When it comes to workers’ compensation claims, both the employee and employer have responsibilities. These claims are expensive, so the employer in California has to ensure that the employee is being honest. This requires due diligence for the employer and patience from the employee. The following is an overview of the responsibilities of the employer and employee during the claim process.
What Is a Workers’ Compensation Claim?
A workers’ compensation claim is a formal request for benefits by an employee who suffers a job-related injury or illness. In California, these claims are overseen by the California Division of Workers’ Compensation (DWC) and governed by the California Labor Code.
Workers’ comp benefits in California can include:
- Medical treatment
- Temporary Disability (TD) payments
- Permanent Disability (PD) compensation
- Supplemental Job Displacement Benefits (SJDB)
- Death benefits for surviving dependents
Employer Responsibilities in a California Workers’ Compensation Claim
During a worker’s comp claim, the employer is expected to cooperate with the employee’s insurance provider. When the employee is cleared to return to work, they employee should be welcomed back even though they filed a claim against the company. The employer will work with the workers’ compensation board in the state so that fraud can be prevented. The employer is put in a tough spot because there is a fear that one claim could lead to others. An employer cannot terminate an employee who was right in the claim, however.
Additional Legal Duties for California Employers
- Provide the DWC-1 Claim Form within one working day of being notified
- Report injury to the workers’ comp insurance carrier within 5 days
- Offer access to a certified Medical Provider Network (MPN)
- Cooperate with Utilization Review (UR) for treatment approvals
- Maintain all required documentation and case files
- Accommodate modified or alternative work if an employee is medically cleared
- Avoid retaliation, as prohibited by Labor Code S132a
Employee Responsibilities During the Workers’ Compensation Process
The employee is expected to act responsibly during the claim process and at work. If a claim must be filed, the employee has to report the injury as soon as possible. Cooperation goes both ways. This means that the employee will answer questions as necessary. If the employee is truly injured at the workplace, then the employee must not engage in activities that can worsen the injury or make it seem like their injuries are false.
Specific Employee Duties
- Report the injury to the employer within 30 days
- Seek treatment through the MPN
- Submit to an Independent Medical Examination (IME) or Qualified Medical Evaluator (QME)
- Provide full medical documentation
- Comply with return-to-work recommendations
- Avoid activities or social media posts that contradict injury claims
Understanding the Workers’ Compensation Claim Lifecycle
Here’s how a typical workers’ comp case proceeds in California:
Step-by-Step Timeline:
| Step | Description |
|---|---|
| 1. Injury Occurs | At the workplace or due to job activity |
| 2. Employee Notifies Employer | Within 30 days of the incident |
| 3. Employer Provides DWC-1 | Within 1 working day |
| 4. Claim is Filed | With the employer’s insurer |
| 5. Medical Treatment Begins | Through the MPN and UR system |
| 6. Evaluation by QME or AME | If the injury/disability level is in dispute |
| 7. Temporary Disability Paid | If an employee can’t return to work immediately |
| 8. Return to Work or Disability Settlement | Based on recovery and medical status |
| 9. Claim Resolution | Either via settlement or WCAB hearing |
The Importance of Legal Help in Workers’ Compensation Cases
One way to make the workers’ comp claim process run more smoothly is to seek legal help. Since the employer has the right to conduct their investigation, the employee has to be sure that their case has no holes. By procuring the legal assistance of a lawyer who works on these cases, the case may be more solid, and it may help the employee who requires aid due to the injury.
When to Hire a Workers’ Compensation Attorney
- Your claim is denied or delayed
- You’re asked to undergo a QME or IME
- Employer disputes your version of the injury
- Your injuries cause permanent disability
- You face retaliation or termination
An attorney can help appeal to the Workers’ Compensation Appeals Board (WCAB) or dispute unfavorable findings.
What Happens If a Workers’ Comp Claim Is Denied?
Denied claims can be appealed. Steps include:
- Request a Qualified Medical Evaluator (QME)
- File an Application for Adjudication with WCAB
- Attend a Mandatory Settlement Conference (MSC)
- Prepare for trial if needed
Legal representation is highly recommended during this process.
Temporary vs. Permanent Disability in California
- Temporary Disability (TD): Paid while recovering and unable to work
- Permanent Disability (PD): Paid when injury leads to lasting limitations
The percentage of disability determines the final settlement or benefit amount.
Return-to-Work Programs and Accommodations
California law encourages employers to reintegrate injured workers. Options include:
- Modified duty
- Shortened hours
- Ergonomic changes
- Vocational retraining (via SJDB vouchers)
Employers can also consult with physicians and the QME to plan a safe return.
Preventing Workers’ Compensation Fraud
Both employers and employees can commit fraud, intentionally or unintentionally.
Common Types of Fraud:
- Employee exaggerates or fakes injuries
- Employer misclassifies workers to avoid premiums
- Employer discourages claim reporting
Fraud is punishable by fines, benefit loss, and even jail time under California Penal Code S550.
Frequently Asked Questions (FAQs)
1. How long do I have to file a workers’ comp claim in California?
You must report the injury within 30 days and file your claim within one year from the date of injury.
2. Can I sue my employer for a workplace injury?
Generally, no. Workers’ compensation is an exclusive remedy, but if the injury was due to intentional misconduct or lack of insurance, you may have grounds to sue.
3. What is a Qualified Medical Evaluator (QME)?
A QME is a state-certified doctor who evaluates your injury when there is a dispute between you and the insurance company.
4. What if my QME and personal doctor disagree?
You may need to go through a Panel QME process, or use an Agreed Medical Evaluator (AME) if both parties consent.
5. Can I choose my own doctor?
Only if you had pre-designated a physician before the injury. Otherwise, you must use a provider in the Medical Provider Network (MPN).
6. How long do benefits last?
Temporary Disability benefits are usually paid for up to 104 weeks within 5 years. Permanent Disability varies based on the rating.
Need Legal Support for Your Workers’ Comp Case in California?
At Hussain & Gutierrez Law, we specialize in guiding injured workers through the complex California workers’ compensation system. Whether you’re filing your first claim, dealing with a denial, or preparing for a QME appointment, we’re here to help you secure your rightful benefits.
Contact us today for a free case evaluation
