before your injury. You are also limited to 24 visits to your chiropractor before choosing another primary provider will be required. If you did not predesignate a chiropractor or acupuncturist as part of your medical team, using them as your care provider for a workers’ compensation claim will not be possible.
Other approved treatments include:
- Physical therapy
- Pain management
- Occupational therapy
- Psychological counseling (if medically necessary and legally valid)
Navigating Medical Disputes: What to Do When You Disagree With a Diagnosis or Treatment Plan
It is not uncommon to have disagreements regarding your medical care. Working with a Qualified Medical Evaluator (QME) or an Agreed Medical Evaluator (AME) will help you and the claims administrator resolve any differences you have throughout the process. This is much like working with a mediator. Read any correspondence you get about your claim, and speak up if you feel there are inaccuracies. Following proper procedures, time limits, and requirements can make the entire process easier.
Important: The QME/AME’s report will be used to determine:
- Your work restrictions
- Whether you’ve reached Maximum Medical Improvement (MMI)
- Permanent disability ratings
- Ability to return to work
What If Medical Treatment Is Denied? (Independent Medical Review – IMR)
If the claims administrator denies or modifies a treatment request recommended by your doctor, you can request an Independent Medical Review (IMR). This is a process conducted by Maximus Federal Services, independent from your employer and insurer.
- You have 30 days to request an IMR.
- The IMR determines if the denial was medically appropriate.
- The decision is final and binding, unless there is fraud or conflict of interest.
Workers’ Compensation Benefits You May Be Entitled To
A successful claim may entitle you to:
- Medical treatment: Fully covered if deemed medically necessary
- Temporary disability benefits: Two-thirds of lost wages (subject to caps)
- Permanent disability benefits: Based on impairment rating and wage loss
- Supplemental job displacement benefits: Vouchers for skill retraining
- Death benefits: For dependents, if the injury is fatal
Can You Get Workers’ Comp for Mental Health Issues?
Yes, but psychological claims in California must meet strict standards:
- The injury must be at least 51% caused by work-related stressors.
- There must be a diagnosed mental disorder (e.g., PTSD, anxiety, depression).
- These claims often face extra scrutiny, and legal help is strongly advised.
Return-to-Work and Vocational Rehabilitation Options
If you’re medically unable to return to your prior job, you may qualify for:
- Modified or light-duty work assignments
- Supplemental Job Displacement Benefit (SJDB) vouchers
- Career counseling or state-funded vocational rehabilitation programs
Ask your physician and attorney about eligibility and timing.
Legal Representation: Why It Matters
Do you need legal support and representation for your workers’ compensation claim? Contact us at Hussain & Gutierrez today, and get the information and guidance you are looking for. We know that an injury on the job can cause stress and uncertainty, but legal help makes navigating the workers’ compensation process easier. We want to ensure your rights are protected and you receive all the compensation to which you are entitled.
You don’t have to handle this alone. A seasoned attorney can:
- Ensure your claim is filed correctly and on time
- Challenge claim denials or underpayments
- Represent you in depositions, hearings, and appeals
- Maximize your medical and wage benefits
Frequently Asked Questions (FAQs)
What if I disagree with the doctor’s opinion?
You can request a QME/AME evaluation to resolve disputes about diagnosis, treatment, or disability status.
How long do I have to report a workplace injury?
You must report your injury to your employer within 30 days and file a claim within 1 year.
What does Maximum Medical Improvement (MMI) mean?
It means your condition is stable and no further functional improvement is expected. This triggers a permanent disability assessment.
Can I change my treating doctor?
Yes, after the first 30 days, you may switch to a new physician within the MPN, or outside it, if allowed by law.
What happens if my treatment is denied?
You can request an Independent Medical Review (IMR) to appeal the denial. This process is free and binding.
What if my employer didn’t give me a claim form?
That’s a violation of California law. Contact a workers’ comp attorney immediately to preserve your rights.
Can I sue my employer instead of filing a claim?
In most cases, workers’ comp is your exclusive remedy. However, if a third party (e.g., equipment manufacturer) caused your injury, you may have a separate personal injury case.
Your Health, Income, and Future Are Worth Protecting
Navigating the California workers’ compensation system can be overwhelming, especially when you’re in pain, confused, or frustrated. You need legal guidance, medical clarity, and a plan.
Whether your claim is new, denied, or in dispute, the team at Hussain & Gutierrez is here to help.
- Fight denied claims
- Maximize benefits
- Reduce delays
- Get peace of mind
Contact us now for a FREE consultation and let us protect your rights.
