April 16, 2024 | Article by Beatriz Trejo Social Share
First and foremost, the California workers’ compensation system is designed to pay for your medical treatment if you’re injured in a workplace accident. But you may be concerned that your benefits will run out before you’ve fully recovered from your injuries.
Some workers’ compensation benefits are limited to a certain time period. For example, temporary disability payments stop after a maximum of 104 weeks.
However, California’s workers’ compensation law is clear that an employer is responsible for providing all medical care “reasonably required to cure or relieve” injured workers from their injuries—regardless of how long it takes. Your treatment may last days, months, years, or the rest of your life.
Medical care includes:
- Emergency care
- Doctor’s visits
- Surgery
- Hospitalization
- Chiropractic care (limited to 24 visits)
- Physical or occupational therapy (limited to 24 visits each)
- Acupuncture
- Medicines
- Medical supplies and equipment
- Prosthetics
- Reimbursement for transportation (e.g., to appointments for medical care or to pick up prescriptions)
Workers’ comp will pay the medical bills for your work-related injury or illness—with no monetary cap on the cost—until you’re fully healed or your recovery plateaus at what’s called maximum medical improvement. But there are plenty of rules to follow that make medical care under workers’ comp different from an ordinary visit to your usual healthcare provider.
In this FAQ, we’ll cover the details of medical care under California workers’ compensation insurance.
Getting Started: Filing a Workers’ Compensation Claim
If you need emergency care for your injury, don’t hesitate to get it. You can file your workers’ compensation claim once your condition is stable.
The procedure for getting workers’ comp benefits is fairly simple:
- Report the injury to your employer in writing as soon as possible.
- Fill out a workers’ comp form (called DWC-1) and give it to your employer.
- Your employer must fill out the remainder of the form and send it to their insurer.
- While your claim is being processed, the insurance company must provide up to $10,000 toward your medical treatment.
- Once insurance approves your claim, they will pay for your care until you are healed or reach maximum medical improvement.
Medical Care Under Workers’ Comp FAQs
When you use workers’ compensation benefits to pay for medical care, you shouldn’t have out-of-pocket costs. But you’re not free to see any healthcare provider you want or follow a treatment regimen you choose on your own.
Unless you took the time—before your injury—to predesignate your primary care physician as your healthcare provider under workers’ comp, your choice of doctors will be somewhat limited.
Many workers’ comp insurers have a medical provider network (MPN)—a group of doctors with a range of specialties who treat injured workers. If your insurance carrier uses an MPN, you need to see doctors within the network.
Other insurance companies or self-insured employers use independent, state-approved provider networks called healthcare organizations (HCOs). If your workers’ comp coverage uses an HCO, you need to see doctors with the HCO.
If an MPN or HCO isn’t involved in your care, your employer can still decide which doctor you can see for the first 30 days of your care. After 30 days, you may be able to choose your own doctor.
In California, workers’ compensation medical treatment—whether through an MPN, HCO, or with your usual primary care doctor—must follow state rules. The state approves a medical treatment utilization schedule (MTUS) that provides guidelines for treating work-related injuries.
Here are the steps involved in a typical workers’ compensation case:
- A doctor assesses your injuries and recommends a treatment plan, which must follow the MTUS guidelines.
- The doctor submits the plan to your insurance carrier for approval.
- If the insurance company approves the plan, you may proceed with treatment.
- If the insurance company doesn’t agree with the doctor’s recommendations, they may ask for a utilization review (UR)—a formal review of your records to determine if the recommended treatment is medically necessary.
If you disagree with the doctor’s recommendations, the insurance company’s decision, or the results of a utilization review, you must follow additional procedures.
Your medical care should continue to be covered until:
- Your injuries have healed.
- Or your doctor determines that you’ve reached maximum medical improvement.
Maximum medical improvement (MMI) is when your condition is stable and your doctor believes that further treatment is unlikely to result in additional improvements. At this stage, your doctor will evaluate your level of permanent disability.
The law makes employers responsible for medical treatment, but typically, your employer’s workers’ compensation insurance carrier pays the bills. Insurance companies are for-profit businesses, meaning their primary motivation isn’t necessarily to pay out more workers’ compensation benefits.
The insurance company may suggest a settlement at any stage in your treatment, but especially when you reach MMI. The details of a settlement can profoundly affect whether you are covered for any future treatment you may need.
We strongly recommend talking to a workers’ comp lawyer before signing a settlement agreement.
Bakersfield Workers’ Compensation Attorneys
Workers’ compensation benefits are an important safety net for California workers. However, the system doesn’t always work as intended, and it can be overwhelming when workers are trying to heal from injuries.
The experienced workers’ compensation lawyers at Chain | Cohn | Clark can help you:
- Get the benefits you deserve
- Deal with the insurance company
- Appeal unfair decisions
- Negotiate a settlement that meets your needs
- File third-party claims against the parties responsible for your accident
Contact us today for a free, no-obligation review of your case.
