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Section 2


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Guaranty: We win, or you don’t pay us a fee!

Frequently Asked Questions – Page One of Six

Workers Compensation Frequently Asked Questions – Page One of Six

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What does it mean if I have an “Accepted Claim”?

Generally speaking, there are two critical parts to having a valid workers’ compensation claim.

  1. You have to have suffered an injury.
  2. The injury must have occurred in the “course and scope of your employment”.

A claim is generally considered “accepted” if the insurance company agrees you’ve had some type of injury on the job. However, just because the claim is accepted, there are challenges. For example, the insurance company may dispute the extent of the injury and whether the injury should be apportioned to prior injuries.

What is an Agreed Medical Evaluator (AME)?

An Agreed Medical Evaluator, or AME, is the doctor your workers’ compensation attorney and the claims adjuster have mutually chosen to evaluate your condition.

What does it mean when my employer is offering me alternative work?

If your doctor says you will not be able to return to your job after your injury, your employer is encouraged, under the law, to offer you alternative work instead of supplemental job displacement benefits or vocational rehabilitation benefits. The alternative work must meet your work restrictions, last at least 12 months, pay at least 85 percent of the wages and benefits you were paid at the time you were injured, and be within a reasonable commuting distance to where you lived at the time of injury.

Are there rules for physicians in determining workers’ compensation disabilities?

Physicians who determine disabilities and/or work impairments are rated using the American Medical Association guidelines. Physicians are required to use these guides to rate disabilities.

Can I be discriminated for having a disability?

Your current employer cannot discriminate against you for having a workers’ compensation disability or a workers’ compensation claim. If your disability is permanent, future employers may be required to not discriminate and may be required to provide you reasonable accommodations for a disability under the Americans with Disabilities Act (ADA).

What do the terms AOE/COE mean?

To have a claim covered by workers’ compensation insurance, or be administered within the workers’ compensation system, the claim must be AOE/COE. AOE/COE is an acronym used by attorneys within the workers’ compensation system. It means, “arising out of and occurring in the course of employment.” Simplified, it means your injury may have happened on the job.

What do they call a Plaintiff in the Workers’ Compensation system?

The workers’ compensation system is theoretically a non-adversarial system. Unlike the civil system, employees are not referred to as “Plaintiffs”. They are called “Applicants”.

What court are workers’ compensation claims heard?

Disputes in the workers’ compensation system are heard by highly specialized Administrative Law Judges. Most of them were attorneys representing employees or insurance carriers within the workers’ compensation system. If you do not agree with an Administrative Law Judge’s decision, it can be appealed to the Workers’ Compensation Appeals Board. This board is made up of seven commissioners appointed by the sitting governor to reconsider the Administrative Law Judges decision. These commissioners are sometimes referred to as the Reconsideration Unit.

How are workers’ compensation claims apportioned?

The concept of apportionment in the workers’ compensation system is very complex. Theoretically, the goal is to determine what portion of a pending claim is attributable to the injury that occurred and what part might be attributable to a prior injury or illness that may or may not have been work related. Besides AOE/COE, apportionment issues are some of the most complex and difficult areas. In these cases, it’s wise to hire a workers’ compensation attorney.

What does the WCAB audit unit do?

The WCAB audit unit is a division within the workers’ compensation system that is responsible for investigating complaints against insurance companies and claims administrators. It’s often the first place to complain if you feel your claim is not being handled in accordance with California law.

What is a Benefit Notice?

The insurance company handing a workers’ compensation claim is required to send out a benefits notice informing the applicant of potential benefits he or she is entitled to receive. If you do not receive this notice, contact a workers’ compensation attorney immediately.

Can I file a CAL/OSHA claim?

CAL/OSHA is a unit within the California Division of Occupational Safety and Health. Much like a local police department, its job is to investigate and enforce safety laws in the workplace. Filing a claim with CAL/OSHA for a violation or unsafe health condition in the workplace is a great idea because they typically enforce the laws and require the employer to remedy the situation. However, CAL/OSHA is not the forum for reviewing compensation for your work related injuries. Those claims should be brought directly before the Workers’ Compensation Appeal Board, on in some cases, the Superior Court of the State of California.’.pdf

What is a Labor Code 132a violation?

California Labor Code 132a is the codification of the public policy against discriminating against an employee for having filed a workers’ compensation claim. It sets forth a system and remedies against any employer who discriminates against an employee for filing a claim.

What is a Union Carve-out?

Carve-out agreements traditionally apply to unions, but can involve private employees. They allow them to create certain alternatives to the workers’ compensation system, benefits, and even dispute resolutions. Carve-outs must be at least as favorable to the employee as the traditional workers’ compensation. However, there are strict rules for carve-out agreements. If you feel a carve-out agreement is unfavorable or not valid, contact a workers’ compensation attorney. They can also see if you have rights beyond the purported carve-out agreement.

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