California Workers’ Compensation Attorneys

If your claim is denied, you must first be aware that it was not the decision of your boss or employer. Instead, it is the decision of a claims administrator working for or with an insurance company. Due to the disconnection between yourself and the people handling your claim, simply asking for a second review of your paperwork for potential errors will likely be fruitless.

To get to the source of the problem, you will likely need to file for an appeal, administrative review, and a mandatory settlement conference (MSC). During the MSC, you will meet with your claims administrator and attempt to reach an amicable settlement. It is highly recommended that you work closely with a professional attorney at this time so you do not accept lowballed amounts. If your MSC is unsuccessful and you were not given the chance to receive fair compensation, your case will go to an administrative review, which is considered a form of trial in California; again, the presence of a workers’ compensation lawyer will be incredibly useful.

During your administrative review or trial, you will be able to:

• Make arguments as to why you require workers’ compensation
• Present evidence for your case
• Refute claims presented by the claims administrator

The verdict or ruling for your trial will not be issued immediately. You will have to wait anywhere between 30 to 90 days for a written decision to be mailed to you. A petition for reconsideration can be filed if the decision is not in your favor, and a final, similar process begins.

After you suffer a workplace injury, you should be given an amount of workers’ compensation benefits to help you rest and recover without needing to worry about your job and your bills. Not all workers’ comp claims are the same, and so not all benefits packages or amounts are the same.

The severity of your injury, and how long it is expected to affect you, can change your compensation by categorizing your claim into one of four different classes:

• TTD: An injury that completely prevents a worker from completing their regular job functions but also is not severe enough to stop an eventual recovery creates a temporary total disability (TTD) case. At least 8 or more work days must be missed for an injury to be considered to cause TTD. For example: If your job was to patrol a property on foot as a security officer but you broke an ankle in a fall accident, you could not make your patrols while recovering but you would, in theory, be able to return to work eventually.
• TPD: A disabling injury that prevents only some work to be completed but should eventually heal given the right treatments creates a temporary partial disability (TPD) case. For example: If you were a retail worker who stocked shelves but suffered a back injury, you could be asked to put away light items within comfortable reach but not heavy items or those that require stooping.
• PD: When an injury is so severe that it is never expected to fully heal and completely removes a person from the workforce, it is known as a permanent disability (PD). The most dramatic of disabilities, a PD will often reward the most compensation to the injured party, as any sort of work could be considered dangerous. For example: If you were a firefighter who became paralyzed after a collapsing roof struck you, you should be granted PD.
• PPD: Some wounds never heal entirely but also do not completely remove a person’s ability to work. This is a partial permanent disability (PPD). For example: If you worked for a local delivery company but broke a leg, making any amount of walking painful, you could be reassigned and retrained for seated office work at the same company.

When you are injured on the job, there is a process that you must go through to file for benefits. One step of the process for a workers' compensation claim is to be examined by an approved physician. During this examination, the physician will make notes of both your injuries and state of disability, if there is one. This information goes into your medical record and is an essential part of securing benefits or a disability rating.

At Alvandi Law Group, our Orange County workers' compensation attorneys can help you navigate the process and prepare for the AME.

There is a special process involved in choosing the medical evaluator so that there is no bias. You will need to agree with the insurance claim administrator on a doctor, which a skilled attorney can help with. Otherwise, the Division of Workers' Compensation Medical Unit may be involved in this selection. The outcome of the AME (agreed medical examination) and your physician's notes will have a significant impact on your case.

The purpose of an AME includes the following:

• Establishing a medical opinion on any existing treatment needed
• Determining whether future medical treatment will be needed.
• Providing a professional medical opinion on any relevant issues
• Establishing whether there is a permanent impairment or disability

At Alvandi Law Group, we know how to spot insurance companies' attempts and questions intended to deny claims, which we can use to your advantage. Hiring a workers' compensation lawyer can benefit your case greatly, especially if your workers' comp claim is complex or if you are concerned about whether or not you qualify.

A few examples of questions you might be asked include:

• Basic information, such as your name and background.
• How was your injury caused or what led to the accident?
• Have you undergone medical treatment and if so, what type?
• Did you have any previous injuries that were not work-related?
• What were your duties at jobs before your existing jobs?
• What type of physical hobbies do you have, such as sports?
• Does your injury prevent you from doing your current job?
• Does your injury stop you from doing any work at all?

The workers’ compensation benefits that you ultimately receive through your employer’s workers’ comp plan will be significantly affected by when you reach your maximum medical improvement or MMI. A patient has reached their MMI when the treating physicians believe that no amount or type of continued care will help them heal more from their injuries than they already have. Once MMI is reached, the patient’s care will shift from curative procedures to medical treatments designed to make life more comfortable, like routine physical therapy and prescription medications.

MMI is so important in a workers’ compensation case because it is a defining point in terms of what the injured employee will be able to do for work in the future. If you reach your MMI and you still experience sharp pain when standing for an extended period, for example, then you will need sedentary work with minimal physical exertion. Your employer and the insurance company need to be ready to accommodate and compensate you based on your post-MMI health.

Once you reach your MMI, the following determinations, and more, must be made:

• By your employer: You cannot be expected to continue a job position that would exacerbate your injuries or disabilities that appear to be permanent now that you have reached your MMI. Your employer will need to find a role for you that is safe for your health conditions but also pays the same or more than what you earned pre-injury. If they cannot, then your workers’ compensation benefits might be expanded to include vocational retraining that helps you start a new career or seek an advanced educational degree or certification.
• By the insurer: Upon reaching MMI, the insurer handling your case will have to determine if you qualify for extended wage replacement benefits, like permanent total or partial disability pay. Additionally, and importantly, the insurer will likely have the option to pay for fewer medical treatments once you reach MMI because treatments shift from curative to palliative. Secondary medical services are designed to help you maintain MMI, and the insurer will not be compelled to pay for experimental or optional treatments that could feasibly improve your health.

After suffering a work-related accident or illness and filing a claim under workers’ compensation, you may be contacted by an adjuster from your employer’s workers’ comp insurance provider.

Do you know what to say, or, more importantly, what not to say?

• Do not agree to anything: Speaking to a workers’ comp claims adjuster in any capacity is usually a bad idea, since it can only serve to hurt your claim. While adjusters may present a friendly outward façade or claim that they are there to help, in reality, claims adjusters have one objective in mind: to save their insurer money. Any and all information you provide to an adjuster may potentially be used to limit or deny your claim.
• Do not discuss your medical condition: Avoid discussing your medical condition, as insurers may try to claim that your injuries are not caused by a work accident. If an insurer pushes you to discuss your health, have them discuss this with your attorney.
• Do not accept an offer without consulting an attorney: In many cases, it is not uncommon for workers’ comp insurers to have adjusters contact claimants in an attempt to get them to settle their case early and on their own, oftentimes for much lower than what they actually deserve. This can be dangerous. Settling early can cause a person to be held financially liable for any medical expenses or losses that exceed the limits of their settlement. For this reason, if you are contacted by a claims adjuster, it is highly recommended you do not agree to any settlements or authorizations of any kind and get in touch with an attorney as soon as possible. A lawyer can handle all negotiations and advocate for maximum compensation on your behalf, allowing you to focus on your recovery with peace of mind.

After suffering a work-related injury, your primary concern will likely be to seek medical treatment as soon as possible. But can you see your primary care physician, or do you have to wait and see a doctor designated by workers’ compensation? More importantly, when should you see a doctor?

Is your injury an emergency?

If your injuries require emergency medical treatment, call 911 or head to the nearest emergency room as soon as possible. Your employer must make sure you have access to emergency treatment immediately and may tell you where to go for treatment. Be sure to inform the medical staff that your injury or illness is job-related.

If your injuries are not an emergency, you should first report the injury to your supervisor or some other figure of authority immediately. For injuries which develop over time, such as tendinitis, be sure to report your injury as soon as you feel symptoms or have reason to believe that it was caused by your job. The sooner you report your injury, the more likely you will avoid problems and delays in receiving your benefits. In fact, if you wait more than 30 days, you could lose your right to benefits entirely.

Did you predesignate?

Aside from emergency situations, injured workers will usually be required to wait to receive treatment until they are directed to a physician approved by their employer’s workers’ compensation insurance unless they previously informed their employer in writing the name and address of their primary physician or medical group prior to being injured. This is known as predesignating. Those who have predesignated may see their personal physician immediately after being injured.

It is important to note that you may only predesignate if you have health care coverage for medical conditions that are unrelated to work. To predesignate, you must prepare your own written statement, use DWC Form 9783, or use a form provided by your employer.

Be sure to include the following information:

• The date
• The name of your employer
• Your name
• Your physician’s name, address, and phone number
• Your signature
• A statement authorizing your personal physician to provide care

The purpose of a consultation is to discuss the details of your claim with someone who is familiar with the workers’ compensation system before actually hiring someone, so you can feel confident in your choice. A consultation is also a good platform for asking any questions you have about your own claim, or workers’ compensation in general.

Before you pick up the phone and call a workers’ compensation attorney, you should gather all of the information you have about your claim and think about why you are calling. Compile all of the:

• Medical records
• Job documents
• Witness contact information
• And other information related to your case

A consultation is not only an opportunity for you to meet a lawyer, but it is also an opportunity for the lawyer to meet you — providing comprehensive information will facilitate the process.

Following an on-the-job accident, many questions about your claim will arise naturally, but taking the time to sit down and think about your goals for pursuing legal action will help you arrive at other questions you need answered.

You may want to ask your workers’ compensation attorney questions such as:

• What benefits am I entitled to?
• What are my rights during the claims process?
• What evidence should I gather to help my case?

The attorney you are speaking to will need complete details about your claim to provide fully informed insight. You should be prepared to recount the events that occurred and discuss your injuries and expenses in depth.