Workers Comp 360: The Alpha & Omega: The Injured Worker

By Dan C. Wynn, Former Workers Compensation Manager, Goodwill of Southern California

In this series of Blogs, we will explore the totality of the Workers Compensation process as it relates not only to the injured worker, but also the impact on the other stakeholders in the process. That roster is longer and has names on it that might surprise you, but I assure you everyone impacts the injured worker in some way during this process. Some work for the employer directly and others do not. The essence of this series is that the 360 degrees of the process begin and end in the same place, the injured worker.

Believe it or not the process begins before the injured worker sustains an injury. A forward thinking and aware employer will already be looking at his work processes in advance to prevent injuries. Many companies question the return on investment for prevention, but any claims professional or risk manager would advise that one slip and fall injury requiring surgery could cost one hundred thousand dollars or more. It would seem to be a simple conclusion that the answer is self-evident, but often that is not the case.

Returning to the injured worker, it is important that should he or she sustain an injury they should report it. The injured worker should be aware that the purpose of workers compensation insurance is not a tool for retaliation against real or imagined issues with management. It is not a mechanism for providing salary to cover time off when children are out of school or a vacation is needed or being paid for not working is preferable to working. Workers compensation insurance is for covering injuries that occur or arise out of an employee’s work duties.

If the worker is injured on the job, then after it is reported the employer must provide a DWC-1 claim form to injured worker within one working day. If not, the injured worker can obtain one by downloading it from the forms page of the DWC website or contact the Information and Assistance Unit. Once this is done, it is imperative that the injured worker submit the obtain medical care immediately. This is mutually beneficial for both employer and employee. Determining the extent and scope of the injury early allows the proper treatment to commence and ultimately shortens the length of time the claim will be open. It can also help to avoid the need for litigation. All of these steps save money for both the injured and the employer.

If there is a lack of information about the circumstances surrounding the injury, then it may be necessary to delay the claim. This may cause a delay in benefits for up to 90 days. In the event this happens, it is urgent that the injured worker apply for State Disability Insurance, better known as SDI. As long as there is initial and continued medical reporting then benefits will be provided for up to one year. If the claim later becomes accepted, the employer or insurer will pick up and continue Temporary Total Disability or TTD benefits up to 104 weeks.

If the employer has an HCO or MPN, then the employee or their legal representation, if any, should be provided with either a list or access to the HCO or MPN. This will expedite getting treatment and should ultimately help to reduce the length of the claim. It will also prevent the injured worker for obtaining extraneous treatment that could result in liens at the end of the claim. 

While no employer wants to report a recordable injury, because it has a negative impact on ex-mod or actuarial reporting, it is required by law. The injured worker should have no qualms about reporting a genuine work injury. The injured worker should, however, have serious qualms about falsely reporting an injury, exaggerating an injury, or even magnifying the symptoms of an injury to obtain benefits that are not due. That, in fact, is a crime which is punishable by fines, jail time, or both.

Workers’ Compensation was set up to protect both the injured worker and the employer. That is why it is no fault and tends to favor the injured worker through liberal construction. That being said, it is equally important that both parties work in favor of returning the employee to work. The majority of the time it is possible to do so, but there are times when it is not. We will look at what happens in that instance and other facets of workers compensation. The goal is to provide a clear overview of the workers compensation process that truly begins and ends with the injured worker.