Reporting the Injury:
The employee must promptly report the injury or illness to their employer. This notification triggers the workers' compensation process.
Medical Treatment:
The employer is responsible for providing immediate medical treatment to the injured employee. This includes covering reasonable medical expenses related to the injury.
Filing a Claim:
The employee or their representative files a workers' compensation claim with the California Division of Workers' Compensation (DWC). This initiates the formal process to obtain benefits.
Claims Administration:
The employer's workers' compensation insurance carrier investigates the claim to determine its validity and whether benefits are appropriate. They may accept or deny the claim.
Benefits Determination:
If the claim is accepted, the injured employee may receive various benefits, including medical care, temporary disability benefits (income replacement), permanent disability benefits (if applicable), vocational rehabilitation, and death benefits (if the injury results in death).
Dispute Resolution:
Disputes over benefits or claim denials can be resolved through the DWC's dispute resolution process, which may involve neutral medical evaluation (QME or AME), negotiations, mediation, or hearings before a workers' compensation judge.
Appeals:
Either party can appeal decisions regarding benefits or disputes to the Workers' Compensation Appeals Board (WCAB), which provides a final administrative review.
Return to Work:
Employers are encouraged to facilitate the injured employee's return to work through modified duties or vocational rehabilitation if needed.
Overall, California's workers' compensation system is a complex legal framework governed by various statutes and regulations, making it difficult for a layperson to navigate.