workers comp lawyer, Professional corporation fighting for injured workers in vista and oceanside CA

This website will take you through the steps of a workers compensation claim to provide a quick summary and roadmap of how to get work comp benefits.

Employers and insurance companies are in business to make money, not to spend it on injured workers.  We make them do their job by taking them to court at every stage of the work comp process.

The process can be broken down to 5 basic stages:

1. getting medical treatment to recover from work injury
2. getting money while out of work and recovering from work injury
3. recovery - getting back to work
4. getting medical reports that can be used as evidence in court
5. getting a settlement that compensates an injured worker for damage to their body after being injured at work

The first thing needed is a good doctor that cares about the injured worker more than the insurance company.  

The treating doctor is called the Primary Treating Physician (PTP).  The PTP is very important because this doctor will make all decisions about medical treatment and money.  

However, changing doctors is not easy.  The insurance companies want to keep injured workers with their doctors because it saves the insurance company money.  That is why they have the Medical Provider Network.

The process of changing doctors depends on whether a claim is accepted or denied.  You can read more about Denied Claims, or even worse, when a claim is Delayed.  If your claim is denied or delayed the insurance will send a letter saying so.

If the insurance is paying for doctors and did not send a delay or denial letter, the claim is probably accepted.  

To change doctors on an accepted claim, the insurance keeps control of the medical process.  An injured worker will need to send a specific letter, called a 4600 Letter, to the insurance company to change doctors.    

Unfortunately, doctors will not set an appointment unless they get a specific letter back from the insurance company, this is a 9785 Letter.  

The 9785 letter from the insurance lets the doctor know the insurance will pay the doctor to treat an injured worker. 

Insurance companies usually ignore a workers' request to switch doctors, so we frequently go to court to force the insurance to provide the letter of authorization to the doctor.

Once we have a doctor, the doctor will say whether an injured worker can go back to work, needs light work/work restrictions, or is off work altogether.  

If the doctor says a worker needs restricted work, or is off work, then we go to court to get wages paid while recovering from injury.  You can read more about Temporary Total Disability here.

Workers Compensation benefits can be broken down to two main categories, money and medical help - but the bigger picture of work comp benefits includes:

• doctor consultations
• x-rays
• MRI
• electro diagnostic testing
• shoch wave therapy
• chiropractic adjustments
• massage therapy
• physical therapy
• acupuncture
• epidural injections
• cortisone injections
• surgical consultations
• surgery
• crutches, wheelchairs, braces and orthotics
• medication
• transportation
• house remodeling
• in-home caretaker
• money to replace wages
• money to compensate for damage to the body
• money to reimburse for gas

Here is a link to the form needed to get reimbursed for driving to doctor appointments-medical mileage expense request form.

All of these benefits must be properly requested by the Primary Treating Physician and get through the Utilization Review process.  

If you don't agree with your doctor, you can get a Second Opinion and even use that opinion to pressure insurance to provide treatment that was denied.  

Every worker has their treating doctor that is very important at the beginning of the case because they make all decisions early on.  However, each worker is able to object to reports and get a second opinion.  

Unfortunately, the second opinion process is a long and slow-moving process.  The second opinion will come from a neutral doctor supplied by the state of California called a Qualified Medical Evaluator, a QME.

The QME is a doctor that is not necessarily there to treat injuries but is there to provide a second opinion and they do so in a very formal report.  

Because they are neutral and providing a long, detailed report, the report is better evidence to have in court.  But because it takes so long to get a report that can be used in court, it doesn't help as much to fight specific medical disputes.  However, the QME usually decides all the issues when it is time for the final settlement. 

There are basically two ways to settle a workers compensation claim, via Compromise and Release or a Stipulation with Request for Award.  You can read more about the Settlement Process.

Workers compensation is a slow process and benefits are often ignored and delayed.  Here are some common issues that arise in work comp and laws that we use to overcome insurance delays.