Join us in the fight to bring fairness and balance to California's Workers' Compensation System.
Almost one million workers each year get injured or killed on the job. The good news is that the frequency of injuries had steadily declined over the last decade. For those who are injured or killed, they or their dependents must become involved in the workers' compensation system. In California, the system is guaranteed by the state constitution and requires that the system provide necessary medical treatment and adequate compensation without regard to fault. The state legislature is then given the power to develop the system.
The system has always seen its share of the problem - both for workers and their employers. Benefit levels have traditionally been too low to protect workers from losing their savings and homes, and employers have seen rising insurance premiums that affect job creation. Most injuries, however, are legitimate and workers with permanently disabling injuries suffer financially, physically, and emotionally. Workers need good medical care, prompt payment of benefits, and help in returning to work. All of these things are problems in today's system.
The most urgent problem today for injured workers is their medical care. All doctors who treat injured workers are required to follow strict guidelines that are, according to a recent study commissioned by the state, insufficient and do not cover many necessary treatments. As a result, many treating physicians are told "No" by insurance company physicians when they try to get approval for their treatment plan. In addition, urgent conditions are often improperly ignored or misdiagnosed and thus go untreated for long periods of time. If you would like to review the study, click here.
Every employer or insurance company is required to have a "Utilization Review" program to make sure that the recommended medical treatment is appropriate. This is supposed to be completed no later than 14 days from the time the doctor requests it. Unfortunately, it is often taking much longer than this, and even the appropriate care is being denied because of the inadequacy of the approved medical treatment guidelines.
For workers who are injured on or after 1/1/04, the law limits a worker to 24 Physical Therapy visits and 24 Chiropractic visits. This is a real problem for people who already "used up" their visit before a needed surgery and who are denied the ability to rehabilitate from surgery by the arbitrary limit. This ignores the medical needs of workers and standard protocols developed by physicians, leaving workers more disabled than they should be. And, because the treatment guidelines are so limited, holistic treatments such as acupuncture are regularly denied.
As of January 1, 2005, injured workers will lose their ability to choose their own doctor if the insurance company or employer has set up their own network of doctors. Even workers who have a long-term relationship with their doctor may be required to switch to a network physician, according to the recent government regulations. You can get more information by clicking here.
For most injury claims, the new law arbitrarily limits temporary disability benefits to no more than 104 weeks within a two-year period from when payments start. This means that, if you have broken periods of temporary disability - say you go back and try to work for a few weeks, you can only receive temporary disability benefits within that two-year time frame. So, under these time limits, workers could be limited to substantially less in temporary disability benefits even if additional surgeries or treatment are needed. This will cause additional financial harm to workers and their families, as well as stress on other government programs such as social security disability and state disability benefits.
For workers injured on or after 1/1/04, there are no more vocational rehabilitation benefits. So, if you get injured to the point where you cannot continue with your regular work, and if your employer cannot or does not take you back, you will have to figure out what else you can do to make a living. The only thing left to help is a "voucher" for schooling or retraining, the amount of which depends on your percentage level of permanent disability. The amount payable directly to the school is between $4000 and $10,000 but you will not get this until very late in your case and you will not know the amount until your level of disability benefits is decided.
If you become permanently disabled as a result of a work injury, the disability is automatically going to be reduced if you had any prior injury that caused the disability. What percentage is left as a result of the injury is paid either weekly or in a lump sum settlement depending on your percentage of disability - a process that drastically changed after 1/1/05.
There is nothing in the law to regulate the price that insurers can charge to employers. In 1993, the laws were changed to eliminate a "minimum rate" that the state required insurers to charge so as to prevent them from charging too little and going bankrupt. Once this requirement was eliminated, insurers began a "rate war" that caused premiums to decrease - a welcome change for employers except that they reduced them so much that most of the California insurance companies were forced out of business. Premiums that were too low to cover the claims rose rapidly, causing the outcry from employers that prompted the last several rounds of cost-cutting legislation. Unfortunately, former Governor Schwarzenegger decided to cut benefits to workers but not regulate prices, so that the "savings" are not being passed along to employers.
A great deal of fraud was present in the system in the early 1990s, with some medical providers and lawyer providers and lawyers providing services and filing claims for workers who were not truly injured. The 1993 reforms enacted strict laws that made the prosecution of workers' compensation fraud a priority. The Department of Insurance Fraud Bureau did a good job of getting rid of the medical mills that were making the system unfair for both employers and workers. While fraud still exists in the workers' compensation system on an individual basis, the "fraud rings" have largely been prosecuted and eliminated. Individual fraud can take the form of workers filling false claims, employers providing false information in order to qualify for cheaper insurance, medical professionals billing for services that they did not provide, lawyers who file false claims, or insurance companies that falsify in order to save money. The problem is that the issue of fraud continues to drive policy decisions that unfairly affect legitimately injured workers.