California Worker's Compensation - Help For Injured California Workers

• California Worker's Compensation - Quick facts about worker's compensation law, benefits and lawyer fees.

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  1. #1
    Join Date
    Mar 2007
    Location
    Southern Calif
    Posts
    13

    Default Can I Sue a WC Company For?

    Is it possible to sue a wc insurance company for denying surgery for over a year and thus prolonging my recovery process?

    The settlement I have been offered is a slap in the face considering I went through seven years of pure hell. I'm no kid and I have lost out on retirement and social security contributions. Forget retirement ha. I have been unable to find a decent paying job given my limitations.

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Can I Sue a WC Company For?

    Is it possible to sue a wc insurance company for denying surgery for over a year and thus prolonging my recovery process?
    Generally...no.

    The settlement I have been offered is a slap in the face considering I went through seven years of pure hell.
    The 'settlement' is based on your WPI/PD rating...and the number of weeks indemnity is set by law.

    A 'delay, modification, denial' to any requested treatment is determined through the UR process... the requested treatment by your PTP, must be according to ACOEM/MUTS/EBM and substantiated by peer reviewed medicine...determined to be 'medically necessary, and reasonable', on an industrial medicine basis.

    I'm no kid and I have lost out on retirement and social security contributions.
    Sadly, you are one of millions finding themselves in the same situation...there is no comfort in any statement made regarding WC...but, that's just the way it works..

    Your legislative representative is the one to bring your complaints to...get him/her riled up enough and maybe something will happen... but don't count on it 'til Arnold is back in his own bed...

  3. #3
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: Can I Sue a WC Company For?

    you can't in civil court for a work comp matter. Issues and disputes concerning work comp has to taken to the work comp court (WCAB.)
    workers comp is the exclusive remedy.

  4. #4
    Join Date
    Mar 2008
    Posts
    21

    Default Re: Can I Sue a WC Company For?

    I feel for you its taken 10yrs and I am still on wc like you what retirement I was 31 when I left work due to the injury and now I can hope for a bail out for injuried workers LOL sorry but all you can do is laugh about it since were all screwed

  5. #5
    Join Date
    Nov 2008
    Posts
    4

    Default Re: Can I Sue a WC Company For?

    Miss Moon

    You sure can make your voice heard, if you have been denied treatment ...
    if you have more than one complaint make each on a stand only form go to:
    www.dir.ca.gov/dwc than goto - forms - Audit Unit

    How to file a complaint with the Audit Unit

    The Audit Unit does not resolve disputes about benefits, but it tracks complaints against all workers’ compensation claims administrators (insurance companies, self-insured employers and third party administrators) and takes action to make sure the law is followed. While not all complaints result in investigations or audits, it is important for the Audit Unit to hear your complaint.

    The audit referral form (DWC-AU-906) may be used to file a complaint against the claims administrator. When not using the audit referral form, please include the following information in a complaint:

    1. Claims administrator company name, address and telephone number
    2. Injured worker name, address and telephone number
    3. Claim number and date of injury
    4. Employer name
    5. Workers' Compensation Appeals Board case number, if applicable
    6. Attach copies of any supporting documentation.

    Send the completed audit referral to:
    DWC Audit Unit Attention: Complaint Desk
    2424 Arden Way, Suite #305
    Sacramento, CA 95825-2403

    Complaints may also be filed electronically with the Audit Unit at
    dwcauditunit@dir.ca.gov. Any complaint with more than five pages of supporting documentation should be submitted to the Audit Unit by mail.
    A copy of any complaint can also be sent to the claims administrator. Sometimes this helps to resolve a problem.

    Because of confidentiality restrictions imposed by Labor Code Section 129, you will not be informed of the results if your claim is audited. Any dispute over benefits must be brought before the Workers’ Compensation Appeals Board (WCAB).

    Further information about the provision of workers’ compensation benefits is
    available from the Division of Workers’ Compensation Web site:
    http://www.dir.ca.gov/dwc.
    Form DWC-AU-905 (Rev 06/06)

  6. #6
    Join Date
    Sep 2008
    Posts
    132

    Default Re: Can I Sue a WC Company For?

    GT, that assumes the IC did something wrong, which without all the facts, no way to know what is going on with the surgical denial. UR may have reviewed and non certified the surgery already. Filing complaints might make you feel better mentally, but won't help you get the surgery.

    More facts would be helpful in trying to assist you. Have you seen an AME? PQME? Spinal Surgical Second Opinion?

  7. #7
    Join Date
    Mar 2007
    Location
    Southern Calif
    Posts
    13

    Default Re: Can I Sue a WC Company For?

    Thanks so much for your advice, and everyone else as well. The reason I asked my question is I am feeling pressure from my attorney to just accept the offer and be done with it. I want to be informed before I make my decision. I was imjured before the laws changed in 2004 and another question I'm researching is does my attorney collect the pre 2004 percentage and how much is that, or the new percentage which I have learned is between 19-20%. I had a court date but then the insc company popped up with a settlement amount. This has not been a difficult case and I am not going to see all my money in my attorneys pocket. Nor will I be swept under the carpet by the insurance company. I want what is fair and reasonable, and if that means letting a judge decide, then so be it.

  8. #8
    Join Date
    Mar 2007
    Location
    Southern Calif
    Posts
    13

    Default Re: Can I Sue a WC Company For?

    Thanks for this great advice! I will definitely be checking into this. Another question I have and no one seems to understand or answer.If an injury occurred before 2006, does the attorney collect on the old percentage or the new[percentage.QUOTE=GT 2002;101886]Miss Moon

    You sure can make your voice heard, if you have been denied treatment ...
    if you have more than one complaint make each on a stand only form go to:
    www.dir.ca.gov/dwc than goto - forms - Audit Unit

    How to file a complaint with the Audit Unit

    The Audit Unit does not resolve disputes about benefits, but it tracks complaints against all workers’ compensation claims administrators (insurance companies, self-insured employers and third party administrators) and takes action to make sure the law is followed. While not all complaints result in investigations or audits, it is important for the Audit Unit to hear your complaint.

    The audit referral form (DWC-AU-906) may be used to file a complaint against the claims administrator. When not using the audit referral form, please include the following information in a complaint:

    1. Claims administrator company name, address and telephone number
    2. Injured worker name, address and telephone number
    3. Claim number and date of injury
    4. Employer name
    5. Workers' Compensation Appeals Board case number, if applicable
    6. Attach copies of any supporting documentation.

    Send the completed audit referral to:
    DWC Audit Unit Attention: Complaint Desk
    2424 Arden Way, Suite #305
    Sacramento, CA 95825-2403

    Complaints may also be filed electronically with the Audit Unit at
    dwcauditunit@dir.ca.gov. Any complaint with more than five pages of supporting documentation should be submitted to the Audit Unit by mail.
    A copy of any complaint can also be sent to the claims administrator. Sometimes this helps to resolve a problem.

    Because of confidentiality restrictions imposed by Labor Code Section 129, you will not be informed of the results if your claim is audited. Any dispute over benefits must be brought before the Workers’ Compensation Appeals Board (WCAB).

    Further information about the provision of workers’ compensation benefits is
    available from the Division of Workers’ Compensation Web site:
    http://www.dir.ca.gov/dwc.
    Form DWC-AU-905 (Rev 06/06)[/QUOTE]

  9. #9
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: Can I Sue a WC Company For?

    attorney fees were not changed by the reform laws; they can still only collect 12-15 % of the disability awarded.

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Can I Sue a WC Company For?

    This has not been a difficult case and I am not going to see all my money in my attorneys pocket. Nor will I be swept under the carpet by the insurance company. I want what is fair and reasonable, and if that means letting a judge decide, then so be it.
    The only time a case goes to trial is when the parties cannot agree informally on the issues of a claim, basically the PD/WPI rating, and the PTP or AME/PQME report defining the need for future medical treatment.

    You cannot force the ER/IC into a C&R/lump sum settlement...they are fully within their rights to let the PD indemnity pay out bi-weekly, and leave the medical open.
    In fact, there are ways to delay an MSC while paying the PDA/advances on your PD indemnity...and avoid that part of the process all together.

    If your case does go to trial, after the MSC attempt at settlement, the judge has only one option...(well 2) and that is a Finding & Award...determine the PD/WPI %, paid over time, and open medical...the other is a 'take nothing'...which can happen.

    So, ''fair and reasonable''...? Rare to happen. Furthermore, that would be in the eye of the receipient/payor...

    I'd have to ask SH for the authority on the "collect 12-15 % of the disability awarded." ...the AA fees are based on the full amount of the award...whether that is indemnity only, or a C&R that includes medical compensation.
    In a stipulated agreement, the fees are ''commuted off the far end''..meaning the number of weeks you receive PDA's are reduced to satisfy the amount of the commutation.
    CCR 10775 states: Reasonable atty fees states, "In establishing a reasonable atty's fee the WCJ or arbitrator shall consider the (a) responsibility assumed by the atty., (b) care exercised in representing the applicant, (c) time involved, (d) results involved. Reference will be made to guidelines contained in the Policy and Procedural Manual.... (see below) 1.140 Attorney's Fees, Lien for
    Issued by
    MERLE C. RABINE
    Chairman
    Workers' Compensation Appeals Board RICHARD P. GANNON
    Administrative Director
    Division of Workers' Compensation
    Effective: October 6, 2003


    --------------------------------------------------------------------------------

    The Labor Code imposes an obligation on WCJs to determine what is a reasonable attorney's fee in cases submitted to them for decision.
    The WCAB recognizes the valuable service rendered to applicants by competent attorneys. The WCAB recognizes, too, that reasonable fees must be sufficient to encourage such competent attorneys to participate in this field of practice. The WCAB has seen instances where fees appear to be unreasonably low or high. The WCAB has seen, too, instances where attorneys accept sizeable fees for services which are largely unnecessary because there is little dispute and little time, effort or skill involved.

    The WCAB also recognizes that because of the lack of any increase in permanent disability benefits since April 1, 1972 in many cases a fee based solely on a percentage of permanent indemnity may be inadequate to compensate an attorney for his services.

    To encourage attorneys to render a more balanced service and to increase opportunity for attorneys to be more adequately compensated (particularly in view of increased statutory temporary disability) the following is promulgated as a guideline for the use of the WCJs.

    1. In cases of average complexity, the WCAB believes that a reasonable fee will be in the range of 9 percent to 12 percent of the permanent disability indemnity, death benefit or compromise and release awarded. In addition thereto, a fee equivalent to 9 percent to 12 percent of the temporary disability indemnity and out-of-pocket medical benefits to the extent that they are obtained or awarded as a result of applicant's attorney's services may be allowed.

    2. In cases of above average complexity, a fee in excess of the normal upper limit of 12 percent applicable to all benefits described in Paragraph 1 hereof is warranted. Such cases may include, but are not limited to:

    a. cases establishing a new or obscure theory of injury or law;

    b. cases involving highly disputed factual issues, where detailed investigation, interrogation of prospective witnesses, and participation in lengthy hearings are involved;

    c. cases involving highly disputed medical issues;

    d. cases involving multiple defendants.

    3. In cases of below average complexity, the fee applicable to all benefits described in Paragraph 1 hereof may range downward from the 9 percent - 12 percent range to as low as 1 percent. Such cases may include, but are not limited to:

    a. the uncontested death cases where normal proof of dependency is all that is required of counsel;

    b. the undisputed statutory 100% permanent disability case or other undisputed presumption cases;

    c. other essentially undisputed cases.

    A $750 fee in a $75,000 death benefit award provides ample compensation for the time and skill involvement of applicant's attorney where counsel is required to do no more than provide a marriage certificate and birth certificate. The WCAB emphatically rejects the theory that the applicant in such a case should pay a higher fee to provide an offset for the cases which counsel handles at a loss. There is no reason for the deserving widow, the blind, the paraplegic or other employee with a major disability to underwrite the case of the employee with a minor or questionable claim.

    4. In considering the value of counsel's services, the criteria set forth in Bentley v. IAC, 11 CCC 204, and Rose, Klein & Marias v. WCAB, 39 CCC 771, are to be given full consideration. It should be realized that the time involvement of a recognized specialist, who has demonstrated his skill in the field, is to be valued much more highly on an hourly basis than the time involvement of a person less knowledgeable and skilled in the field of workers' compensation law.

    5. If the record does not establish, to the satisfaction of the WCJ, a sufficient basis for determining the value of counsel's services, the WCJ should request counsel to supply the desired information. This need not be done orally on the record or by written communication, but the WCJ should be satisfied that there is an adequate basis for justifying the fee determination if it should be made an issue."
    Last edited by BvIA; 11-17-2008 at 12:27 PM.

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