IF MY CLAIM IS ACCEPTED
Time limit: The insurance company has 90 days from the date you provided the claim form to your employer to issue a notice on whether your claim has been accepted or denied. If the insurance company fails to issue the notice within 90 days, your injury will be presumed to be accepted (covered). That means you are entitled to all of the available workers' compensation benefits per California law.
What benefits am I entitled to is my claim is accepted?
Workers' compensation insurance provides five basic benefits:
What if I have a disagreement about my benefits? Even if your case has been accepted, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. When there is a disagreement, you may be evaluated by a qualified medical evaluator (QME).
To qualify as a QME, a physician must meet additional educational and licensing requirements. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process so that they can adequately issue medical legal opinions based on the AMA Guides.
If you have an attorney, your attorney and your claims administrator can opt to use an agreed medical evaluator (AME) instead. AMEs have undergone the same educational and licensing requirements as QMEs and tend to be reputable physicians that have demonstrated a good grasp of evaluating work comp injuries. The process for choosing an AME and scheduling an evaluation can also be much more streamlined, leading to less wait time to ultimately resolve your case.
Once you receive an evaluation from a QME or AME, they will issue a report that highlights issues such as ongoing work restrictions, any need to continue being off work, any need for additional diagnostics, and so on. Click here to find out more about going back to work.
What benefits am I entitled to is my claim is accepted?
Workers' compensation insurance provides five basic benefits:
- Medical care: Paid for by your employer/your employer's insurance to help you recover from an injury or illness caused by work. The insurance company pays only for medically necessary medical treatment as determined by a 3rd party company known as the Independent Medical Review (IMR). All treatment recommended to you by your work comp primary treating physician must be reviewed by a 3rd party company (IMR) to be authorized. If IMR denies your medical treatment as not being medically necessary, you have a short time period to file an appeal.
- Temporary disability (TD) benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering. These are formulated based on your wages and calculated per California law. There is a floor and ceiling on the amount of payments you are entitled to.
- Permanent disability (PD) benefits: Payments if you don't recover completely. PD is based on the your whole person impairment that is due to the injury. The way of evaluating this must follow the AMA Guides.
- Supplemental job displacement (SJDB) benefits: If your date of injury is in 2004 or later, you may receive vouchers to help pay for retraining or skill enhancement if you don't recover completely and can't return to work for your employer.
- Death benefits: Payments to the spouse, children, or other dependents if a worker dies from a job injury or illness.
What if I have a disagreement about my benefits? Even if your case has been accepted, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. When there is a disagreement, you may be evaluated by a qualified medical evaluator (QME).
To qualify as a QME, a physician must meet additional educational and licensing requirements. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process so that they can adequately issue medical legal opinions based on the AMA Guides.
If you have an attorney, your attorney and your claims administrator can opt to use an agreed medical evaluator (AME) instead. AMEs have undergone the same educational and licensing requirements as QMEs and tend to be reputable physicians that have demonstrated a good grasp of evaluating work comp injuries. The process for choosing an AME and scheduling an evaluation can also be much more streamlined, leading to less wait time to ultimately resolve your case.
Once you receive an evaluation from a QME or AME, they will issue a report that highlights issues such as ongoing work restrictions, any need to continue being off work, any need for additional diagnostics, and so on. Click here to find out more about going back to work.