I’ve Just Been Injured on the Job, What Happens Now?
Having an on-the-job injury or illness can be a traumatic event. While you recover, you are faced with the task of understanding your rights and responsibilities under the State of California Workers’ Compensation system. The following information, along with the information provided in the Notice of Potential Eligibility, will hopefully answer most of the questions you have regarding a recent injury.
What happens after you have returned the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility (e3301) to your employer?
Although you have up to a year from the date of your injury to file a claim form (e3301), it is important that you promptly return the completed claim form to avoid the risk of losing benefits to which you may be entitled. Once you have returned the claim form to your employer, it is forwarded to the State Compensation Insurance Fund (State Fund). State Fund is the adjusting agent that manages your claim for workers’ compensation benefits and provides you with benefits to which you are entitled. State Fund will establish your workers’ compensation claim and within fourteen days send you notification that your claim has been delayed, accepted, or denied. State Fund makes all liability determinations regarding your claim of injury or illness based on available medical documentation and relevant facts.
What happens if your claim is delayed?
If your claim is delayed, State Fund needs additional information in order to make a liability determination. State Fund has 90 days from your employer’s date of knowledge that you are claiming a work-related injury or illness to make its determination. Your employer will pay for up to $10,000 in medical treatment until a liability determination has been made. If the $10,000 cap is reached prior to a liability determination, then you or your medical insurance carrier are responsible for paying the cost of any additional medical treatment that you receive as a result of your injury or illness. Also, you will not be compensated for any lost time from work pending State Fund’s liability determination. If you miss time from work during the delay period, you should contact your personnel office to find out about other leave options that may be available to you. State Fund may send an investigator to gather more information or request that you attend a medical evaluation. You will be asked to complete and sign medical release forms so that State Fund can obtain copies of your prior medical records. State Fund will use all relevant information to make a liability determination regarding your claim.
What happens if your claim is accepted?
If your claim is accepted, State Fund will pay for all approved medical treatment, hospital visits, and reasonable medical transportation. State Fund will reimburse you or your insurance carrier for approved medical treatment received prior to the acceptance of your claim. State Fund will require you to submit a receipt with any requests for reimbursement of out-of-pocket medical expenses (for example, co-payment, parking fees). State Fund will provide you with all benefits to which you are legally entitled as described on the Notice of Potential Eligibility.
What happens if your claim is denied?
If your claim is denied, you or your medical insurance carrier will be responsible for the costs of any medical treatment that you receive as a result of your injury or illness. You will not be provided with any type of compensation. If you have lost time from work, you should contact your personnel office to discuss other leave options that may be available to you. If you agree with the denial, your claim will be closed. If you disagree with the denial, you have a right to dispute State Fund’s determination. Your options for disputing the determination are outlined in the denial letter that is sent to you by State Fund.
What are your responsibilities?
As an injured worker, you should know that your entitlement to workers’ compensation benefits is based on the medical information received regarding your injury. Your employer must rely upon medical information in order to coordinate all return to work issues that may arise. To alleviate any delays in the provision of your Workers’ Compensation benefits, it may be helpful for you to remember that you are responsible for the following:
- Accept examination and treatment by the medical provider arranged for you by your employer, unless you have pre-designated (prior to your injury) a treating physician or medical group in writing.
- Provide State Fund and your employer with copies of medical notes or reports that you receive from your treating physician. These notes or reports contain information regarding your ability to work including any restrictions which must be considered by your employer.
- Inform both State Fund and your employer of any name or address changes.
- If you have lost time from work due to your injury, make sure to submit an Absence Request form (STD 634) each month that clearly notes the lost time due to your work-related injury or illness.
Who can you contact if you have additional questions or concerns?
Your department’s Return to Work Coordinator.
