Workers’ comp requirements and coverage vary by state, insurance provider, other factors. But generally speaking, workers’ comp insurance covers the following:
● Medical care for a work-related injury, illness, or disease
● Temporary disability benefits for wages lost due to a work-related injury or illness
● Permanent disability benefits for wages lost due to a work-related injury that has a permanent effect on the employee’s physical or mental ability to perform the job
● Supplemental job displacement benefits to pay for retraining or skill enhancement for employees who qualify for permanent disability benefits but do not return to work for the same employer
● Death benefits and/or or burial benefits paid to the family of an employee killed on the job
The amount received by the employee or the employee’s family depends on the severity and long-term effect of the injury or illness.
Requirements for a California Workers Comp Claim
The insurance coverage and specific circumstances of the injury will affect the process, but here are the general steps involved in a workers comp claim in California:
Reporting the Work-Related Injury
First, the employee must report the injury or illness to the employer. The employer has one working day to provide the employee with a Workers’ Compensation Claim Form (DWC 1).
The employee must fill out the DWC 1 form to request workers’ compensation benefits. This form asks the employee to describe the injury completely and sign their name to the statement. The form is officially filed once it is completed and given back to the employer. (The sooner this form is filed, the sooner the claim can be evaluated and resolved.)
In an emergency situation, the employee should seek emergency medical services (and note to the medical provider that the injury is believed to be work-related).
In a non-emergency situation, the employee must be evaluated by a a medical professional, known as the “primary treating physician.” The treating doctor will manage the employee’s overall care for the injury or illness, including determining if and when the employee can return to work, what kind of work can be done during the recovery process, and whether or not the employee needs to see a specialist.
During the evaluation, the employee will have to describe the symptoms of the illness or injury, the events at work they believe led to the injury, and the overall environment of their work. It is important for employees to tell treating medical providers they believe the injury is work-related so all parties ask the right questions and submit the right documents.
Claim Administrator Accepts or Denies the Claim
The claim administrator, also known as the claim examiner or adjuster, is usually employed by the insurance company or another workers’ comp organization authorized to review your company’s claims. This administrator will either accept or deny the claim.
If the claim is accepted, your injury or illness is covered by workers’ compensation coverage, and you will receive compensation for medical care, lost wages, or other payments according to your coverage.
If the claim is denied, the administrator does not agree the injury is work-related and/or covered by workers’ comp coverage. You can challenge this denial by filing additional paperwork to try to further demonstrate your injury or illness should be covered by workers’ comp.
What Qualifies as a Work-Related Injury?
A work-related injury could be a one-time event, such as a fall from a ladder or a burn from a chemical. It can also be caused by repeated, work-related exposure, such as an injury from repeated motion or hearing loss from constant loud noise without ear protection.
Some, but not all, workers’ compensation policies cover psychological injuries caused by work, such as stress-induced illnesses and injuries. The workers’ comp policy may or may not cover injuries reported to an employer after the worker is told they will be terminated or laid off.
Always refer to your employer’s workers’ comp policy or speak to a qualified workers’ comp specialist to determine specific requirements.
California Workers’ Comp Insurance from Fairbanks Insurance Brokers
Fairbanks Insurance Brokers offers Workers’ Compensation insurance for California contractors. Our workers comp policies are designed to fulfill California legal requirements for workers comp insurance and protect contractors from financial and physical losses.