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 Workers Comp 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

Getting Medical Treatment in Workers Compensation

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.

Getting Money While Out of Work

The insurance company really does not want to pay a worker to stay home from work to recover from an injury.  That is why they try so hard to keep workers with their doctors.  Because if a doctor says that an injured worker cannot work the insurance will have to pay 66% of the worker's gross wage.  Taxes are not taken out of these benefits. 

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 can go to court to get wages paid while recovering from injury.  You can read more about Temporary Total Disability here.

Recovering From Injuries

Medical help can include many different types of care.  The law says whatever will cure or provide relief.  This 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.

Getting The Medical Reports Needed to Win in Court

All work comp 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 from a doctor called a Qualified Medical Evaluator.  The QME serves many purposes and is used on almost every case because they write better reports than treating doctors.  Those reports need to hold up in court, so it's important to have a good, well written report.  

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. 

Settlements in Workers Compensation

In order to settle the parties need to agree on settlement.  If the worker and the insurance do not agree, and cannot agree, then the case will be submitted to a judge.  The judge will pretty much follow what the doctor says the case is worth according to the charts found in the AMA Guides and the worker will get to keep the right to medical treatment if more is needed in the future, but this will result in a lot less money for the worker.

If the parties can agree on a settlement the case does not have to be given to the judge to decide.  

There are 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.

At Workers Comp Lawyer, Professional Corporation, we handle the claim for our clients.  This means that our clients do not need to contact the insurance company because we handle that.  If they ignore us we take the insurance company to court.

We also have knowledge of the doctors that are available in workers comp.  Not every doctor will accept patients with work comp injuries.  We have experience with these doctors, both treating doctors and Qualified Medical Evaluators.

We get the proper evidence together to provide the most strength in negotiating with insurance companies and get the best settlements.  

We go to court whenever necessary to keep the insurance company on the case, so they don't ignore our clients. 

We get medical treatment and money for our clients. 

The workers compensation process is beset broken down into 3 parts.  First, a worker needs to find medical treatment and recover from the injury.  The second part of the work comp process is either modified work duties or getting paid while off work.  Finally, after making a recovery to maximum medical improvement there is a process of negotiating and litigating to determine the final settlement.

If you are interested in reading more about the Workers Compensation process you can read here

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.