California has specific laws that define the procedure for employees who suffer an injury on the job. The California Division of Worker’s Compensation (DWC) investigates and handles worker’s compensation claims. Here is an overview of the legal process an employee and employer must follow after an injury or illness that occurred as a result of a work-related injury.
ERM offers Workers’ Compensation Insurance to businesses in Southern California.
Step 1: Accident Report
The first step is to report any work-related accidents and any injuries to your employer. An injury qualifies for workers’ compensation coverage if the damage or harm an employee suffers is the direct result of an accident or exposure to a hazardous environment in the course of employment.
Employees must notify their supervisors within 30 days of when an injury takes place. Failing to report the injury can result in a delay in the claims process or a denial of the claim altogether. If an employee waits more than one year to report an injury, the DWC may not allow the employee to recover all costs from the employer or its insurance carrier.
If an employer wants to dispute a claim, they have to go through arbitration or independent medical review before seeking a hearing with the Workers’ Compensation Appeals Board (WCAB) or in the judicial system.
Employees and their legal counsel should first try to resolve any claim disputes directly with their employers or the employer’s insurance carrier. If matters remain unresolved, the parties must submit to arbitration if the dispute is related to insurance coverage or the right of contribution. Other matters must also go through arbitration if the parties agree to this dispute resolution process.
A party that is dissatisfied with the arbitration award can request the WCAB to review it. The WCAB may refer the matter to an administrative judge or hold a hearing to evaluate the award. The board will reconsider its decision only if a party can prove its final order was unjust or unlawful.
If the parties to a disputed claim remain dissatisfied with the final administrative order, they can request judicial review. However, this type of review is limited; a court cannot re-hear a disputed claim, admit new evidence or issue an independent judgment on the evidence presented. In the end, the WCAB decision will be upheld or remanded for further administrative proceedings.
Independent Medical Review
Due to an amendment to California’s workers’ compensation law, medical treatment disputes (including disputed spinal surgery recommendations) must go through an Independent Medical Review Process, effective Jan. 1, 2013.
Appealing an IMR decision is difficult under California law. A party can appeal an IMR decision only if it can prove with clear and convincing evidence that:
- The decision was made without or in excess of the reviewer’s authority;
- The decision was procured by fraud;
- The IMR physician was subject to a material conflict of interest;
- The decision was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color or disability; or
- The decision was the result of a plainly erroneous express or implied finding of fact (the fact must be based on ordinary knowledge, not subject to expert opinion).
The appellate courts and the California Supreme Court have the authority to review, correct or annul an order or judgment. However, employers must go through the channels described above before they can submit their case to an appellate court.
Contact your local experts, ERM Insurance Brokers (949) 222-0444 for more information on workers’ compensation laws in California.