Workers Compensation Glossary
This Glossary is intended to assist Injured Workers with respect to the multitude of terms that are used within California Workers’ Compensation and is intended to assist Injured Workers through all phases of a workers’ compensation case. The terms cover the entire spectrum of a workers’ comp claim: from the injury itself, to the medical reporting, to the claims procedures and court proceedings. This glossary also includes terms used when dealing with Insurance Companies, Attorneys, Evaluating Physicians, and terms dealing with the Workers’ Compensation Appeals Board.
An ACCEPTED CLAIM is one in which the Claims Administrator has accepted liability for the claim and for which they will adjust the claim accordingly and pay benefits. While a claim may be accepted, the Claims Administrator may contest their obligation to provide or pay benefits.
ACTIVITIES OF DAILY LIVING:
ACTIVITIES OF DAILY LIVING are used to measure one’s impairment under the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition. Activities of Daily Living include self-care, communication, physical activity, sensory function, nonspecialized hand activities, travel, sexual function, and sleep.
An ACUTE CONDITION, in the California Labor Code, is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. See Labor Code Section 4616.2
ADEQUACY is a requirement with respect to workers’ compensation settlements that are approved by a Workers’ Compensation Judge. A settlement should compensate the Injured Worker for the effects of their workers’ compensation claim.
If Stipulations with Request for Award are to be considered adequate and an Award be issued, the stipulated level of permanent disability should be reasonably within the range of evidence based on the medical reports submitted. Medical care is awarded where appropriate based upon the medical reports submitted. Any other issues are adequately resolved by the stipulations will be approved as well.
If compensability is not disputed, a Compromise and Release shall be considered adequate and shall be approved where the settlement is properly executed, and the amount of the settlement includes consideration for: (1) permanent and temporary disability that is reasonably within the range of evidence based on the medical reports submitted, (2) medical treatment, where appropriate, based on a reasonable estimate of future medical expenses; (3) any other issues included in the settlement, such as penalties or the right to reopen, in a reasonable amount. In cases dealing with threshold issues (i.e. injury AOE/COE, employment, jurisdiction or statute of limitations), when assessing the adequacy of a settlement, consideration shall be given to the viability of these issues. A determination that a settlement is adequate based upon the preceding analysis should be approved; the settlement should not be disapproved nor should the case to set for adequacy based solely on the WCJ’s belief that the settlement is less than the optimal amount.
An ADJ NUMBER is the same as a CASE NUMBER: See CASE NUMBER.
ADMISSIBLE is a term that is used with respect to evidence when a matter is proceeding to Trial. An item of evidence, if it is going to be accepted into the record and be considered by the Workers’ Compensation Judge, must be considered admissible. Sometimes, medical reports or records may not be considered admissible. There are many reasons for an item to be considered not admissible. These reasons may be based upon due process or technical reasons. For example, a medical report may not based upon be admissible if it was not signed by the doctor.
An ADMITTED CLAIM means that the Claims Administrator has admitted liability for the claim. They will adjust the claim accordingly and pay benefits. While a claim may be accepted, the Claims Administrator may contest their obligation to provide or pay benefits. Also see ACCEPTED CLAIM.
ADJUSTED FOR AGE AND OCCUPATION:
The term ADJUSTED FOR AGE AND OCCUPATION refers to the rating formula in the Schedule for Rating Permanent Disabilities. A permanent disability rating, to be completed, must be adjusted for age and occupation. See the SCHEDULE FOR RATING PERMANENT DISABILITIES.
The AGE ADJUSTMENT is part of the rating formula in which the rating is adjusted for the worker’s age on the date of injury. This is accomplished by using the table for determining the age adjustment. See SCHEDULE FOR RATING PERMANENT DISABILITIES
AGE AT DATE OF INJURY:
AGE AT DATE OF INJURY is simply the age of the Injured Worker at the date that the injury was sustained. The Injured Worker’s age at the date of injury is used as a component to determine the permanent disability percentage. A younger age lowers the overall rating and an older age raises the overall rating. See Section 6, of the Schedule for Rating Permantent Disability (2005)
AGGRAVATION is a change in a pre-existing condition which may either cause a temporary or permanent disability. This may represent an injury under workers’ compensation law.
AGREED MEDICAL EVALUATOR/AGREED MEDICAL EXAMINER (AME):
An Agreed Medical Evaluator or Examiner is one in which the parties to the action have agreed to resolve disputed issues. The parties determine the nature and extent of the issues that they wish the Agreed Examiner to address. AME opinions are given “great weight.” Caselaw has indicated that an AME’s opinions should ordinarily be followed unless there is good reason to find that opinion unpersuasive. See Power vs. WCAB (1986) 51 Cal. Comp. Cases 114
AGREED QUALIFIED PANEL MEDICAL EVALUATOR:
An AGREED QUALIFIED PANEL MEDICAL EVALUATOR is merely a Qualified Panel Medical Evaluator for which the parties agreed to use as the Panel Qualified Medical Evaluator.
AGREED VOCATIONAL EVALUATOR:
An AGREED VOCATIONAL EVALUATOR is a vocational evaluator who was chosen by the parties to act in a neutral capacity in the same fashion as an Agreed Medical Evaluator. Likewise, the Workers’ Compensation Judge would likely follow their opinion absent good reason to find the opinion unpersuasive.
ALMARAZ GUZMAN described a series of caselaw that addresses the concept that “ based upon the physician’s judgment, experience, training, and skill each reporting physician (treater or medical-legal evaluator) should give an expert opinion on the injured employee’s Whole Person Impairment using the chapter, table, or method of assessing impairment of the AMA Guides that most accurately reflects the injured employee’s impairment.” In summary, Almaraz Guzman allows the physician to use the “four corners” of the Guides when making an assessment of the Injured Worker’s Whole Person Impairment.
ALTERNATIVE EMPLOYMENT is where the employee returns to the employer and performs a job different from their usual and customary duties.
ALTERNATIVE WORK is a new job with the Injured Worker’s employer. Alternative work may have an impact on benefits to be received in certain circumstances. Alternative work is a job different from their usual and customary position. The alternative work must meet the Injured Worker’s work restrictions, last at least 12 months, pay at least 85 percent of the wages and benefits they were paid at the time they were injured, and be within a reasonable commuting distance of where they lived at the time of injury.
ALTERNATIVE WORK ASSIGNMENT:
An ALTERNATIVE WORK ASSIGNMENT is when the Injured Worker continues to work at the employer and is placed in another position either on a temporary or permanent basis.
AMERICAN MEDICAL ASSOCIATION:
The AMERICAN MEDICAL ASSOCIATION is a national physician’s group. The American Medical Association publishes a variety of books in the medical field. The State of California had adopted one of their publications, the “Guides to the Evaluation of Permanent Impairment” (5th Edition), to be employed to calculate permanent disability for Injured Workers.
AMERICAN MEDICAL ASSOCIATION GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT (5TH EDITION):
The AMERICAN MEDICAL ASSOCIATION GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT (5TH EDITION) is a publication from the American Medical Association and has been adopted by the State of California to be used in the calculation of permanent disability. The guides describe impairment in terms of Whole Person Impairment. The Whole Person Impairment is placed with a formula to calculate the permanent disability.
AMERICAN WITH DISABILITIES ACT:
The AMERICAN WITH DISABILITY ACT prohibits discrimination against people with disabilities in several areas. This includes employment, transportation, public accommodations, communications and access to state and local government’ programs and services. As it relates to employment, Title I of the ADA protects the rights of both employees and job seekers.
ANXIETY refers to a psychiatric condition. Some of the symptoms of anxiety include restlessness, fatigue, difficulty concentrating, irritability, muscle tension and sleep disturbance. ANXIETY is referred to in the symptom severity analysis of the GLOBAL ASSESSMENT FUNCTIONING score. There are a variety of different anxiety disorders.
AOE/COE PRIORITY CONFERENCE:
An AOE/COE PRIORITY CONFERENCE is a hearing before the Workers’ Compensation Appeals Board. It is a conference calendar hearing for cases in which the employee is represented by an attorney. An AOE/COE Priority Conference involves issues in dispute which are employment or injury arising out of employment or in the course of employment. See Labor Code 5502 (c). In AOE/COE Priority Conferences, a trial shall be set as expeditiously as possible unless good cause is shown why discovery is not complete.
This APPEALS BOARD is an abbreviation for the Workers’ Compensation Appeals Board. It can refer to either the Main Office or a Local Office.
APPLICANT generally refers to the Injured Worker who is the person who most likely will file the Application for Adjudication concerning a claim for Worekers’ Compensation benefits. In the Workers’ Compensation System, there are other individuals who are permitted to file Applications and they will be considered as the “Applicant.”
An APPLICANT’S ATTORNEY is an Attorney who represents Injured Worker on their workers’ compensation claim.
APPLICATION FOR ADJUDICATION OF CLAIM:
The APPLICATION FOR ADJUDICATION OF CLAIM is a form which is used to open a case at a local Workers’ Compensation Appeals Board if there is a dispute concerning the compensation on a workers’ compensation claim. The form can be found at the Department of Industrial Relations website.
APPORTIONMENT is the legal assessment made by a physician concerning the allocation of permanent disability among various factors. See Labor Code Section 4663. Usually, there are causes that are industrial and non-industrial. If there are multiple claims of injury, Apportionment may be between dates of injury. See Benson.
ARISING OUT OF AND IN THE COURSE AND SCOPE OF EMPLOYMENT(AOE/COE):
ARISING OUT OF AND IN THE COURSE AND SCOPE OF EMPLOYMENT is the threshold issue in order to have a compensable workers’ compensation claim. All compensable claims for workers’ compensation must legally be considered to have arose out of employment and to have occurred during the course and scope of employment.
An ASSIGNMENT is the act by which the WCAB assigns a case for Trial before a designated Workers’ Compensation Judge.
ATTORNEY CLIENT PRIVILEGE:
ATTORNEY CLIENT PRIVILEGE is an evidentiary privilege with respect to the relationship between a client and their attorney. The client, whether or not a party, has a privilege to refuse to disclose, and to prevent another from disclosing, a confidential communication between themselves and the lawyer to other parties.
ATTORNEY’S FEES in Workers’ Compensation Case for Injured Workers are generally done on a contingency basis. This means that there is only a fee if there is a recovery on the case. Fees must be approved and ordered by the Workers’ Compensation Judge who either approved the award or tried the case and issued a findings and award. The fees must be reasonable.
The WCAB has addressed the guidelines for the amount of Applicant’s attorney’s fees which are ordered based upon a contingency fee basis. An Award of Reasonable Attorney’s Fees considers the responsibility assumed by the attorney, the care exercises in representing the Applicant, the time involved and the results obtained. Further, “in cases of above average complexity, a fee in excess of the normal upper limit of 12 percent…is warranted.” The section then goes on to give examples of what might be included in these types of cases as follows: “cases establishing a new or obscure theory of injury or law; cases involving highly disputed factual issues, where detailed investigation, interrogation of prospective witnesses, and participation in lengthy hearings are involved; cases involving highly disputed medical issues; and cases involving multiple defendants.” See Rules of Policies and Procedures. Generally, Attorney’s Fees in the amount of 15 percent are awarded.
Attorney’s Fees in workers’ compensation can also arise out of a variety of events. Attorney’s Fees, in certain circumstances, are payable by the Claims Administrator. Fees charged by an Applicant’s Attorney in connection with representing an Applicant during a deposition pursuant to Labor Code Section 5710 are to be paid by the Claim’s Administrator, Representing an In Pro Per Applicant after Defendant files a Declaration of Readiness to Proceed are also to be paid for by the Claim Administrator. Attorney’s Fees which are ordered with respect to either sanctions or for having to respond to a frivolous writ, are to be paid by the Claims Administrator as well.
ATTORNEY WORK PRODUCT:
ATTORNEY WORK PRODUCT is not discoverable by the opposing party. Attorney Work-Product includes statements of witnesses taken by an attorney or his agent. See Hardesty vs. McCord (1976) 41 C.C.C. 111.
An AUDIT, with respect to an Injured Worker, is a review of the file from a State Agency that makes sure that benefits were administered in a proper and correct way. An Audit can give rise to discipline and the imposition of fines and penalties for the failure of the Claims Administrator to properly adjust a file. An Applicant can request that their claim be audited by the State of California.
The AUDIT UNIT is a department within the Division of Workers’ Compensation. The Audit Unit audits insurance companies, self-insured employers, and third-party administrators to ensure that they have met their obligations under the Labor Code and the Administrative Director’s Regulations. By assessing penalties and ordering that unpaid compensation be paid, the Unit ensures that proper benefits are delivered accurately and in a timely manner.
An AUDITOR is a trained individual who is knowledgeable about the Claims Procedure. They are the individuals who conduct audits. Auditors may be employees of the State. Also, at times, there are non-governmental auditors as well.
AUTHORITY has multiple meanings within workers’ compensation. In claims, authority means that the individual has been provided with the power to effectuate a particular action. Authority can be extended to adjusters, attorneys, or hearing representatives. Those granting authority can be an Employer’s Risk Managers. It may be an authority to agree on an Agreed Medical Examiner, it may be an authority to authorize medical treatment, or it may be an authority to settle the base by a certain dollar amount.
Likewise, the authority may refer to the question as to whether a Workers’ Compensation Judge has the authority to take a particular action.
Finally, the authority may refer to case law, the Labor Code, or Regulations as the basis to take a particular action or take a particular position.
AUTHORIZATION is a term generally used concerning medical treatment. Authorization means that the Claims Administrator will pay the vendor and that they are guaranteed payment.
An AUTOPSY is a medical-legal procedure which is available within Workers’ Compensation. In death cases before the WCAB, if there is a dispute on causation, the Appeals Board may require an autopsy. An autopsy is conducted by a physician and that physician’s report may be received into evidence at the WCAB. An autopsy is a post-mortem examination of a corpse which is done to determine the cause and manner of the death. See Labor Code Section 5706.
AVERAGE WEEKLY WAGE:
AVERAGE WEEKLY WAGE is a term which is used to determine benefits. In general, the average weekly earnings shall be the number of worker’s days a week, times the daily earnings at the time of the injury. There are alternative ways of calculating it as well.