Frequently Asked Questions - Qualifying for Workers Compensation

Workers Compensation only operates in the context of work related injuries. If your injury did not occur during the course of your employment, while on the job, then you will not qualify for workers compensation benefits. However, if your injury occurred as a result of another party, whether it was a traffic related accident, a slip and fall inside a commercial business, or the result of a defective product, you should consult with a personal injury attorney. You may be able to pursue a negligence action in civil court. Go to:

AOE/COE means Arising Out of Employment/ during the Course of Employment. Workers Compensation is a no fault system, so if you are injured at work, you do not need to prove that your employer was negligent in some way. However, it is the injured party’s burden to show that the injury did in fact occur while at work, while employed as an employee, and while undertaking some activity for the benefit of the employer. The injury itself must have been caused by the accident, or employment conditions, and not from some other non-industrial related factors. Where there are disputes on these issues, a judge and/or a medical examiner will have to make a finding of fact as to whether the employment condition caused the accident. You should obtain an attorney if your case is denied on AOE/COE grounds.

An injury may be what is called a “cumulative trauma,” if it was caused by work over a long period of time (usually over a year). Typical examples of cumulative trauma injuries include carpal tunnel from repetitive typing, neck or back strains from ergonomically improper work stations, or hearing loss from repetitive exposure to loud noises. If you suspect that your work activities are causing injury, you should report it to your supervisor and hire an attorney.

If you are injured at work, or suspect that your work activities are causing injury, you should report your injury to your supervisor as soon as you can, and ask to be seen by a doctor. Your employer is required to provide you with a DWC1 claim form within 24 hours of requesting it. The top half is completed by the employee and the bottom half completed by the employer. If your employer does not provide you with a claim form, you may down load it from this web- site, by clicking here DWC-Form 1. You can also obtain the form, and instructions on how to complete it, from your local Workers Compensation Appeals Board (WCAB). Complete the claim form and give it to your supervisor, or human resource director. Within a few days, you should be contacted by the employer’s insurance carrier. They will notify you in writing with respect to your claim. If your employer refuses to provide you with their insurance information, you should contact an attorney immediately. Important tip: Be sure to list all the body parts injured on the DWC Form-1 affected by the injury. If you forget to list a body part, the carrier will deny it later if when you ask for treatment.

There are time limits for prosecuting your claim:

  • When you are given a claim form (DWC-Form 1), you should complete it within 30 days and return it to the employer, (this is especially important if you are terminated from employment, because if you wait too long, the employer may raise what is called a post termination defense).
  • You have one year from the date of injury to file an application of adjudication of claim (click to download), with the WCAB if no benefits have been provided.
  • If medical treatment or monetary payments of any sort were furnished by the employer or carrier, you have one year from the date of receipt of those benefits to file an application.
  • If you filed a cumulative trauma claim, alleging occupation disease or repetitive stress injury, the date of injury is considered to be the date on which the employee should have reasonably known that his/her injury was caused by work.
  • You have five years from the date of injury to reopen your case for new and further disability, when benefits have been provided and the claim accepted.

Generally, once you file a claim form or application, which effectively notifies the employer of your injury, the insurance carrier can take up to 90 days to investigate your claim and then accept or deny the case. The carrier can withhold all benefit accept medical treatment during this investigation period.

The WCAB is the special administrative court system set up by the State of California, whose sole jurisdiction is hear and review work injury cases. It is often referred to as the “Board” by attorney’s, judges and doctors. Every WCAB office has an Information and Assistance (I&A) officer who can help you with completing the necessary paper work if you are unrepresented. Click here to view the listing of WCAB’s throughout California.

If your orthopedic injury results in having to live with chronic pain, you may find that:

  • you become depressed and anxious.
  • you develop gastro intestinal problems such as acid reflux, ulcers, chronic constipation or diarrhea. This often occurs as a side effect of pain medications.
  • you lose or gain considerable weight.
  • you lose significant amount of sleep which reduces your daytime functioning.
  • sexual functioning is significantly diminished.
  • you develop diabetes and/or high blood pressure, or hypertension.
  • you develop pain in the opposite (non-injured) limbs due to overuse and overcompensation.

Discuss with both your doctor and your attorney any additional consequential medical or health problems that arise as a result of your injury. Your attorney may file allegations of additional injuries which could be compensable.