This Glossary is intended to assist Injured Workers with respect to the multitude of terms that are used within the California Workers’ Compensation System. The Glossary has terms that are used through all phases of a workers’ compensation case. These Glossary Terms include ones relating to workers’ compensation process from the injury itself, to the medical reporting, to the claims procedures and court proceedings. This Glossary also includes popular terms used by Insurance Companies, Attorneys, Evaluating Physicians, Treating Physicians and 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.
ADMINISTRATIVE DIRECTOR OF THE DIVISION OF WORKERS’ COMPENSATION:
Official given the responsibility to contract with an Independent Medical Review Organization (IMRO) to conduct reviews and to determine whether an IMR application is eligible for review and assign IMR applications to the IMRO.
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 Employer’s Risk Managers. It may be authority to agree on an Agreed Medical Examiner, it may be authority to authorize medical treatment, or it may be authority to settle the base by a certain dollar amount. Likewise, authority may refer to the question as to whether a Workers’ Compensation Judge has the authority to take a particular action. Finally, authority may refer caselaw, 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.
AVERAGE WHOLESALE PRICE:
AWP is used to price Medicare Part D drugs included in the calculations for the WCMSA funding amount.
BENEFITS COORDINATION & RECOVERY CENTER:
The BCRC performs a number of functions for CMS, the pertinent one for this guide being the receipt and initial processing of hard copy WCMSA proposals.
The term BENSON refers to a seminal case on the issue of apportionment. The BENSON case allows for apportionment between separate dates injury. This case set the framework for the allowance of separate awards for separate injuries to the same parts of the body. Within the workers’ compensation community, is it not uncommon to hear the term “BENSONIZE” if the evaluating Physician is needed address apportionment in this fashion. See Benson vs. WCAB (2009) 74 C. C.C. 113.
A BILL REVIEWER or MEDICAL BILL REVIEWER is a person who is not a claims adjuster or medical-only claims adjuster and who only reviews or adjusts workers’ compensation medical bills. They do so on behalf of an insurer, including employees or agents of the insurer or employees or agents of a medical billing entity. “Medical Bill Reviewer” also includes an experienced medical bill reviewer.
BURIAL EXPENSES are the expenses that are provided in connection to a workers’ compensation death case. Reasonable burial expenses are to be provided and not to exceed $5,000 for injuries before Jan. 1, 2013, and $10,000 for injuries on or after Jan. 1, 2013.
CAL/OSHA is a unit within the state’s Division of Occupational Safety and Health (DOSH.) Cal/OSHA inspects workplaces and enforces laws to protect the health and safety of workers in California. If there is a serious work injury, CAL/OSHA may come out investigate the work-site concerning workplace safety and possible safety violations.
CALENDAR refers to the fact that the Workers’ Compensation Appeals Board allows parties to set and sets matters for hearings on particular dates. Therefore, they maintain a Calendar. The WCAB will calendar a case and assign a date, time and Judge who is to hear the matter. It is common for there to be Trial Calendar days and Conference Calendar days. On Trial Calendar dates, the Workers’ Compensation Judge (WCJ) will usually only have Trials and Expedited Hearings. On Conference Calendar dates, the WCJ will usually have only conferences.
A CALENDAR CLERK is an employee at the WCAB who is responsible for calendaring hearing dates. Secretaries, in certain circumstances, perform the calendaring function.
CALIFORNIA CHILD SUPPORT SERVICES PROGRAM:
California’s Child Support Services Program works with parents – custodial and noncustodial – and guardians to ensure children and families receive court-ordered financial and medical support. Child support services are available to the general public through a network of 49 county and regional child support agencies (LCSAs). If an Injured Worker has child support obligations, deduction from workers’ compensation payments or settlements may occur.
CALIFORNIA COMPENSATION CASES (C.C.C.):
The CALIFORNIA COMPENSATION CASES, according to Lexis/Nexis, is an “annual publication provides complete and current coverage of the activity of the Workers’ Compensation Appeals Board as well as workers’ compensation cases from the California Appellate Courts.
All En Banc Opinions and selected Panel Decisions of the Appeals Board are reported, as are selected Independent Medical Review decisions. The digests of important decisions denied judicial review are the only source of information about them other than the actual pleadings for cases pre-2007. Also included are: the complete text of published and unpublished California Appellate Court and Supreme Court opinions; a cumulative table of workers’ compensation cases granted and denied review by the California Supreme Court; and extensive cross-references to California Law of Employee Injuries and Workers’ Compensation.
The California Compensation Cases are one of the most important research tools for Workers’ Compensation Judges and Attorneys. In the industry, they are often referred to as the “CCCs.”
CALIFORNIA DEPARTMENT OF CHILD SUPPORT SERVICES:
The CALIFORNIA DEPARTMENT OF CHILD SUPPORT SERVICES is a state department which works with parents – custodial and noncustodial – and guardians to ensure children and families receive court-ordered financial and medical support. If an Injured Worker is in arrears with respect to their child support obligations, the Department will assist in obtaining funds from workers’ compensation payments for support payments. They can either contact the carrier and receive funds from ongoing payments of benefits or file a Lien Against Compensation at the WCAB.
CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING:
The CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING has a mission to protect the people of California from unlawful discrimination in employment, housing and public accommodations (businesses) and from hate violence and human trafficking in accordance with the Fair Employment and Housing Act (FEHA), Unruh Civil Rights Act, Disabled Persons Act, and Ralph Civil Rights Act. The employment antidiscrimination provisions of the FEHA apply to public and private employers, labor organizations and employment agencies. They investigate discrimination complaints and cases of systemic discrimination; facilitate mediation and resolution of disputes involving civil rights; and enforce the laws by prosecuting violations in Civil Court.
CALIFORNIA FAIR EMPLOYMENT & HOUSING ACT:
The CALIFORNIA FAIR EMPLOYMENT& HOUSING ACT is based upon the State’s public policy that that it is necessary to protect and safeguard the right and opportunity of all persons to seek, obtain, and hold employment without discrimination or abridgment on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran status. The act created laws to eliminate discrimination by provide effective remedies that will both prevent and deter unlawful employment practices and redress the adverse effects of those practices on aggrieved persons. The law attempts to provide for the opportunity to seek, obtain, and hold employment without discrimination because of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran status is hereby recognized as and declared to be a civil right.
CALIFORNIA INSURANCE GUARANTEE ASSOCIATION:
The CALIFORNIA INSURANCE GUARANTEE ASSOCIATION has a fund to deal with workers’ compensation claims. CIGA’s revenue is derived from assessments of Member Insurers, distributions from the estates of insolvent Member Insurers, and investment income. Of the revenues received, some are allocated to the fund for workers’ compensation claims and are used to pay the claims. CIGA has successfully taken over the covered claim responsibilities of over one hundred insolvent Member Insurers.
CIGA CLAIM PROFESSIONALS:
CIGA CLAIM PROFESSIONALS are uniquely trained and qualified in administering workers’ compensation benefits in accordance with CIGA’s statutory obligations in conjunction with its third party administrators. CIGA is dedicated to providing quality medical care through its Medical Provider Network and Pharmacy Program.
Additionally, CIGA’s claim staff is trained in identifying suspected workers’ compensation fraud and through its Special Investigation Unit (SIU) partner reports cases of suspected fraud to the California Department of Insurance Fraud Division and district attorneys throughout the State of California.
CALIFORNIA LABOR CODE:
The CALIFORNIA LABOR CODE contains within it the Laws of Workers’ Compensation. Division 4 of the Labor Code contains the Workers’ Compensation Laws. Labor Code Sections are frequently evoked to claim rights and benefits.
CALIFORNIA STATE DISBURSEMENT UNIT:
The CALIFORNIA STATE DISBURSEMENT UNIT pertains to Child Support Payments. Child support payments are collected and processed by a single entity, the SDU. Required by federal law, the SDU processes 100% of child support payments that used to be handled at the Local Child Support Agencies.
CALIFORNIA STATE TEACHERS RETIREMENT SYSTEM:
The CALIFORNIA STATE TEACHERS RETIREMENT SYSTEM provides retirement, disability and survivor benefits for full-time and part-time California Public School Educators through its Defined Benefit, Defined Benefit Supplement and Cash Balance Benefit programs.
CALIFORNIA VICTIM COMPENSATION BOARD:
The CALIFORNIA VICTIM COMPENSATION BOARD can help pay bills and expenses that result from violent crime. Victims of crime who have been injured or have been threatened with injury may be eligible for help. It is not uncommon that an Industrial Injury was caused as a result of a violent crime.
CALPERS is a Retirement System in the State of California for which various government agencies participate within it. The System provides for disability retirements. If a disability appears to be permanent and the injured worker is unable to perform the usual duties of their current position, they may be eligible for a disability retirement. CalPERS can expedite emergency retirement for those facing a terminal illness.
CARPAL TUNNEL SYNDROME:
CARPAL TUNNEL SYNDROME is a common workers’ compensation injury that it commonly pled as a cumulative or repetitive trauma injury. It is considered an injury to the wrist. Essentially, carpal tunnel syndrome is a condition that is caused by the compression of the medical nerve with the carpal canal of the wrist. Symptoms involve numbness and tingling in various fingers.
A CARVE OUT refers to a program from the State of California that allows employers and unions to create their own alternative workers’ compensation delivery and dispute resolution program. Carve outs are part of a Collecting Bargaining Agreement between the Employer and the Union. Carve Out Programs do not use the Local WCABs to resolve their disputes. They will usually employ an Ombudsman and a Mediator.
A CASE refers to an individual claim that has been filed at the WCAB. When an Application for Adjudication of Claim has been filed at the WCAB, a case number will be issued. Each case has its own file.
CASE IN CHIEF:
A CASE IN CHIEF is the main case which is at issue within a workers’ compensation case. Usually, the Case in Chief refers to Injured Worker’s claim for injury and benefits.
CASE MANAGER can refer to a Nurse Case Manager. A Nurse Case Manager will assist and facilitate the provision of medical care to an Injured Worker. This can involve them attending doctor appointments and having interactions with medical providers. A Case Manager can act either in person and attend appointments or do it telephonically.
A CASE NUMBER refers to the number assigned by the WCAB for a particular case. Currently, they are assigned a number that begins alphabetically with the letters ADJ.
CASELAW refers to legal decisions which are used as authority to rule on cases. They are used to interpret various Labor Code Sections and Regulations. Caselaw refers to decisions from the Supreme Court, Court of Appeal and Workers’ Compensation Appeals.
CAUSATION, per AMA, is an identifiable factor, such as an accident or exposure, that results in a medically identifiable condition.
Centers for Disease Control:
The CDC provides annual life expectancy tables used in the calculations for the WCMSA funding amount.
Centers for Medicare & Medicaid Services:
CMS is the government agency responsible for administering Medicare and Medicaid.
A CHALLENGE refers to the ability of a Party to an action disqualify a Judge as being the Trial Judge. There are two types of challenges: the parties are allowed one challenge irrespective for cause. Also, there are challenges for cause.
CHANGE OF TREATING PHYSICIAN:
A CHANGE OF TREATING PHYSICIAN is when either the Injured Worker or Claims Administrator elects to choose a new treating physician. Changes of Treating Physicians are permitted in workers’ compensation. Injured Workers are permitted to change treating physicians. See Labor Code Section 4600. Also, a Claims Administrator may request a change of treating physician upon a showing of good cause. A Petition must be filed. See Labor Code Section 4603.
CHILD SUPPORT LIEN:
A CHILD SUPPORT LIEN can be with respect to ongoing payments or a lien on the case in chief. In other words, monies can be deducted when a non-custodial parent has a workers’ compensation claim. Child Support can claim up to up to 25% of ongoing temporary disability benefits can be withheld by Income Withholding Order to pay current support and arrears. A lien against any compensation awarded to the non-custodial parent may also be filed with the Workers’ Compensation Appeals Board (WCAB) for any arrears that accumulated from the date the non-custodial parten was injured.
CHRONIC PAIN is pain that extends beyond the expected period of hearing or is related to a progressive disease. The designation of Chronic Pain in worker’s compensation can trigger certain treatment protocols which have been created to treat chronic disease
A CLAIM ADJUSTER means a person who, on behalf of an insurer, is responsible for determining the validity of a workers’ compensation claim. There are regular claims examiners and medical only claims examiners. The adjuster may also establish a case reserve, approve and process indemnity and medical benefits, may hire investigators, attorneys or other professionals and may negotiate settlements of claims. “Claims adjuster ” also means a person who is responsible for the immediate supervision of a claims adjuster but does not mean an attorney representing the insurer or a person whose primary function is clerical. See Section 2592.01
CLAIM ADJUSTER MEDICAL ONLY:
A CLAIMS ADJUSTER MEDICAL ONLY is an adjuster who handles claims which are medical only. This means that the claims only involve the adjusting of the medical care on the matter. They do not deal with liability or indemnity issues on the underlying claim.
A CLAIM ADMINISTRATOR is the entity that is charged with expediting the delivery of workers’ compensation benefits and services to injured workers without unnecessary litigation or delays. A Claims Administrator may be the employer acting as a self-insured, a Third Party Administrator who acts on behalf of the employer, or an Insurance Company in which the employer has purchased insurance to cover its responsibility. Claims Administrator” means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, a group self-insurer, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, group self-insurer, or joint powers authority.
A CLAIMS EXAMINER is another term for a CLAIMS ADJUSTER. See CLAIMS ADJUSTER
A CLAIM FORM is the document which initiates a workers’ compensation claim. It is also known as a “DWC 1.” An employer must give or mail an injured worker a claim form within one working day after learning about your injury or illness.
A person who submits a WC claim. A claim is a request for payment for services and benefits you received.
A CLAIMED INJURY refers to an injury claim that has not been accepted by the Claims Administrator as being industrial.
An insurer, self-administered self-insured employer, or third- party administrator responsible for adjusting workers’ compensation claims. A claims administrator is obligated to perform UR on medical treatment recommendations, issue UR decisions, and compensate providers for treatment costs. “Claims administrator” includes a utilization review organization (URO) contracted by the claims administrator to specifically conduct UR. Also called claims examiner or claims adjuster.
A CLAIMS MANAGER is a supervisory position with a Claims Administrator. They review and process claims. They participate in settlement negotiations, the recommend loss control strategies, they ensure that the program conforms with applicable laws and regulations. They are required to prepare reports, monitor and evaluate the program activities to ensure the delivery of quality services.
COLLECTIVE BARGAINING AGREEMENT:
A COLLECTIVE BARGAINING AGREEMENT is an agreement between Management and a Union. In workers’ compensation, a Collective Bargaining Agreement can provide for Alternative Dispute Resolution.
COMBINED VALUES CHART:
The COMBINED VALUES CHART is a chart in the AMA Guides which is used to combine multiple impairments and ensure that the value will not exceed 100 percent impairment. The chart is also located in the Schedule for Rating Permanent Disabilities.
COMING AND GOING RULE:
For COMING AND GOING RULE See Going and Coming Rule
COMMISSION ON HEALTH AND SAFETY AND WORKERS COMPENSATION:
COMMISSION ON HEALTH AND SAFETY AND WORKERS COMPENSATION is a joint labor-management body created by the workers’ compensation reform legislation of 1993. It is charged with examining the health and safety and workers’ systems in California and recommending administrative or legislative modifications to improve their operation. The Commission was established to conduct a continuing examination of the workers’ compensation system and the state’s activities to prevent industrial injuries and occupational illnesses and to examine those programs in other states.
A COMMISSIONER is a member of the Main WCAB which is located in San Francisco. It is an appointed position for a limited term. Commissioners are the individuals who participate in ruling on Petitions for Reconsideration and Petitions for Removal.
A COMMUTATION is a lump sum payment which is derived from the acceleration of a payment stream of a permanent disability award. A commutation is ordered by a Workers’ Compensation Judge. Lump sum payments can be made to the Applicant. Also, they are used to pay attorney’s fees in a lump sum. There are various methods of making commutation. They can be from the far end of the award or from the side of the award.
A COMPENSABLE CLAIM is one in which is considered to arising out of and be in the course and scope of employment. This is claim that is considered as an accepted claims for which benefits will be provided.
A COMPENSABLE CONSEQUENCE is an injury that relates back to the original injury for liability purposes. Where a subsequent injury is the direct and natural consequence of an original industrial injury, the subsequent injury is considered to relate back to the original injury and—unless it also occurred at work or under other conditions that might make it industrial—it is not treated as a new and independent injury.
COMPENSATION refers to ” every benefit or payment conferred by Division 4 upon an injured employee” (italics added), as broadly defined in section 3207 to include medical treatment payments, medical-legal fees and vocational rehabilitation costs, as well as all indemnity benefit payments. See Ferguson vs. WCAB (1995) 60 Cal. Comp. Cases 275.
COMPLEX REGIONAL PAIN SYNDROME:
COMPLEX REGIONAL PAIN SYNDROME also is called Reflex Sympathetic Dystrophy and Causalgia. It is a serious disease that usually occurs as a result of an injury to either an upper or lower extremity.
COMPREHENSIVE MEDICAL-LEGAL EVALUATION:
A COMPREHENSIVE MEDICAL-LEGAL EVALUATION is an evaluation of an employee which is either performed by a Qualified Medical Evaluator, an Agreed Medical Evaluator or a Primary Treating Physician. The purpose of such an examination is to prove or disprove a contested claim. While an injury may be an accepted claim, there may be portions of a claim, i.e. disputed body part or nature and extent permanent disability, that would be considered as a contested issue which would warrant the evaluation.
COMPROMISE AND RELEASE:
A COMPROMISE AND RELEASE is a settlement document which is used within workers’ compensation to resolve cases. A Compromise and Release usually permanently closes all aspects of a workers’ compensation claim except for vocational rehabilitation benefits, including any provision for future medical care. The Compromise and Release usually is paid in one lump sum to you. It must be reviewed and approved by a Workers’ Compensation Judge.
A payment made by Medicare for services for which another payer is responsible.
CONDITIONALLY NON-CERTIFIED (CNC) DECISION:
A UR decision that has been denied because the treating physician has not provided the medical information requested by the claims administrator that is required to make a medical necessity determination on the treatment recommendation.
CONFERENCE MINUTES is a form that is prepared and completed at a Conference. The WCJ is responsible for signing of on the Conference Minutes. The Conference Minutes document the disposition of the case. The disposition could be an order off-calendar, an order continuing the case to a further proceeding, or an order setting the matter for trial. The Conference Minutes may note what transpired at the hearing or the issuance of an order.
A CONSULTATIVE RATING is a rating are performed for represented workers or workers who have filed pro per applications. Consultative ratings may be issued on AME reports, QME reports and treating physician reports.
CONTEMPT is an unlawful interference with the proceedings of the court. Contempt applies to all parties before the WCAB and their representatives. Examples of contempt may include disorderly, contemptuous, or insolent behavior toward the judge while holding the court, or conduct tending to interrupt the due course of a trial or other judicial proceeding. Also, it can include misbehavior or other willful neglect or a violation of duty by an attorney
A CONTINUANCE is when a calendared matter is moved to a difference date. The hearing is therefore continued. WCAB authorization is required for any continuance.
CONTINUITY OF CARE:
CONTINUITY OF CARE relates to a terminated provider from a Managed Provider Network who serviced an Injured Worker. The Continuity of Care regulation, in certain circumstances, allows the terminated provider, at the request of a covered employee, an insurer, employer, or an entity that provides physician network services that offers a medical provider network, provides an authority to allow the provider to complete the treatment. See Regulation 9767.10
CONTINUOUS TRAUMA is a form of injury that develops over a period of time.
A CONTRACTOR generally in workers’ compensation relates to construction projects. Contractors are usually required to maintain workers’ compensation insurance unless they are exempt. There are General Contractors and Special Contractors. For example, in California, a General Building Contractor is a contractor whose principal contracting business is in connection with any structure built, being built, or to be built, for the support, shelter, and enclosure of persons, animals, chattels, or movable property of any kind, requiring in its construction the use of at least two unrelated building trades or crafts, or to do or superintend the whole or any part thereof.
COURSE OF EMPLOYMENT:
COURSE OF EMPLOYMENT is part of the requirement that makes an injury compensable.
A COURT REPORTER is used in workers’ compensation for a variety of purposes. Most commonly, they are used to do deposition of witnesses are usually the Applicant or Medical Providers and/or Experts. Court reporters are allowed to be present in medical examinations at the cost of the party requesting. Court reports also are present at the WCAB for recording hearings. At the WCAB, they are primarily used for trial. They are considered as Officers of the Court for proceedings.
They are educated and trained to record and transcribe verbatim. A court reporter is a professional who is most often licensed and/or certified to record proceedings using a stenotype machine. Most court reporters Achieve an expert shorthand speed (usually about 225 wpm) Be proficient in realtime writing and computer-aided transcription (CAT) Be proficient in English grammar, spelling and punctuation Have an excellent understanding of legal principles and medical terminology Possess excellent interpersonal communication skills Have an understanding and appreciation of legal and business ethics Possess a high level of professionalism.
COVERAGE refers to whether an insurance policy is in effect during a certain period of time. If the insurance company has a policy in effect for that certain period of time, then it is described as them having coverage.
CREDIT is a term which is used concerning benefits. Credit usually occurs when there is an overpayment of benefits. A credit can also occur when there is a settlement of a Third Party Case. See Third Party Credit.
CROSS-EXAMINATION OF THE DISABILITY EVALUATION SPECIALIST:
The CROSS-EXAMINATION OF THE DISABILITY EVALUATION SPECIALIST occurs after there is the issuance of Formal Rating Instructions on a case and the Disability Evaluation Specialist issues a Formal Rating. The cross-examination of the Disability Evaluation Specialist allows for the parties to question the Specialist and present rebuttal evidence.
CUBITAL TUNNEL SYNDROME:
CUBITAL TUNNEL SYNDROME is an injury to the upper extremities which involves the compression or irritation of the ulnar nerve. The irritation or compression of the nerve is at the elbow.
A CUMULATIVE INJURY is repetitive mentally or physically traumatic activities extending over a period of time, the combined effect of which causes any disability or need for medical treatment. See Labor Code Section 3208.1
CUMULATIVE TRAUMA INJURY:
A CUMULATIVE TRAUMA INJURY is the same as a Cumulative Injury. See CUMULATIVE INJURY.
Being CURED means a complete recovery from the disease, illness or condition.
CURRENT POLICY TERM:
CURRENT POLICY TERM is the term used for the period of time in which the activity policy is in effect.
DATE OF ACCIDENT:
DATE OF ACCIDENT refers to the date that the injury occurred. See DATE OF INJURY
DATE OF INJURY:
DATE OF INJURY is a medical-legal determination. The date of injury can be the date of the accident. The date of the injury for a cumulative trauma is when applicant knew or should have known that his disability was work-related. See Labor Code Section 5412.
DE QUERVAINS is a disease that effects the upper extremities that is a common workers’ compensation injury. It is caused by the inflammation of tendons and their sheaths at the styloid process of the radius that often causes pain in the thumb side of the wrist.
DEATH BENEFITS are payments to the spouse, children or other dependents of a working who dies from a job injury or illness.
A DEATH CLAIM is a claim that can arise if an employee dies from a work-related injury or illness. Death benefits are due to a spouse, children or other dependents.
DEATH WITHOUT DEPENDENTS:
Whenever any fatal injury is suffered by an employee under circumstances that would entitle the employee to compensation benefits, but for his or her death, and the employee does not leave surviving any person entitled to a dependency death benefit, the employer shall pay a sum to the Department of Industrial Relations equal to the total dependency death benefit that would be payable to a surviving spouse with no dependent minor children.
DEATH WITHOUT DEPENDENTS UNIT:
The Death Without Dependents Unit, although technically an “employer,” acts only in the capacity of an “other applicant.” It is a Unit within the Department of Industrial Relations which handles these cases.
DECLARATION OF READINESS TO PROCEED:
A DECLARATION OF READINESS TO PROCEED refers to the legal document which is used by the parties to obtain a hearing date before the WCAB. Hearings are used to resolve disputes. This form may be obtained at the WCAB website.
A DEFENSE ATTORNEY is a lawyer who has been retained by either a Claims Administrator, Insurance Company, or Employer, to represent them before the WCAB.
A DELAY LETTER is an administrative letter that a Claims Administrator will send out when benefits or treatment will be delayed and not provided. The letter will provide information as to why there has been a delay and as to when there will be a decision.
A DEMAND refers to a formal request for the opposing party to respond. It may be a settlement demand or a demand to provide some benefits. It may be a demand relating to discovery. A demand may be considered as an effort to resolve an issue. For example when filing a DOR, specific, genuine, good faith efforts to resolve the dispute. In essence, a demand would constitute such an effort.
A DENIED CLAIM is one in which the Claims Administrator has denied liability for the claim. Denials can be based upon medical or legal grounds. Also, denials can be based upon lack of coverage for the date or period upon which there was a claimed injury.
DEPARTMENT OF LABOR (UNITED STATES):
The DEPARTMENT OF LABOR (UNITED STATES) is a department of the Federal Government which is to foster, promote, and develop the welfare of the wage earners, job seekers, and retirees of the United States; improve working conditions; advance opportunities for profitable employment; and assure work-related benefits and rights. Among the agencies within the Department of Labor include OSHA which is to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance. Also, there is the Offices of Workers’ Compensation Programs. which administers four major disability compensation programs which provide wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to certain workers or their dependents who experience work-related injury or occupational disease.
A person who makes a deposition or affidavit under oath.
A DEPOSITION is a legal method of discovery in which sworn testimony and document production is permitted. In essence, it is the questioning of an individual under penalty of perjury. In California, there are some unique rules which apply when taking the deposition of an Applicant for benefits. This can include a dependent. They include the provision of All reasonable expenses of transportation, meals, and lodging incident to the deposition. Reimbursement for any loss of wages incurred during attendance at the deposition. One copy of the transcript of the deposition, without cost, and a reasonable allowance for attorney’s fees for the deponent, if represented by an attorney licensed by the State Bar of this state.
DEPRESSION is a diagnosis that can be part of a workers’ compensation psychiatric injury.
Depression, more specifically a major depressive disorder, is a common and serious medical illness that negatively affects how a person feels, the way a person thinks, and how a person acts. Depression causes feelings of sadness and/or a loss of interest in activities that a person once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.
DESCRIPTION OF EMPLOYEE’S JOB DUTIES FORM:
The DESCRIPTION OF EMPLOYEE’S JOB DUTIES FORM is that shall be developed jointly by the employer and employee and is intended to describe the employee’s job duties. The completed form will be reviewed to determine whether the employee is able to return to work.
DESIGNATED RECORDS are records which are to be submitted to Court. In doing so, only the relevant pages from the records are submitted. Further, if there is handwriting that may be eligible, some transcription may be involved. In accordance with WCAB Rule 10629, specific reference should be made to the relevant portions of records which are offered, and only the relevant excerpts of medical records should be admitted into the evidentiary record.
CMS’ decision about whether the proposed WCMSA includes enough money to cover the claimant’s anticipated future medical claims that would otherwise be covered by Medicare. If CMS disagrees with the proposed amount, the determination will include the amount CMS determines is appropriate.
The process of collecting additional information about a case. CMS will issue a development letter to a claimant who provided insufficient information in a WCMSA submission, and the case will be in development until sufficient information is obtained.
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH EDITION (DSM-V):
THE DSM is a publication from the American Psychiatric Association. This book lists and describes the criteria necessary to meet a psychiatric diagnosis.
A DIGIT IMPAIRMENT is a form of impairment within the The AMERICAN MEDICAL ASSOCIATION GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT (5TH EDITION)which applies to fingers.
A DISABILITY is a physical or mental impairment that limits your life activities. A condition that makes engaging in physical, social and work activities difficult.
DISABILITY EVALUATION SPECIALIST:
A DISABILITY EVALUATION SPECIALIST is an employee of the DWC Disability Evaluation Unit who rates your permanent disability after reviewing a medical report or a medical-legal report describing your condition. They determine permanent disability ratings by evaluating medical descriptions of physical and mental impairment. The determinations are used by workers’ compensation administrative law judges, injured workers and insurance claims administrators to determine permanent disability benefits.
DISABILITY EVALUATION UNIT:
The DISABILITY EVALUATION UNIT determines permanent disability ratings by evaluating medical descriptions of physical and mental impairment. The determinations are used by workers’ compensation administrative law judges, injured workers and insurance claims administrators to determine permanent disability benefits. The DEU prepares three types of ratings: Formal, done at the request of a workers’ compensation judge, Consultative, done on litigated cases at the request of an attorney or DWC information and assistance officer, Summary, done on non-litigated cases at the request of a claims administrator or injured worker.
A DIABILITY RATER can be both a government employee or a private rater. Private raters have had training in rating and may have formally held a position as a Disability Evaluation Specialist. Private Disability Rater’s ratings are informative in nature but are not legally binding. Disability Evaluation Specialists are also referred to as Disability Raters.
A DISABILITY RATING is a formula that determines a percentage of permanent disability, account shall be taken of the nature of the physical injury or disfigurement, the occupation of the injured employee, and his or her age at the time of the injury, consideration being given to an employee’s diminished future earning capacity. A final permanent disability rating is obtained only after the impairment rating obtained from an evaluating physician is adjusted for diminished future earning capacity, occupation and age at the time of injury.
A DISABILITY RETIREMENT can be both Disability and Industrial. If a disabling injury or illness that prevents a person participating in a government pension system from performing their usual job duties with their current employer, they may be eligible for disability or industrial disability retirement. If their disability or industrial disability retirement is approved, they will receive a monthly retirement payment for the rest of their life or until they recover from their injury or illness..
For certain government employees, if they become disabled from their usual and customary occupation, they may be able to claim a disability retirement from the agency that handles their pensions. It is not uncommon that an individual who works for a government agency has a workers’ compensation injury that prevents them from returning to their usual and customary occupation.
DISCOVERY is the pre-trial process in which parties to an action obtain information, documentation and other evidence concerning their litigation. Discovery can take many forms, deposition, subpoena, subrosa, and the interviewing of witnesses. Per case law, liberal pre-trial discovery is desirable and beneficial for the purpose of ascertaining the truth checking and preventing perjury detecting and exposing false, fraudulent and sham claims and defenses making available in a simple, convenient and inexpensive way facts which otherwise could not be proved except with great difficulty educating the parties in advance of trial as to the real value of their claims and defenses, thereby encouraging settlement expediting litigation safeguarding against surprise preventing delay, simplifying and narrowing the issues and expediting and facilitating both pre-trial preparation and trial. See Hardesty v. McCord & Holdren, Inc. (1976) 41 CCC 111
DISCOVERY CUT-OFF is a time in which the WCAB has ordered that no further formal discovery can proceed. Discovery Cut-Off usually occurs when a matter is set for Trial. The Labor Code provides that Discovery shall close on the date of the mandatory settlement conference. Evidence not disclosed or obtained thereafter shall not be admissible unless the proponent of the evidence can demonstrate that it was not available or could not have been discovered by the exercise of due diligence prior to the settlement conference. See Labor Code Section 5502.
A DISCOVERY ORDER is an order from a WCJ concerning an aspect of discovery. Commonly is Discovery Order can be an order compelling a party to appear at a deposition. It can also be an order quashing the production of documents.
DISFIGUREMENT is the altered appearance of skin or a body part. If it is significant, it may represent an Impairment.
DISMISSAL FOR LACK OF PROSECUTION:
A DISMISSAL FOR LACK OF PROSECUTION is a dismissal which occurs when a case file has been inactive before the Workers’ Compensation Appeals Board. Unless a case is activated for hearing within one year after the filing of the Application for Adjudication or the entry of an order taking off calendar, the case may be dismissed after notice and opportunity to be heard. Regulation 10582. The fact that a case was dismissed for lack of prosecution may not bar a claim. Seek legal advice if there is a concern.
DISMISSAL OF ATTORNEY:
A DISMISSAL OF ATTORNEY is the act of a party removing their attorney of record. It is done by completing and filing the form at the WCAB.
A DISPOSITION generally occurs at a hearing on a case. The disposition is the final action taken on behalf by the WCJ to conclude a hearing. Common dispositions are off-calendar, continuance, or submission.
A DISPUTE is when a party is contesting an issue. A dispute can relate to a specific issue with respect to a case. Such issues include injury being industrial, permanent disability, and need for medical care can be disputed issued. The WCAB is the entity to resolve these disputes. A disagreement about a worker’s right to receive payments, services or other benefits. “Disputed medical fact” means an issue in dispute, including an objection under Section 4062 of the Labor Code to a medical determination made by a treating physician concerning: (1) the employee’s medical condition, (2) the cause of the employee’s medical condition, (3) For injuries that occurred before January 1, 2013, concerning a dispute over a utilization review decision if the decision is communicated to the requesting physician on or before June 30, 2013, treatment for the employee’s medical condition; (4) the existence, nature, duration or extent of temporary or permanent disability caused by the employee’s medical condition; or (5) the employee’s medical eligibility for rehabilitation services.
Treatment requested through UR that has been modified or denied in a UR decision and subsequently submitted for IMR.
A DISTRICT OFFICE are the same as LOCAL OFFICES. The WCAB maintains District Offices at various locations within the State. Individual cases are initially adjudicated at these locations.
DIVISION OF WORKERS’ COMPENSATION:
The DIVISION OF WORKERS’ COMPENSATION monitors the administration of workers’ compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers’ compensation benefits. DWC’s mission is to minimize the adverse impact of work-related injuries on California employees and employers.
DIVISION OF WORKERS’ COMPENSATION MEDICAL UNIT:
The DIVISION OF WORKERS’ COMPENSATION MEDICAL UNIT was formerly called the Industrial Medical Council (IMC) was created to provide policymaking, rulemaking and regulatory authority for the medical component of the new workers’ compensation program.
The Council has the responsibility for: establishing standards for improving health care for injured employees; conducting studies in the field of rehabilitation; monitoring and measuring cost of medical services to injured workers; and administering programs for medical and chiropractic evaluations in workers’ compensation cases.
During 1991 the IMC instituted regulations on the appointment and performance of qualified medical evaluators. The Reform Act authorized the Council to appoint such evaluators for the purpose of assessing permanent disability of an employee injured in an industrial accident. The functions of the IMC were transferred to the administrative director. As of January 1, 2005, the IMC was renamed to the Division of Workers’ Compensation – Medical Unit.
A DOMINANT EXTREMITY is an extremity that is more effective or predominant from the other. Impairments may be given different values if depending whether it was the dominant or non-dominant extremity.
DURABLE MEDICAL EQUIPMENT:
DME includes oxygen and respiratory therapy equipment, hospital beds, wheelchairs and other walking aids, and other such devices and equipment used in the home or in an institution serving as a home.
A DUTY DESCRIPTION is a description of the employee’s job duties. They can be prepared
An ELECTION occurs in any case involving a claim of occupational disease or cumulative injury occurring as a result of more than one employment within the appropriate time period the employee making the claim may elect to proceed against any one or more of the employers. Where such an election is made, the employee must successfully prove his or her claim against any one of the employers named, and any award which the appeals board shall issue awarding compensation benefits shall be a joint and several award as against any two or more employers who may be held liable for compensation benefits. Labor Code Section 5502. (c) In any case involving a claim of occupational disease or cumulative injury occurring as a result of more than one employment within the appropriate time period set forth in subdivision (a), the employee making the claim, or his or her dependents, may elect to proceed against any one or more of the employers. Where such an election is made, the employee must successfully prove his or her claim against any one of the employers named
ELECTRONIC ADJUDICATION MANAGEMENT SYSTEM:
The ELECTRONIC ADJUDICATION MANAGEMENT SYSTEM is the computer-based system that manages the claims that are filed at the Workers’ Compensation Appeals Board. EAMS has a public search tool which allows individuals to view cases online. EAMS was intended to simplify the DWC case management process to more efficiently resolve claims, improve the ability to schedule and manage court calendars, allow files to be shared between multiple users and transform paper files into secure electronic files, reducing the need for physical storage space at local DWC offices and the State Records Center.
EMERGENCY PETITION TO STAY:
An EMERGENCY PETITION TO STAY is a petition from a party to stop an action taken by another party in the action. A party seeking to stay an action by another party may present a petition to the Presiding Judge or a designee of the district office having venue. The petition must comply with the notice and declaration requirements of Rule 10281. If the Presiding Judge or designee determines that the petitioner has timely complied with the requirements, the Presiding Judge or designee shall do one of the following: 1) Deny the petition; 2) Grant a temporary stay and set the petition for a formal hearing; 3) Set the petition for a formal hearing, without either denying the petition or granting a temporary stay.
An EMERGENCY TREATMENT is to treat and stabilize an injured worker presenting for emergency health care services. Further, it could be considered when an injured worker faces an imminent and serious threat to his or her health.
An EMPLOYEE, per the Labor Code, is that any person rendering service for another, other than as an independent contractor, or unless expressly excluded herein, is presumed to be an employee. The definition within workers’ compensation is defined by the Labor Code and case law interpretation. Besides employees there are also Independent Contractors. Whether a worker is an employee or an independent contractor can be determined through the application of the factors contained in common law or employment and statutory provisions with California Law. See Labor Code Section 3357. Certain volunteers are covered under workers’ compensation law as well.
EMPLOYEE CLAIM FORM FOR WORKERS’ COMPENSATION BENEFITS:
An EMPLOYEE CLAIM FORM FOR WORKERS’ COMPENSATION BENEFITS is a form generated from the State of California. It is the document which initiates a workers’ compensation claim. It is also known as a “DWC 1.” An employer must give or mail an injured worker a claim form within one working day after learning about your injury or illness. It is commonly referred to as the “Claim Form.”
An EMPLOYER is the person who hired the employee. Employer can also be defined by the Labor Code. All California employers must provide workers’ compensation benefits to their employees under California Labor Code Section 3700. If a business employs one or more employees, then it must satisfy the requirement of the law.
EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS FORM:
The EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS FORM for which California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health. The filing of the form is not an admission of liability.
EN BANC DECISION:
An EN BANC DECISION is a matter reassigned by the chairman on a majority vote of the commissioners to the Workers’ Compensation Appeals Board as a whole in order to achieve uniformity of decision or in cases presenting novel issues.
END-STAGE RENAL DISEASE:
A person with ESRD may qualify for Medicare benefits.
EPWORTH SLEEPINESS SCALE:
The EPWORTH SLEEPINESS SCALE is a self-administered questionnaire that assesses ‘daytime sleepiness.’ Sleep is an “Activity of Daily Living” which is a consideration for an AMA impairment assessment. Sleep is also considered a medical disorder.
EQUAL OPPORTUNITY COMMISSION:
(United States) The EQUAL OPPORTUNITY COMMISSION enforces Title I of the ADA. Title I, prohibits private employers, state and local governments, employment agencies and labor unions from discriminating against qualified individuals with disabilities in applying for jobs, hiring, firing and job training.
EGONOMICS is the study of how to improve the fit between the physical demands of the workplace and the employees who perform the work. Ergonomics is used in workers compensation to address return to work issues. This can include the selection, designing or modifying equipment and tools. It can also include changing work tasks and the work environment to improve the Individual’s ability to work.
ESCOBEDO is an important case concerning apportionment and factors that can be considered. These “other factors” that may be considered as a non-industrial cause of permanent disability, then the “other factors” may include disability that was apportionable prior to SB 899, i.e., the natural progression of a non-industrial condition or disease, a preexisting disability, or a post-injury disabling event. (See former §§4663, 4750, 4750.5.) In addition, the “other factors” now may include pathology, asymptomatic prior conditions, and retroactive prophylactic work preclusions, provided there is substantial medical evidence establishing that these other factors have caused permanent disability. In this case, the issue is whether an apportionment of permanent disability can be made based on the preexisting arthritis in applicant’s knees. Under pre-SB 899 apportionment law, there would have been a question of whether this would have constituted an impermissible apportionment to pathology or causative factors. Escobedo vs. Marshalls (2005) 70 C.C.C. 604
An EVALUATION in workers’ compensation cases can be done by a multitude of physicians. It can be performed by a treating physician, a QME, an AME, or a Regular Physician. In a medical evaluation generally an injured worker will be asked about their family and medical history as well as the current symptoms being experienced by the employee. A brief physical exam is then conducted that focuses on the injured worker’s claim of injury. If the physician requires more information to make a final decision, he or she will order other types of tests, such as x-rays or lab tests. Once the exam has concluded and all other test results are analyzed, the physician will write up a report that summarizes all of the findings of the medical legal evaluation. This evaluation includes 1) Taking a complete history; (2) Reviewing and summarizing prior medical records; (3) Composing and drafting the conclusions of the report.
EVIDENCE is workers’ compensation is used to prove a fact in dispute. The Workers’ Compensation Appeals Board. This can include (a) Reports of attending or examining physicians; Reports of special investigators appointed by the appeals board or a workers’ compensation judge to investigate and report upon any scientific or medical question; (c) Reports of employers, containing copies of timesheets, book accounts, reports, and other records properly authenticated; (d) Properly authenticated copies of hospital records of the case of the injured employee; (e) All publications of the Division of Workers’ Compensation; (f) All official publications of the State of California and United States governments; (g) Excerpts from expert testimony received by the appeals board upon similar issues of scientific fact in other cases and the prior decisions of the appeals board upon similar issues; (h) Relevant portions of medical treatment protocols published by medical specialty societies. To be admissible, the party offering such a protocol or portion of a protocol shall concurrently enter into evidence information regarding how the protocol was developed, and to what extent the protocol is evidence-based, peer-reviewed, and nationally recognized. If a party offers into evidence a portion of a treatment protocol, any other party may offer into evidence additional portions of the protocol. The party offering a protocol, or portion thereof, into evidence shall either make a printed copy of the full protocol available for review and copying, or shall provide an Internet address at which the entire protocol may be accessed without charge; (i) The medical treatment utilization schedule in effect pursuant to Section 5307.27 or the guidelines in effect pursuant to Section 4604.5; (j) Reports of vocational experts. If vocational expert evidence is otherwise admissible, the evidence shall be produced in the form of written reports. Direct examination of a vocational witness shall not be received at trial except upon a showing of good cause. A continuance may be granted for rebuttal testimony if a report that was not served sufficiently in advance of the close of discovery to permit rebuttal is admitted into evidence.
EX PARTE COMMUNICATION:
An EX PARTE COMMUNICATION is when on party has a private communication with a Judge concerning a disputed matter without the presence of the other party or parties. This can range from a phone call, an appearance at the WCAB, or via written correspondence which was not copied to the other party or parties to the action.
An EXCESS CARRIER generally refers to supplemental insurance which covers a claim after it exceeds a certain dollar threshold. For example, the Carrier or Self-Insured may cover the first $500,000.00, of liability on a claim with an Excess Carrier covering the amounts above.
EXCESS COVERAGE is an insurance policy that is taken out by a self-insured employer to cover amounts exceeding a designated dollar amount.
The term EXCLUSIVE REMEDY limits legal remedies an Injured Worker for work injuries to the provisions of the Labor Code . See Labor Code Section 3600.
An EXPEDITED HEARING are hearings before the WCAB that are within limited issues. An Expedited Hearing is to be set within 30 days. The limited issues are (1) The employee s entitlement to medical treatment pursuant to Section 4600, except for treatment issues determined pursuant to Sections 4610 and 4610.5; (2) Whether the injured employee is required to obtain treatment within a medical provider network; (3) A medical treatment appointment or medical-legal examination; (4) The employee s entitlement to, or the amount of, temporary disability indemnity payments; (5) The employee s entitlement to compensation from one or more responsible employers when two or more employers dispute liability as among themselves; (6) Any other issues requiring an expedited hearing and determination as prescribed in rules and regulations of the administrative director.
EXPERIENCE MODIFICATION FACTOR:
The EXPERIENCE MODIFICATION FACTOR is an element which impacts the workers’ compensation insurance rate that an employer pays. The experience modification compares actual losses to expected losses. In sum, an employer who has greater losses than expected losses will most likely pay more insurance. An employer who has lesser losses than expected will most likely pay less insurance.
Exposure can relate to multiple meanings within workers’ compensation law. Exposure can describe whether this is insurance coverage. Exposure can also relate to an occupational illness as to whether there was “exposure” to a particular environmental factor. For example, exposure to asbestos or radiation.
FAIR EMPLOYMENT AND HOUSING ACT:
The FAIR EMPLOYMENT AND HOUSING ACT applies to public and private employers, labor organizations and employment agencies. It is illegal for employers of five or more employees to discriminate against job applicants and employees because of a protected category, or retaliate against them because they have asserted their rights under the law.The FEHA prohibits harassment based on a protected category against an employee, an applicant, an unpaid intern or volunteer, or a contractor. Harassment is prohibited in all workplaces, even those with fewer than five employees.
FAMILY MEDICAL LEAVE ACT:
The Family Medical Leave Act entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. With respect to workers’ compensation, the eligible employees are entitled to: Twelve workweeks of leave in a 12-month period for: a serious health condition that makes the employee unable to perform the essential functions of his or her job.
FIELD NURSE CASE MANAGER:
A Field Nurse Case Manager is a Nurse Case Manager that goes out in the field. In doing so, beyond performing the usual and customary they In the field, they may visit the Injured Worker at their residence. They may attend medical appointment or therapy visits.
Filed means that a document or item received by the entity. For example, the WCAB may request that a party file documents or items.
Filenet is part of the software program that is part of the EAMS system.
Filing is the act of delivering an item to the WCAB. With respect to filing, it can be done either by delivery to the particular Board location. Also, it can be done electronically through the EAMS system. The date of filing may have legal significance. The term item is used because there are non-documents which may be filed. This would include subrosa film. The date of the filing is the date that it is received.
FINAL DETERMINATION LETTER (FDL):
Letter issued by the IMRO communicating the IMR decision(s) in layperson’s terms, sent to the worker or representative, the physician who requested the treatment, and to the liable employer or insurer. The FDL is issued by the Administrative Director and subject to appeal before the Workers’ Compensation Appeals Board.
A Final Order Is any order, decision or award made by a workers’ compensation judge that has not been appealed in a timely way.
FINDINGS AND AWARD:
A Findings and Award is a written decision by a workers’ compensation judge about an injured worker’s case, including payments and future medical care that must be provided to the worker.
First Aid Means any one-time treatment, and any follow up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and follow up visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel. See Labor Code Section 5401(a)
FIRST REPORT OF INJURY:
A First Report of Injury is a form that California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
FITNESS FOR DUTY EVALUATION:
A Fitness for Duty Evaluation is an evaluation is a medical or psychological evaluation of an employee to determine whether they are fit, either physically or mentally, to perform the essential duties of his or her job. The evaluation is requested by the employer who has concern for the employee’s health and well-being and/or the safety of the employee, co-workers or the public.
A Flare-Up is akin to an aggravation. See Aggravation.
FOOD AND DRUG ADMINISTRATION:
The US FDA is the governmental body responsible for regulating prescription and over-the-counter medications, as well as medical devices.
A Foot Impairment is an impairment within the AMA Guides. A Foot Impairment is converted to a Lower Extremity Impairment which is converted to a Whole Person Impairment.
FORMAL RATING INSTRUCTIONS:
Formal Rating Instructions are instructions from a Workers’ Compensation Judge after a hearing is conducted.
Formal Ratings are based upon instructions from a Workers’ Compensation Judge after a hearing is conducted. These ratings constitute formal evidence and the rater is acting as an expert witness when issuing a Formal rating.
FRAUD in Workers’ Compensation is any knowingly false or fraudulent statement for the purpose of obtaining or denying workers’ compensation benefits.
FULL DUTY means performance of Usual and Customary Duty with no limitations.
FUNCTIONAL CAPACITY EVALUATION:
A FUNCTIONAL CAPACITY EVALUATION is a series of tests administered to a workers’ comp claimant by a physical therapist or other health care professional. They can be beneficial in determining an injured worker’s capabilities and restrictions. FCE evaluators can review job descriptions and make a determination regarding whether the injured employee is capable of performing certain jobs. After a claimant undergoes an FCE, the evaluator typically provides a detailed report on the results, including the claimant’s capabilities and restrictions.
FUTURE MEDICAL CARE:
FUTURE MEDICAL CARE from a workers’ compensation award is an award of lifetime medical care.
A GENERAL CONTRACTOR is one who contracts for the construction or an entire building or project rather than a portion of the work. The General Contractor hires subcontractors and coordinates all of the work and is responsible for payment to the subcontractors.
GLOBAL ASSESSMENT OF FUNCTION SCALE:
The GLOBAL ASSESSMENT OF FUNCTIONAL SCALE is a scale which is used to calculate an Injured Workers’ psychological impairment. The scale considers the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. It does not include impairment in functioning due to physical (or environmental) limitations.
GOING AND COMING RULE:
The GOING AND COMING RULE precludes [recovery under the Workers’ Compensation Act] for an injury suffered during the course of a local commute to a fixed place of business at fixed hours in the absence of exceptional circumstances. (Hinojosa v. Workmen’s Comp. Appeals Bd. (1972) 37 C.C.C. 734.
GOOD FAITH PERSONNEL ACTION:
GOOD FAITH PERSONNEL ACTION is a defense that can be raised by the Claims Administrator to defeat a psychiatric workers’ compensation claim. It is an evidentiary burden that a substantial cause of a psychiatric claim, 35-40 percent may not be the result of good faith personnel action. Good Faith Personnel actions have been defined.
GROUP SELF-INSURANCE is a form of workers’ compensation insurance by non-affiliated companies is permitted under California regulation. It is permitted for both private and public sector employers.
A HAND IMPAIRMENT is an impairment within the AMA Guides which then becomes converted to an Upper Extremity Impairment. An Upper Extremity Impairment then becomes converted to a Whole Person Impairment.
HEALTH CARE ORGANIZATION:
A HEALTH CARE ORGANIZATION is an organization certified by the Division of Workers’ Compensation that contracts with an employer or insurer to provide managed care in the California Workers’ Compensation System.
HEALTH INSURANCE CLAIM NUMBER:
The HICN is an identification number assigned by the Social Security Administration to Medicare beneficiaries. (See also Medicare Beneficiary Identifier.)
A HEARING is a legal proceeding in which a Workers’ Compensation Judge discusses the issues in a case or receives information in order to make a decision about a dispute or a proposed settlement. There are a variety of hearings which include Expedited Hearings, Mandatory Settlement Conferences, Pre-Trial Conferences, Priority Conferences, Status Conferences, and Trials.
A HEARING REPORTER is a court reporter that is an employee of the State of California. They perform the stenographic support at the Workers’ Compensation Appeals Board.
HEAVY LIFTING preclusion contemplates the individual has lost approximately 50% of pre-injury capacity for lifting.
HEAVY LIFTING AND REPEATED BENDING AND STOOPING:
HEAVY LIFTING AND REPEATED BENDING AND STOOPING is a preclusion which contemplates the individual has lost approximately 50% of pre-injury capacity for lifting, bending and stooping.
HEAVY WORK is a restriction which contemplates the individual has lost approximately 50% of pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling, and climbing or other activities involving comparable physical effort.
HOME HEALTH CARE SERVICES:
HOME HEALTH CARE SERVICES are part of the medical treatment provided under workers’ compensation law. Home health care services shall be provided as medical treatment only if reasonably required to cure or relieve the injured employee from the effects of his or her injury and prescribed by a physician and surgeon.
Caselaw has referred to HORSEPLAY as “rough, boisterous play or fun.” See Venegas vs. WCAB (1998) 63 C.C.C. 269. It is the rule in California that injury suffered by an employee while engaged in horseplay is not compensable. There are some exceptions.
An IMPAIRMENT, according to the AMA Guides, is a loss, a loss of use, or derangement or any body part, organ system or organ function.
An IMPAIRMENT EVALUATION is a medical evaluation performed by a physician trained to use the AMA Guides. In doing so, they used the AMA Guides to determine whether there is any permanent impairment associated with a medical condition.
An IMPAIRMENT RATING is a percentage that estimates how much a worker has lost the normal use of injured parts of the body. Impairment ratings are determined based on guidelines published by the American Medical Association (AMA). Different from “permanent disability rating.”
IN FORCE mean in effect or valid.
IN PRO PER:
IN PRO PER is a Latin Term which means in propria persona,” meaning “for one’s self. In Workers’ Compensation, most commonly, injured workers who are not represented are considered as being In Pro Per. At times Claims Administrators, Employers or Lien Claimants may also be without representation on the claim and also be considered as In Pro Per.
INCOME WITHHOLDING NOTICE: CHILD SUPPORT:
An INCOME WITHOLDING NOTICE, or Order/Notice to Withhold Income for Child Support (FL-195), also called the Income Withholding for Support, is an order served on employers, which requires them to garnish or withhold an employee’s wages for payment of child support. This form may also be referred to as: wage assignment, garnishment order, and income withholding order. A person may be served by a local child support agency (LCSA), private party, or another state’s child support agency.
INCOME WITHHOLDING ORDER: CHILD SUPPORT:
An INCOME WITHHOLDING ORDER, or Order/Notice to Withhold Income for Child Support (FL-195), also called the Income Withholding for Support, is an order served on employers, which requires them to garnish or withhold an employee’s wages for payment of child support. This form may also be referred to as: wage assignment, garnishment order, and income withholding order. A person may be served by a local child support agency (LCSA), private party, or another state’s child support agency.
An INDEPENDENT CONTRACTOR is a someone who does work for another person or entity who, under workers’ compensation law, would not be considered as an Employee. As a result, they would not be eligible to claim workers’ compensation benefits. The fact that a person is called an “Independent Contractor” does not necessarily mean that workers’ compensation law will consider the person an Independent Contractor. The determination of Independent Contractor status is a case by case definition. There is a the “multi-factor” or the “economic realities” test adopted by the California Supreme Court in the case of S. G. Borello & Sons, Inc. v Dept. of Industrial Relations (1989) 48 Cal.3d 341. In applying the economic realities test, the most significant factor to be considered is whether the person to whom service is rendered (the employer or principal) has control or the right to control the worker both as to the work done and the manner and means in which it is performed. Additional factors that may be considered depending on the issue involved are: 1.. Whether the person performing services is engaged in an occupation or business distinct from that of the principal; 2. Whether or not the work is a part of the regular business of the principal or alleged employer; 3. Whether the principal or the worker supplies the instrumentalities, tools, and the place for the person doing the work; 4. The alleged employee’s investment in the equipment or materials required by his or her task or his or her employment of helpers; 5. Whether the service rendered requires a special skill; 6. The kind of occupation, with reference to whether, in the locality, the work is usually done under the direction of the principal or by a specialist without supervision; 7. The alleged employee’s opportunity for profit or loss depending on his or her managerial skill; 8. The length of time for which the services are to be performed; 9. The degree of permanence of the working relationship; 10. The method of payment, whether by time or by the job; and 11. Whether or not the parties believe they are creating an employer-employee relationship may have some bearing on the question, but is not determinative since this is a question of law based on objective tests.
Further, Even where there is an absence of control over work details, an employer-employee relationship will be found if (1) the principal retains pervasive control over the operation as a whole, (2) the worker’s duties are an integral part of the operation, and (3) the nature of the work makes detailed control unnecessary. (Yellow Cab Cooperative v. Workers Compensation Appeals Board (1991) 226 Cal.App.3d 1288)
Other points to remember in determining whether a worker is an employee or independent contractor are that the existence of a written agreement purporting to establish an independent contractor relationship is not determinative (Borello, Id.at 349), and the fact that a worker is issued a 1099 form rather than a W-2 form is also not determinative with respect to independent contractor status. (Toyota Motor Sales v. Superior Court (1990) 220 Cal.App.3d 864, 877)
INDEPENDENT MEDICAL EVALUATOR/EXAMINER:
INDEPENDENT MEDICAL EVALUATORS/EXAMINERS, under current workers’ compensation law, do not exist. Qualified Medical Evaluators are considered to act in an independent, unbiased manner.
INDEPENDENT MEDICAL EXAMINATION:
An IME may be used as part of the supporting documentation in a WCMSA proposal.
INDEPENDENT MEDICAL REVIEW (IMR):
INDEPENDENT MEDICAL REVIEW refers to two different processes. There is the Independent Review of a decision, communicated by a claims administrator, to deny or modify treatment recommended by a treating physician. An injured worker may request this type of IMR if the worker’s date of injury is on or after January 1, 2013, or the claims administrator communicated the decision to deny treatment on or after July 1, 2013. There is also Independent review of a treatment decision made by a treating physician in a medical provider network (MPN). An injured worker may request this type of IMR if the worker is being treated in an MPN and has obtained opinions from two other physicians in the MPN.
INDEPENDENT MEDICAL REVIEW
The application form (DWC Form IMR) used to request IMR. The application form must be completed by the claims administrator, except for the signature of the employee, and included with a copy of the UR decision that denies or modifies a medical treatment recommendation. A complete IMR application must be signed and include a copy of the disputed UR decision.
INDEPENDENT MEDICAL REVIEW
Decision of the IMRO (deemed the decision of the DWC administrative director), made on the basis of medical necessity, regarding a single disputed treatment. An IMR decision is communicated in an FDL, which may contain multiple treatment decisions.
INDEPENDENT MEDICAL REVIEW
Organization under contract with the Administrative Director to conduct IMR of eligible cases.
INDUSTRIAL MEDICAL COUNCIL:
The INDUSTRIAL MEDICAL COUNCIL was created to provide policymaking, rulemaking and regulatory authority for the medical component of the new workers’ compensation program.
The Council has the responsibility for: establishing standards for improving health care for injured employees; conducting studies in the field of rehabilitation; monitoring and measuring cost of medical services to injured workers; and administering programs for medical and chiropractic evaluations in workers’ compensation cases.
During 1991 the IMC instituted regulations on the appointment and performance of qualified medical evaluators. The Reform Act authorized the Council to appoint such evaluators for the purpose of assessing permanent disability of an employee injured in an industrial accident. The functions of the IMC were transferred to the administrative director. As of January 1, 2005, the IMC was renamed to the Division of Workers’ Compensation – Medical Unit.
INEXTRICABLY INTERTWINED is a legal term that is of import with respect to apportionment. If a doctor finds that the apportionment causation is inextricably intertwined, it means that the doctor could not separate a medical conditions impairment between two or more dates of injury and therefore cannot be rated separately. See BENSON
An INFORMAL RATING is a rating of medical report(s) requested by a party from the Disability Evaluation Unit. It is an informative rating and is not binding.
INFORMATION AND ASSISTANCE OFFICER:
A INFORMATION AND ASSISTANCE OFFICER is an employee of the Division of Workers’ Compensation who answers questions, assists injured workers, provides written materials, conducts informational workshops, and holds meetings to informally resolve problems with claims. Most of their services are designed to help workers who do not have an attorney.
INFORMATION AND ASSISTANCE UNIT:
The INFORMATION AND ASSISTANCE UNIT is the unit within the Division of Workers’ Compensation that provides information to all parties in workers’ compensation claims and informally resolves disputes.
INTEREST attaches to benefits provided. With respect to Awards from the WCAB, interest accrues from the date of award at the legal rate. For non-governmental employers, the interest rate is 10 percent. For governmental employers, the interest rate is 7 percent. Lien Claimants can also claim interest.
An INITIAL AGGRESSOR is the “initial physical aggressor” who first engages in physical conduct which a reasonable man would perceive to be a “‘real, present and apparent threat of bodily harm . . . .”‘ Briglia v. Industrial Accident Commission (1962) 27 C.C.C. 217, 218.
An INJURY may be either: (a) “specific,” occurring as the result of one incident or exposure which causes disability or need for medical treatment; or (b) “cumulative,” occurring as repetitive mentally or physically traumatic activities extending over a period of time, the combined effect of which causes any disability or need for medical treatment. The date of a cumulative injury shall be the date determined under Section 5412. See Labor Code Section XXX.
INJURY AND ILLNESS PREVENTION PROGRAM:
An INJURY AND ILLNESS PREVENTION PROGRAM is a health and safety program that employers are required to develop and implement. This requirement is enforced by Cal/OSHA.
An INITIAL ASSIGNMENT is the first assignment made to a particular Workers’ Compensation Judge who is to be the Trial Judge.
The term INTERNAL refers to claims of an internal nature. It is a vague term which is frequently used to describe conditions such as cardiovascular, gastro intestinal, colorectal, or headaches. Frequently, people in the industry will use the term “internal” when talking about any claim that is not of an orthopedic or psychiatric nature.
An INTERPRETER in worker’s compensation must be a qualified interpreter. The Labor Code provides for interpreters to an injured worker for medical treatment and for depositions. Also, for deponents who do not proficiently speak or understand the English language.
INTOXICATION DEFENSE is a possible affirmative defense for an Employer to contest a workers’ compensation claim. LC Section 5705
An INVESTIGATOR either an employee of the Claims Administrator or a Private Investigator who may conduct an accident investigation. An accident investigation could include taking pictures, taking measurements and taking witness statement.
IRS FORM 941:
The IRS FORM 941 is a form which Employers use this form to report income taxes, social security tax, or Medicare tax withheld from employee’s paychecks, and to pay the employer’s portion of social security or Medicare tax.
A JOINDER is the act of the upon which the WCAB joins a party as a Defendant. A joinder can join either an employer or a Claims Administrator. When the employer is illegally uninsured, the Uninsured Employers Benefits Trust Fund may be joined.
JOINT POWERS AUTHORITIES:
JOINT POWERS AUTHORITIES is an agency which allows for government entities to pool their resources. This includes workers’ compensation liability.
JUDGE PRO TEM:
A JUDGE PRO TEM is an attorney who volunteers their time and preside over conferences at the WCAB.
JURISDICTION is a legal which confers authority to a legal agency the power to make legal decisions and judgment. Jurisdiction for the Labor Code. The WCAB has Jurisdiction for the recovery of compensation, or concerning any right or liability arising out of or incidental thereto, for the enforcement against the employer or an insurer of any liability for compensation imposed upon the employer by this division in favor of the injured employee, his or her dependents, or any third person, for the determination of any question as to the distribution of compensation among dependents or other persons, for the determination of any question as to who are dependents of any deceased employee, or what persons are entitled to any benefit under the compensation provisions of this division; for obtaining any order which by Division 4 the appeals board is authorized to make, for the determination of any other matter, jurisdiction over which is vested by Division 4 in the Division of Workers’ Compensation, including the administrative director and the appeals board. See Labor Code Section 5300.
LACK OF COVERAGE:
LACK OF COVERAGE is a term used by Insurance Companies when the policy holder did not have their policy with the particular Insurance Company in effect on the date of the injury.
LEBOUEF is a case in which the ability to perform suitable gainful employment was a factor relating to disability. This case is used to address permanent total disability. LeBoeuf v. W.C.A.B. (1983) 34 Cal. 3d 234
LIBERAL CONSTRUCTION refers to Labor Code Section 3202 which provides that the Labor Code pertaining to Workers’ Compensation law shall be “liberally construed by the courts with the purpose of extending their benefits for the protection of persons injured in the course of their employment.”
A LIEN is a claim for payment arising out of the workers’ compensation claim. There are a variety of liens within workers’ compensation. There are liens against compensation which may include attorney’s fees, burial expenses, living expenses of the employee’s spouse or minor children, the amount of unemployment compensation disability benefits paid pending a determination of a work-related injury; The amount of unemployment compensation benefits and extended benefits or family temporary disability insurance benefits to the extent such benefits duplicate period of the injured employee’s entitlement to temporary total disability, The amount of indemnification granted by the California Victims of Crime Program, and The reasonable expense incurred by or on behalf of the injured employee for reasonable medical treatment to cure or relieve the effects of the industrial injury except medical treatment disputes subject to independent medical review or independent bill review. Other liens can be against the employer/claims administrator. This includes State Disability Payments, Short or Long Term Disability Payments, or Group Health Insurance payments.
LIEN AGAINST COMPENSATION:
A LIEN AGAINST COMPENSATION is a lien for which the monies are to be taken out of the injured worker’s recovery.
A LIEN CLAIMANT is the person or entity which holds the lien. It can be an attorney for attorney’s fees, it can be a medical provider for medical services.
A LIEN TRIAL is a trial which addresses the liens on a case. They are given a lower priority as far as being heard if there are Cases In Chief are the Worker’s Compensation Judge’s calendar.
LIFE EXPECTANCY is the expectancy that that the injured work will live based upon actuarial tables. Life Expectancy may factor into it an injured worker’s illnesses or chronic conditions. Sex is also a factor. Life Expectancy is considered when settling cases with life pensions and cases with future medical care.
An Award of 70 percent or more entitles an Injured Worker to receive a life pension after the payment of the Award. A Life Pension is only payable while an Injured Worker is alive.
LIGHT DUTY Is a form of modified work. Light Duty is usually assigned by a doctor during the period upon which the injured worker has not been determined as permanent and stationary.
LIGHT WORK is a limitation which contemplates the individual can do work in a standing or walking position, with a minimum of demands for physical effort.
LOWER EXTREMITY IMPAIRMENT:
A LOWER EXTREMITY IMPAIRMENT is an AMA term which is used for the purposes of assessing impairment for the feet, the hindfeet, the ankles, the legs, the knees, the hips, and the pelvis. To calculate whole person impairment from a lower extremity impairment, multiply by 0.4
LUMP SUM SETTLEMENT:
A settlement in which the agreed-on funds are paid out in one amount.
MANAGED PROVIDER NETWORK:
MANAGED PROVIDER NETWORK is an entity or group of health care providers set up by an insurer or self-insured employer and approved by DWC’s administrative director to treat workers injured on the job.
MANDATORY SETTLEMENT CONFERENCE:
MANDATORY SETTLEMENT CONFERENCE is a conference in which the Workers’ Compensation Judge has the authority to inquire into the adequacy and completeness, including provision for lien claims, of compromise and release agreements or stipulations with request for award or orders, and to issue orders approving compromise and release agreements or awards or orders based upon approved stipulations. The workers’ compensation judge may make orders and rulings regarding admission of evidence and discovery matters, including admission of offers of proof and stipulations of testimony where appropriate and necessary for resolution of the dispute(s) by the workers’ compensation judge, and may submit and decide the dispute(s) on the record pursuant to the agreement of the parties. The workers’ compensation judge shall not hear sworn testimony at any conference. If the dispute cannot be resolved, the parties shall file at the mandatory settlement conference a joint pre-trial statement setting forth the issues and stipulations for trial, witnesses, exhibits, and the proposed permanent disability rating as provided by Labor Code Section 4065. The parties may modify their proposed ratings only when evidence, relevant to the proposed ratings, and disclosed or obtained after the mandatory settlement conference, becomes admissible pursuant to Labor Code Section 5502, subdivision (e)(3).
MAXIMUM MEDICAL IMPROVEMENT:
Per the AMA Guides, MAXIMUM MEDICAL IMPROVEMENT is a condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Over time, there may be some change, however, further recovery or deterioration is not anticipated. Over time, there may be some change, however, further recover or deterioration is not anticipated.
MEDICAL BILL REVIEWER:
A MEDICAL BILL REVIEW is a person who is not a claims adjuster or medical-only claims adjuster and who only reviews or adjusts workers’ compensation medical bills on behalf of an insurer, including employees or agents of the insurer or employees or agents of a medical billing entity. “Medical bill reviewer” also includes an experienced medical bill reviewer.
In workers’ compensation, MEDICAL CARE is medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury shall be provided by the employer. Medical care can include Home Health Care Services.
MEDICAL CONTROL refers to whether the Claims Administrator can control the medical care of an injured worker. Labor Code Provides that Unless the employer or the employer’s insurer has established or contracted with a medical provider network as provided for in Section 4616, after 30 days from the date the injury is reported, the employee may be treated by a physician of his or her own choice or at a facility of his or her own choice within a reasonable geographic area. See Labor Code Section 4600.
MEDICAL LEGAL is a term of art in workers’ compensation which refers to matters in the medical arena which are for the used for the purposes of proving up an injury or the nature and extent of the injury. A medical evaluation, diagnostic testing or the obtaining of medical records would be considered as Medical-Legal. This would include an AME evaluation and an MRI that the AME asked for as part of that evaluation. This is in contrast to provision of medical evaluation and testing which is done for the purposes of treatment.
MEDICAL LEGAL EXPENSE means any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the appeals board for X-rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as needed, interpreter’s fees, for the purpose of proving or disproving a contested claim. The cost of medical evaluations, diagnostic tests, and interpreters is not a medical-legal expense unless it is incidental to the production of a comprehensive medical-legal evaluation report, follow-up medical-legal evaluation report, or a supplemental medical-legal evaluation report and all of the following conditions exist:
A MEDICAL-LEGAL REPORT is a report written by a doctor to help clarify one or more disputed medical issues concerning a worker’s injury or medical condition.
MEDICAL-LEGAL TESTIMONY means expert testimony provided by a physician at a deposition or workers’ compensation appeals board hearing, regarding the medical opinion submitted by the physician.
MEDICAL ONLY CLAIM ADJUSTER:
A MEDICAL ONLY CLAIM ADJUSTER means a person who, on behalf of an insurer, including an employee or agent of an entity that is not an insurer, is responsible for determining the validity of workers’ compensation claims only involving medical workers’ compensation benefits, as defined under Article 2 (commencing with Labor Code section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code. The medical-only claims adjuster may also establish medical treatment reserves, approve and process medical benefits, and negotiate settlement of medical benefit claims. “Medical-only claims adjuster” also means a person who is responsible for the immediate supervision of a medical-only claims adjuster but does not mean an attorney representing the insurer or a person whose primary function is clerical. “Medical-only claims adjuster” also includes an experienced medical-only claims adjuster. “Medical-only claims adjuster” does not include the medical director or physicians utilized by an insurer for the utilization review process pursuant to Labor Code section 4610.
MEDICAL PROVIDER NETWORK:
A MEDICAL PROVIDER NETWORK is a set of physicians and other health care providers selected by an employer or insurer to treat injured workers in the California workers’ compensation system. MPNs must be approved by the Division of Workers’ Compensation
MEDICAL RECORDS are records from facilities at which an injured worker received treatment. Medical records can refer to both records for the work injury as well as records for non-industrial conditions. Medical Records can include records for mental health treatment as well as substance abuse. In certain circumstances, Medical Records can be privileged.
MEDICAL RESEARCH is the investigation of medical issues. It includes investigating and reading medical and scientific journals and texts. “Medical research” does not include reading or reading about the Guides for the Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the American College of Occupational and Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers’ Compensation (including the Physicians’ Guide), or other legal materials.
MEDICAL TREATMENT, Per the AMA Guides, is the action and manner of treating an individual either medically or surgically. Treatment may also include modalities recommended by a health care provider. Treatment under the Labor Code is Medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury shall be provided by the employer. In the case of his or her neglect or refusal reasonably to do so, the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment and (b) As used in this division and notwithstanding any other law, medical treatment that is reasonably required to cure or relieve the injured worker from the effects of his or her injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27. See Labor Code Section 4600.
MEDICAL TREATMENT UTILIZATION SCHEDULE (MTUS) :
Evidence-based standards of medical care adopted by the Division of Workers’ Compensation, to be used as treatment guidelines in the California workers’ compensation system. Treating physicians, UR reviewers, and IMR physician reviewers are required to use it, when relevant, as the basis of treatment, UR decisions, and IMR decisions. The MTUS is presumed to be correct and is rebuttable with a preponderance of the scientific/medical evidence.
The MEDICAL UNIT is a unit within the DWC that oversees medical provider networks (MPNs), independent medical review (IMR) physicians, health care organizations (HCOs), qualified medical evaluators (QMEs), panel QMEs, utilization review (UR) plans, and spinal surgery second opinion physicians. Formerly called the Industrial Medical Council (IMC).
A MEDICARE LIEN is a lien for medical services which were provided to the injured worker and initially paid by Medicare.
MEDICARE SET ASIDE:
A MEDICARE SET ASIDE is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease. These funds must be depleted before Medicare will pay for treatment related to the workers’ compensation injury, illness, or disease.
All parties in a workers’ compensation case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving cases that include future medical expenses. The recommended method to protect Medicare’s interests is a WCMSA. The amount of the WCMSA is determined on a case-by-case basis.
MEDICAL TREATMENT UTILIZATION SCHEDULE:
Per the DIR, the MEDICAL TREATMENT UTILIZATION SCHEDULE is a tool which treating’s doctors in the workers’ compensation system are to employ. Doctors in California’s workers’ compensation system are required to provide evidence-based medical treatment. That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses. Those treatments are laid out in the medical treatment utilization schedule (MTUS), which contains a set of guidelines that provide details on which treatments are effective for certain injuries, as well as how often the treatment should be given, the extent of the treatment, and for how long, among other things. A set of guidelines and an analytical framework adopted by the Division of Workers’ Compensation, based on scientific evidence and nationally recognized standards of care, that address the appropriate extent and scope of treatment commonly performed in workers’ compensation cases.
The MEDICAL UNIT is within the Division of Workers’ Compensation that oversees utilization review (UR) plans, independent medical review (IMR) of decisions to deny treatment recommended by a treating physician, medical provider networks (MPNs), independent medical review (IMR) of treatment decisions made by MPN physicians, health care organizations (HCOs), and qualified medical evaluators (QMEs).
MEMORANDUM OF POINTS AND AUTHORITIES:
A MEMORANDUM OF POINTS AND AUTHORITIES are briefs prepared by attorney to assist the Court with the facts and the issues on a case. Particularly, a Workers’ Compensation Judge may request that the parties submit them.
The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).
MEDICARE BENEFICIARY IDENTIFIER:
The MBI is an identification number assigned by the Social Security Administration to Medicare beneficiaries. This number replaces the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.
MEDICARE SECONDARY PAYER:
MSP is the term used by Medicare when Medicare is not responsible for paying first. With the addition of the MSP provisions to federal law in 1980 (and subsequent amendments), Medicare is secondary payer to group health plan insurance in specific circumstances, but is also secondary to liability insurance (including self-insurance), no-fault insurance, and Workers’ Compensation.
MILEAGE REIMBURSEMENT is allowed in workers’ compensation. It is payment of “reasonable expenses of transportation” includes mileage fees from the employee’s home to the place of the examination. It can include any bridge tolls. The mileage and tolls shall be paid to the employee at the time he or she is given notification of the time and place of the examination. Mileage Reimbursement is also permitted for depositions.
MINUTES OF HEARING:
The MINUTES OF HEARING is a form which the Workers’ Compensation Judge is responsible for the completion of minutes of hearing for each case assigned to him or her. The minutes of each hearing should be prepared for each case as soon as a disposition is reached, or as soon thereafter as possible. Regardless of which form is used, or in the event a hearing reporter is used, the minutes for each hearing shall contain, at a minimum, the following information, written legibly: Name of WCJ, Date, time and place of hearing, Appearances by parties and attorneys, Interim orders, Stipulations and issues (trial setting), Exhibits offered or received into evidence (trial setting), and Disposition. Minutes of Hearing can be used for conferences, trials or walk-throughs.
MODIFIED JOB is the worker’s old job with changes that meet the doctor’s work restrictions.
MODIFIED WORK is the worker’s old job with changes that meet the doctor’s work restrictions.
MULTIPLE BODY PARTS:
MULTIPLE BODY PARTS refers to workers’ compensation claim which involve more than one part of the body or more than one body system.
NATIONAL DRUG CODE:
The NDC is a unique number assigned to pharmaceuticals.
A NON-ATTORNEY REPRESENTATIVE is a person who has filed a letter of authorization in the case pursuant to Policy & Procedural Manual Index No. 1.120, and for who May make APPEARANCES In each case in which a law firm representing an injured worker appears by an employee not holding current active membership in the State Bar of California, pursuant to Rule 10773, the employee shall file at the time of his or her first appearance at the WCAB an original document that: 1. discloses to the board and to the applicant that he or she is not licensed to practice law in the State of California; 2. states the name of the attorney directly responsible for supervising the employee; 3. specifically states that the employee is authorized by the supervising attorney to sign settlement documents; and 4. is signed by the supervising attorney and the client. In each case in which a law firm representing a defendant appears by an employee not holding current active membership in the State Bar of California, the employee shall file at the time of his or her first appearance at the WCAB a document that complies with the paragraph above, except that it need not be signed by the client.
NOTEWORTHY PANEL DECISIONS:
NOTEWORTHY PANEL DECISIONS are workers’ compensation cases that LexisNexis editorial consultants have deemed this panel decision noteworthy because it does one or more of the following: (1) Establishes a new rule of law, applies an existing rule to a set of facts significantly different from those stated in other decisions, or modifies, or criticizes with reasons given, an existing rule; (2) Resolves or creates an apparent conflict in the law; (3) Involves a legal issue of continuing public interest; (4) Makes a significant contribution to legal literature by reviewing either the development of workers’ compensation law or the legislative, regulatory, or judicial history of a constitution, statute, regulation, or other written law; and/or (5) Makes a contribution to the body of law available to attorneys, claims personnel, judges, the Board, and others seeking to understand the workers’ compensation law of California.
NOTICE is the means upon which the WCAB or the Parties notify the other interested parties of either an event such as a deposition or a hearing.
NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK (DWC-AD 10133.53):
A NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK, For dates of injury 2004 through 2012: A form that an employer or claims administrator sends to an injured worker with a permanent disability. If the employer makes this offer within 30 days after the worker’s final temporary disability (TD) payment, the claims administrator is not required to provide a supplemental job displacement Appendix B. Glossary 60 Workers’ Compensation in California benefit (SJDB). If the worker was injured sometime in 2005 through 2012, the employer has 50 or more employees, and this offer is made within 60 days after the worker’s condition becomes permanent and stationary (P&S), permanent disability (PD) payments are reduced by 15 percent; otherwise, PD payments are increased by 15 percent. Notice of Offer of Regular, Modified, or Alternative Work (DWC-AD 10133.35). For dates of injury in 2013 or later: A form that an employer or claims administrator sends to an injured worker with a permanent disability. If the employer makes this offer within 60 days after the claims administrator learns the worker has a permanent partial disability (PPD) that has become permanent and stationary (P&S), the claims administrator is not required to provide a supplemental job displacement benefit (SJDB). Notice of Offer of Regular Work (DWC-AD 10118). For dates of injury 2005 through 2012: A form that an employer or claims administrator sends to an injured worker with a permanent disability. If the employer has 50 or more employees and this offer is made within 60 days after the worker’s condition becomes permanent and stationary (P&S), permanent disability (PD) payments are reduced by 15 percent; otherwise, PD payments are increased by 15 percent.
NURSE CASE MANAGER:
A NURSE CASE MANAGER Iis sometimes assigned by a claims administrator to monitor and assist with the coordination of medical aspects of workers’ comp claims. Nurse Case Managers may attend medical appointments with workers’ comp claimants. They are not uncommonly used when there is a serious or catastrophic injury.
OBJECTIVE FACTORS refers to both the observations of an evaluating physician or diagnostic studies or tests. Physician’s observations can include range of motion as well as tenderness to palpation. These Objective Factors can be used to formulate what permanent disability or Whole Person Impairment which they Injured Worker may have. Objective Factors are usually documented within a medical-legal report.
OBJECTION TO READINESS TO PROCEED:
An OBJECTION TO READINESS TO PROCEED is an objection filed in response to a Declaration of Readiness to Proceed filed by a party in the case.
OCCUPATIONAL ADJUSTMENT TABLE:
The OCCUPATIONAL ADJUSTMENT TABLE is the table within the Schedule for Rating Permanent Disabilities which takes the Occupational Group Number and converts it to the Occupational Group Variant.
AN OCCUPATIONAL DISEASE is a medical condition produced in the work environment over a period longer than a single workday or shift by such factors as systemic infection, continued or repeated stress or strain, or exposure to hazardous elements such as, but not limited to, toxins, poisons, fumes, noise, particles, radiation, or other continued or repeated conditions or factors of the work environment.
OCCUPATIONAL GROUP NUMBER:
An OCCUPATIONAL GROUP NUMBER is a number which is part of the rating string. The Occupational Group number is is the specific occupation that the employee was engaged in when injured. The number is based upon an analysis. The Schedule divides the labor market into 45 numbered occupational groups. Each group is assigned a three digit code called an occupational group number. The first digit of the code refers to the arduousness of the duties, ranking jobs from 1 to 5 in ascending order of physical arduousness; the second digit separates occupations into broad categories sharing common characteristics; the third digit differentiates between occupations within these groups. The Group Number then translates into an Occupational Variant. See Occupational Variant.
An OCCUPATIONAL HISTORY is the process in which a physician obtain information concerning the Injured Workers work activities. The history allows for the physician to address industrial causation as well impairment.
An OCCUPATIONAL ILLNESS is a medical condition produced in the work environment over a period longer than a single workday or shift by such factors as systemic infection, continued or repeated stress or strain, or exposure to hazardous elements such as, but not limited to, toxins, poisons, fumes, noise, particles, radiation, or other continued or repeated conditions or factors of the work environment.
An OCCUPATION VARIANT is expressed in a letter. This Variant is part of the rating formula. The letters run from “A” to “J.” These tables are designed so that variant “F” represents average demands on the injured body part for the particular impairment being rated, with letters “E”, “D” and “C” representing progressively lesser demands, and letters “G” through “J” reflecting progressively higher demands.
OFFER OF MODIFIED OR ALTERNATIVE WORK RU-94:
OFFER OF MODIFIED OR ALTERNATIVE WORK RU-94: is a form that is generated to offer work at the employment. If there is no offer, then there is entitlement to a voucher.
OFFER OF MODIFIED OR ALTERNATIVE WORK (dwc FORM AD 10133.53):
OFFER OF MODIFIED OR ALTERNATIVE WORK (dwc FORM AD 10133.53) is a form that is generated to offer work at the employment. If there is no offer, then there is entitlement to a voucher.
An ORDER is from a Workers’ Compensation Judge. If it is final Order, it is subject to appeal via a Petition for Reconsideration. If it is not a final Order, it may be subject to a Petition for Removal.
ORDER OF SUBMISSION:
An ORDER OF SUBMISSION is when a WCJ concludes the hearing portion of a trial. At that point in time, the matter may be sent to the Disability Evaluation Unit. An Order of Submission may be delayed for the receipt of designated evidence or for the filing of simultaneous or responsive points and authorities.
The term ORTHOPEDIC refers to musculo-skeletal complaints. In the workers’ compensation industry, if someone had a back injury, it might be described as an “orthopedic” injury.
An OVERPAYMENT occurs when a Claims Administrator pays benefits beyond the period upon which they were legally obligated to do so. Such excessive payments are considered overpayments. Frequently, the Claims Administrator will claim a credit against an overpayment.
A PANEL QME is a Qualified Medical Evaluator who was selected with the QME selection process. This can be a QME chosen off a Panel by an unrepresented injured Worker. It can be a QME chosen by the strike progress by a represented Injured Worker.
A PANEL STRIKE is the process that occurs when the parties obtain a Panel to resolve their medical-legal dispute. After a Panel issued by Medical Unit, each party is afforded the right to strike a doctor after the 3 QME Panel.
A PENALTY are fines that are charged against claims administrators or employers within the administrator of workers’ compensation. There are various penalties within workers’ compensation. They are also referred to as increases in compensation. Penalties are commonly applied with respect to the provision of benefits. See Labor Code Section 5814.
PERMANENT ALTERNATIVE POSITION:
PERMANENT ALTERNATIVE WORK is another position at work that is not regular or modified.
PERMANENT AND STATIONARY:
PERMANENT AND STATIONARY is when a doctor reports that the injured worker’s condition has stabilized, or is not expected to get any better or any worse. For workers whose permanent disability must be rated using the “2005 Schedule for Rating Disabilities,” this is referred to as the point in time when the worker has reached maximal medical improvement (MMI).
PERMANENT AND STATIONARY REPORT:
A PERMANENT AND STATIONARY REPORT is a medical report written by a physician, usually a treating physician, that describes the injured worker’s medical condition when it has stabilized. See also Permanent and Stationary.
PERMANENT DISABILITY is to two kinds. There is permanent total disability and permanent partial disability. Permanent total disability benefits are for workers that have received a 100 percent award. Permanent partial disability are payments to a worker who is partially limited in the kinds work he or she can do.
PERMANENT DISABILITY BENEFITS:
PERMANENT DISABILITY BENEFITS are paid to compensate an injured worker if either a permanent or permanent partial disability has occurred as a result of an industrial injury.
PERMANENT DISABILITY RATING:
A PERMANENT DISABILITY RATING is a percentage that estimates how much a job injury permanently limits the kinds of work the worker can do. It is based on the worker’s medical condition which is translated into a Whole Person Impairment, date of injury, age when injured, occupation when injured, and apportionment (how much the disability is caused by the job compared to other factors.) Also, it is based upon a DFEC adjustment as well.
Per the AMA Guides, PERMANENT IMPAIRMENT is an impairment that has reached maximum medical improvement.
PERMANENT MODIFIED POSITION:
A PERMANENT MODIFIED POSITION is a modified position at the employer which is lasting at least 12 months.
PERMANENT PARTIAL DISABILITY BENEFITS:
PERMANENT PARTIAL DISABILTIY BENEFITS are payments of permanent disability that are less than 100 percent disability.
PERMANENT TOTAL DISABILITY BENEFITS:
PERMANENT TOTAL DISABILITY BENEFITS are payable when an individual receives a 100 percent award.
PERSONAL COMFORT DOCTRINE:
The PERSONAL COMFORT DOCTRINE provides generally that compensation extends to injuries suffered while the employee is engaged briefly and during work hours in a personal act which is necessary or helpful to his or her or convenience. (2 Hanna, op. cit., supra, § 9.03[a], pp. 9–3—9–31.) The personal comfort doctrine is not strictly limited to injuries suffered on the employer’s premises.
A PERSONAL PHYSICIAN is a doctor licensed in California with an MD degree (medical doctor) or a DO degree (osteopath), who has treated the injured worker in the past and has his or her medical records. The doctor must be a general practitioner, internist, pediatrician, obstetrician-gynecologist, or family practitioner who is the worker’s primary care physician. “Personal physician” can refer to a medical group that provides comprehensive medical services mostly for medical conditions unrelated to work. The physician must also agree to be predesignated.
PETITION FOR AUTOMATIC REASSIGNMENT:
A PETITION FOR AUTOMATIC REASSIGNMENT is the request of a party to change the WCJ assigned for the Trial. There are time limits concerning the request to do so.
PETITION FOR COMMUTATION:
A PETITION FOR COMMUTATION is a request for the acceleration of an award of permanent disability. The request is made for a lump sum which may either be for an amount certain or for the entire balance of the award. Financial hardship is a basis for the issuance of a commutation. See Labor Code Section 5100.
PETITION FOR CONTRIBUTION:
A PETITION FOR CONTRIBUTION is a petition filed by a the Claims Administrator who was elected against in a cumulative trauma claim pursuant to Labor Code Section 5500.5. The Petition seek payments from another other Claims Administrator that may have coverage during the period of industrial exposure. See Labor Code Section 5500.5.
PETITION FOR COSTS:
A PETITION FOR COSTS are filed by a party to seek reimbursement of an expense or payment for service that is not allowable as a lien against compensation under Labor Code section 4903. A petition for costs may be filed only by: (1) an employee or the dependent of a deceased employee, (2) a defendant, or (3) an interpreter for services other than those rendered at a medical treatment appointment or medical-legal examination. A petition for costs filed by an employee or a dependent may include, but is not limited to, a claim for reimbursement of payment(s) previously made directly to a provider for medical-legal goods or services, subject to any applicable official fee schedule.
PETITION FOR DISQUALIFICATION:
A PETITION FOR DISQUALIFICATION is a petition to disqualify a Workers’ Compensation Judge. The petition should state in detail facts establishing grounds for disqualification of the workers’ compensation judge to whom a case or proceeding has been assigned. There are time limits with respect to such a filing and these petitions are to be handled by the Workers’ Compensation Appeals Board in the same manner as a Petition for Reconsideration.
PETITION FOR PENALTIES:
A PETITION FOR PENALTIES is a Petition that a party may file in workers’ compensation. Penalties are usually associated with a delay in providing a benefit or paying a benefit due.
PETITION FOR RECONSIDERATION:
A PETITION FOR RECONSIDERATION is a filing by a party to the action to the Workers’ Compensation Appeals Board. A Petition for Reconsideration may be only be filed on a final order. Any party aggrieved by a final decision of the appeals board or a workers’ compensation judge may petition for reconsideration within 20 days after service of the decision by which the party is aggrieved. The grounds for reconsideration are: (1) That the appeals board or workers’ compensation judge acted in excess of its power (2) That the decision was procured by fraud (3) That the decision is not justified by the evidence (4) That there is newly discovered evidence which could not have been produced at the hearing; and (5) That the findings of fact do not support the decision. The Appeals Board must act on the petition within 60 days from its filing. If the appeals board does not act within the time allowed, the petition is denied by operation of law.
PETITION FOR REMOVAL:
A PETITION FOR REMOVAL can be filed by any party of a decision, ruling or action of the WCAB based upon one or more of the following grounds: (1) the order, decision or action will result in significant prejudice (2) the order, decision, or action will result in irreparable harm. The petitioner must also demonstrate that reconsideration will not be an adequate remedy after the issuance of a final order, decision or award. Failure to file the petition to remove timely shall constitute valid ground for dismissing the petition for removal.
PETITION FOR WRIT OF REVIEW:
A PETITION FOR WRIT OF REVIEW is an appeal of a Workers’ Compensation Appeals Board decision to the California Court of Appeal. A Petition for Writ of Review can also be from the Court of Appeal to the California Supreme Court.
PETITION TO QUASH:
A PETITION TO QUASH can relate to an attempt for discovery. This Petition can be in connection with a deposition or a subpoena duces tecum. This petition is an attempt to stop the discovery from occurring. It is a request for the court to provide a protective order.
PETITIONS FOR AUTOMATIC REASSIGNMENT:
A PETITION FOR AUTOMATIC REASSIGNMENT occurs at a Workers’ Compensation Hearing. Reassignments pursuant to WCAB Rule 10453 shall be made, to the extent possible, in such a manner that the identity of the WCJ to whom the case is reassigned is unpredictable. Use of random rotation systems is encouraged. All WCJs in an office must be included in initial assignments to try cases. The fact that a particular attorney, law firm, employer or carrier regularly challenges a particular WCJ is not a sufficient reason to exclude that WCJ from an initial assignment to a case. Upon timely request to reassign, the matter shall promptly be reassigned to another WCJ. If another WCJ is not available in the district office, the PWCJ shall advise the Chief Judge or designee thereof and request reassignment.
PHYSICAL THERAPY is the treatment of a physical injury by use of therapeutic exercise. The Labor Code provides to limits as to how many visits an Injured Worker can received. See Labor Code Section 4604.5
A PHYSICIAN is a medical doctor, an osteopath, a psychologist, an acupuncturist, an optometrist, a dentist, a podiatrist, or a chiropractor licensed in California. See the definition of “personal physician” above.
Licensed medical professional designated by the IMRO to render an IMR decision on the basis of medical necessity regarding a disputed treatment.
POLICY & PROCEDURE MANUAL:
The POLICY AND PROCEDURE MANUAL consists of policies and procedures that DWC/WCAB employees are required to follow and to assist the DWC and the WCAB in providing uniformity and direction to its employees in the day-to-day operation of the Board and its district offices.
POLICY TERM is the period of time in which there is insurance coverage. Employers, from time to time, may take out different policies with different insurance companies. For example, an Employer may have insurance company A covering the year 2016, and insurance company B covering the year 2017. If the injury occurred in the year of 2016, insurance company A would be covering and if it was in 2017, insurance company B would provide coverage.
A Post-Termination Claim is a workers’ compensation claim that is made after an employee receives notice of termination from their employment.
POST-TRAUMATIC STRESS DISORDER:
POST-TRAUMATIC STRESS DISORDER is a Psychiatric Injury which is not an uncommon work injury. Usually, the person who develops a Post-Traumatic Stress Disorder was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to a trauma, indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics.)
A POST-TRIAL BRIEF is a Memorandum of Points and Authorities prepared by a party after Trial to address issues raised at Trial. Usually, a Trial Judge may request certain issues be addressed.
PRE-TRIAL CONFERENCE STATEMENT:
A PRE-TRIAL CONFERENCE STATEMENT is prepared by the parties when if a trial is being set. The Pre-Trial Conference Statement may contain, Interim orders, stipulated facts, issues (trial setting), exhibits offered, and witnesses to be presented at trial. The Pre-Trial Conference Statement is available at the DIR website.
A PREDESIGNATED PHYSICIAN is a physician that can treat an Injured Worker’s work injury if they advised their employer in writing prior to your work injury or illness and certain conditions are met. See Pre-designation.
PREDESIGNATION is a process in which an Injured Worker from their employer that they want their personal physician to treat them for a work injury. An Injured Worker can predesignate their personal doctor of medicine (M.D.) or doctor of osteopathy (D.O.) if: their employer offers group health coverage; the doctor has treated them in the past and has their medical records; prior to the injury their doctor agreed to treat them for work injuries or illnesses and; prior to the injury they provided their employer the following in writing: Notice that they want their personal doctor to treat them for a work-related injury or illness and their personal doctor’s name and business address.
PREDOMINANT CAUSE refers to a burden of proof that is used with respect to certain aspects of workers’ compensation law. Predominant cause means that the cause is predominant to all causes. This means more than 50 percent. This refers to the causation level for certain psychiatric injuries.
PDV is the cost to fund a WCMSA annuity. Regional Office A CMS RO is assigned to each WCMSA case, and that RO makes the final determination of the appropriate funding level for the WCMSA.
A PRESUMPTION is a legal fiction which is an inference that must be made in light of certain facts. Some presumptions are rebuttable. In Workers’ Compensation, in death cases, there are presumptions concerning spouse’s dependency and minor’s dependency. Also, there presumptions which apply to safety personnel concerning injuries to various body systems. Finally, there is the presumption of injury is a claim is not timely denied. See Labor Code Section 5402.
PRIMARY TREATING PHYSICIAN:
The PRIMARY TREATING PHYSICIAN is a doctor who is designated by the Claims Administrator or the Applicant to act as the doctor who is responsible for managing the care of the injured worker. This doctor manages the care by making referrals, if necessary, to doctors in other specialties for evaluation and treatment. The doctor also has some report writing responsibilities as well.
A PRIOR AWARD refers to an award that the Injured Worker received in a prior workers’ compensation case. A prior award could be from a stipulated award which would have been a settlement, or a findings and award which would have been an award which resulted from a trial.
A PRIORITY CONFERENCE is a calendar item which the parties can request on issues requiring an expedited hearing and decision. A hearing shall be held and a determination as to the rights of the parties shall be made and filed within 30 days after the declaration of readiness to proceed is filed if the issues in dispute are any of the following, provided that if an expedited hearing is requested, no other issue may be heard until the medical provider network dispute is resolved:
(1) The employee s entitlement to medical treatment pursuant to Section 4600, except for treatment issues determined pursuant to Sections 4610 and 4610.5; (2) Whether the injured employee is required to obtain treatment within a medical provider network; (3) A medical treatment appointment or medical-legal examination; (4) The employee s entitlement to, or the amount of, temporary disability indemnity payments; (5) The employee s entitlement to compensation from one or more responsible employers when two or more employers dispute liability as among themselves; (6) Any other issues requiring an expedited hearing and determination as prescribed in rules and regulations of the administrative director.
A PRIVILEGE is a legal protection with respect to discovery and production. There are a number of privileges. There is the attorney-client privilege and the spousal-privilege.
PRO BONO is the term used when an attorney undertakes work without charge. It is not uncommon that an attorney will assist a person with little or no income and not charge them for services rendered.
PROOF OF SERVICE:
A PROOF OF SERVICE is a document or item which is frequently attached to legal documents. It represents the date that the document or item was served and the persons that it was served upon.
PSYCHE is the body part generally listed or pled when one is claiming a psychological or mental health injury. Injuries claims to depression, post-traumatic stress disorder or anxiety should be claim as an injury to “psyche.”
PSYCHIATRIC refers to a body part injury to the “psyche.” Psychiatric injuries have a different threshold for causation than other body parts or systems. See Labor Code Section 3208.3. There are other limitations as well.
PUBLIC SAFETY OFFICER:
A PUBLIC SAFETY OFFICER is considered as an individual serving a public agency in an official capacity, with or without compensation, as a law enforcement officer, as a firefighter, as a chaplain, or as a member of a rescue squad or ambulance crew.
PUBLIC SECTOR EMPLOYER:
A PUBLIC SECTOR EMPLOYER is an employer which is some sort of a government agency which hired employees. Public Sector Employers in California include the State, Counties, Municipalities and Cities. It also includes publics schools such as the University of California, California State University System, California Community College System, and School Districts.
PULMONARY FUNCTION TESTS:
According to the AMA Guides, PULMONARY FUNCTION TESTS are studies of lung functions which include measurements such as lung volumes, inspiratory and expiratory flow rates, and efficiency of gas transfer.
A QME PANEL is a three member panel of qualified medical evaluators in a particular medical specialty that are used to conduct a comprehensive medical evaluation.
QUALIFIED INJURED WORKER:
A QUALIFIED INJURED WORKER means that the effects of whose injury, whether or not combined with the effects of a prior injury or disability, if any, permanently preclude, or are likely to preclude, the employee from engaging in either his usual and customary occupation or the position in which he was engaged at the time of injury and who can be reasonably expected to benefit from a rehabilitation program. See California Administrative Code, Title 8, § 10,003
QUALIFIED MEDICAL EVALUATOR:
QUALIFIED MEDICAL EVALUATORs are qualified physicians who are certified by the Division of Workers’ Compensation – Medical Unit to examine injured workers to evaluate disability and write medical-legal reports. The reports are used to determine an injured worker’s eligibility for workers’ compensation benefits. Currently, Qualified Medical Evaluators are provided to the parties as a Panel of three upon which there is a selection process to obtain one of the doctors who will act as the QME on the matter.
Radiculopathy is a pathological condition of the nerve roots. Injured Workers can have radicular complaints in both the upper and lower extremities.
A RATER is an individual who is trained in the art of rating and interpreting medical reports. Also, they are trained with respect to making calculations concerning commutation requests. Raters are usually employees of the State of California Department of Industrial Relations. They have received extensive training to perform these tasks. There are also professional raters who do not have a current affiliation with the State. Their ratings are only of an informative nature. They may or may not conform with the opinions of the Disability Evaluation Unit of the State of California. These ratings may assist parties in resolution of a case. They are not legally binding.
The RATING MANUAL currently refers to the SCHEDULE FOR RATING PERMANENT DISABILITIES, which was issued in 2005.
RATING INSTRUCTIONS are instructions usually from a Workers’ Compensation Judge as to how the medical reports as to be rated. The instructions are provided to the Disability Evaluation Unit and a Rater at that Unit prepares a rating.
REASSIGNMENT is when a Trial, which has already been assigned to a WCJ, is assigned to another WCJ. This case be based upon a Petition for Automatic Reassignment.
REBUTTAL EVIDENCE is evidence that can be used at Trial and also that can be used during the cross examination of the disability evaluator. See Labor Code Section 5704.
REASONABLE MEDICAL PROBABILITY:
REASONABLE MEDICAL PROBABILITY is defined as strong likelihood or chance of something. Reasonable Medical Probability must not be speculative, must be based on pertinent facts and on an adequate examination and history, and must set forth reasoning in support of its conclusions. See Bates v. WCAB (2013) 77 C.C.C. 636.
A RECONSIDERATION is short for a PETITION FOR RECONSIDERATION which is when a party contests an award from a WCJ and seeks an appeal. The grounds for reconsideration are: that the appeals board or workers’ compensation judge acted in excess of its power; that the decision was procured by fraud; that the decision is not justified by the evidence; that there is newly discovered evidence which could not have been produced at the hearing; and that the findings of fact do not support the decision.
RECONSIDERATION OF SUMMARY RATING:
A RECONSIDERATION OF A SUMMARY RATING is a process used when an Unrepresented Injured Worker asks to have a permanent disability rating reviewed to see if there was a mistake.
A REDESIGNATION is when a Workers’ Compensation Judge changes an Expedited Hearing to a mandatory settlement conference, to receive a pretrial conference statement pursuant to Labor Code Section 5502(d)(3), to close discovery, and to schedule the case for trial on the issues presented, if the WCJ determines, after consultation with the PWCJ, that the case is not appropriate for expedited determination. Such re-designation may be appropriate where, for example, the direct and cross examination of the applicant will be prolonged, or where there are multiple witnesses who will offer extensive testimony.
A REGULAR PHYSICIAN is a judge appointed doctor who is employed to develop the record when the records is lacking substantial evidence. This is usually employed when the efforts of the parties have not generated substantial evidence upon which a judge may render a decision. Labor Code Section 133 provides that the Appeals Board has “power and jurisdiction to do all things necessary or convenient in the exercise of any power or jurisdiction conferred upon it under this code.” Sections 5701 and 5310 authorize the WCJ and the WCAB to direct an employee claiming compensation to be examined by a regular physician at any time. (Tyler v. Workers’ Comp. Appeals Bd. (1997) 56 Cal.App.4th 389 [62 Cal.Comp.Cases 924,926].)
REGULAR WORK refers to your old job that you had at the time of the injury. Regular work means that you are receiving the same wages and benefits paid at the time of the injury and it is located within a reasonable commuting distance of where you lived at the time of injury.
REMOVAL occurs as a result of a Petition for Removal being granted.
REPETITIVE MOTIONS OF NECK OR BACK:
REPETITIVE MOTIONS OF NECK OR BACK contemplates the individual has lost approximately 50% of pre-injury capacity for flexing, extending, bending, and rotating neck or back.
REPORT OF WORKERS’ COMPENSATION JUDGE ON RECONSIDERATION:
A REPORT OF WORKERS’ COMPENSATION JUDGE ON RECONSIDERATION is a report issues by a Workers’ Compensation Judge in response to a Petition for Reconsideration.
REPORT OF WORKERS’ COMPENSATION JUDGE ON REMOVAL:
A REPORT OF WORKERS’ COMPENSATION JUDGE ON REMOVAL is a report issued by a Workers’ Compensation Judge in response to a Petition for Removal.
RESERVES are statutory reserves are those assets an insurance company is legally required to maintain on its balance sheet with respect to the unmatured obligations (i.e., expected future claims) of the company. Statutory reserves are a type of actuarial reserve.
A RESIGNATION is when an employee voluntarily terminates their employment.
RETURN TO WORK:
RETURN TO WORK is an important event that can trigger the payment of benefits, the cessation of benefits, and the right to receive a Supplemental Job Displacement Benefits Voucher.
REYNOLDS’ NOTICE refers to the Claims Administrators obligation to notify Injured Workers of the denial of benefits, advise the Injured Worker of their rights, and warn that failure to timely act could result in the loss of the right to benefits. Failure to give Reynolds Notice may act as a toll to the Statute of Limitation. See Reynolds vs. WCAB (1974) 12 Cal. 3d 726
The ROLDA ANALYSIS is the analysis that is done to determine the compensability of a psychiatric injury in which there is a good faith personnel action defense raised. The WCAB must determine: “(1) whether the alleged psychiatric injury involves actual events of employment, a factual/legal determination; (2) if so, whether such actual events were the predominant cause of the psychiatric injury, a determination which requires medical evidence; (3) if so, whether any of the actual employment events were personnel actions that were lawful, nondiscriminatory and in good faith, a factual/legal determination; and (4) if so, whether the lawful, nondiscriminatory, good faith personnel actions were a “substantial cause” of the psychiatric injury, a determination which requires medical evidence.” Rolda vs. Pitney Bowes (2001) 66 C.C.C. 241.
A ROTATIONAL CALENDAR is present on Trial dates at the WCAB. The Presiding Judge has the authority to assign or transfer cases as necessary. The authority allows for the utilization of a “rotational calendar” to assign pending trials. When a Trial Judge’s first trial in order is about to commence, other cases scheduled at the same time shall be referred to the PWCJ for assignment to other available WCJs, when feasible.
ROTATE is the act of the Presiding Judge to assign or transfer cases as necessary.
SALARY CONTINUATION is a provision in the Labor Code and by Union Contract or Memorandum of Understanding that allows for the payment of Salary in lieu of regular workers’ compensation temporary disability benefits.
SANCTIONS in Workers’ Compensation is the act of the workers compensation referee or appeals board ordering a party, the party s attorney, or both, to pay any reasonable expenses, including attorney s fees and costs, incurred by another party. The determination of sanctions shall be made after written application by the party seeking sanctions or upon the appeal board s own motion. The basis for the sanctions are bad-faith actions or tactics that are frivolous or solely intended to cause unnecessary delay. See Labor Code Section 5813.
SCIATICA is a pain across the sciatic nerve. This usually occurs in the back of the thigh.
SCHEDULE FOR RATING PERMANENT DISABILITIES:
The SCHEDULE FOR RATING PERMANENT DISABILITIES is the rating manual. It was propounded in 2005. The Schedule provides the formulas on how to calculate permanent disabilities. Permanent Disability formulas are based upon Whole Person Impairment, DFEC Adjustment, Age and Occupation.
A SEASONAL EMPLOYEE is an employee who does not work year round. They may be agriculture workers who work only during a particular season. For example, the worker only worked during strawberry season and did not work any other time of the year. It may also apply to those who work in the hospitality industry. For example, those who work at ski resorts or at hotels only when it is tourist season.
A SECOND OPINION is permitted in workers’ compensation when an Injured Worker is treating in a Managed Provider Network. If an injured employee disputes either the diagnosis or the treatment prescribed by the treating physician, the employee may seek the opinion of another physician in the medical provider network. If the injured employee disputes the diagnosis or treatment prescribed by the second physician See Labor Code Section 4616.3
SEDENTARY WORK is a limitation that contemplates the individual can do work predominantly in a sitting position at a bench, desk or table with a minimum of demands for physical effort and with some degree of walking and standing being permitted.
A SELF-IMPOSED PENALTY is a penalty paid by a Claims Administrator to an injured worker as a result of late payment of benefits. See Labor Code Section 4650.
SELF-INSURANCE is an alternative for Employers to purchasing a workers’ compensation insurance policy. Both private and public Employers can be self-insured. Employers wanting to self-insure their workers’ compensation liabilities must apply to the Office of Self-Insurance Plans and be approved. There can be group self-insurance as well. Group Self- Insurance by non-affiliated companies is permitted under California regulation for both private and public sector employers.
SELF INSURED refers to employers who choose to self-insure their workers’ compensation liabilities to cover their employees for reasons of cost effectiveness, greater control over their claims programs, and increased safety and loss control management. Self-insurance is an alternative to purchasing a workers’ compensation insurance policy.
SEMI-SENDENTARY WORK is a limitation which contemplates the individual can do work approximately 50% of the time in a sitting position, and approximately 50% of the time in a standing or walking position, with a minimum of demands for physical effort whether standing, walking or sitting
SERIOUS AND WILLFUL MISCONDUCT:
An Injured Worker can claim additional compensation is the employer engaged in SERIOUS AND WILLFUL MISCONDUCT. There are a number of requirements to be eligible. A Petition must be timely filed. Wilful misconduct means something different from and more than negligence, however gross; mere failure to perform statutory duty is not, alone, wilful misconduct, but to constitute willful misconduct there must be actual knowledge, or that which in law is esteemed to be equivalent of actual knowledge, of peril to be apprehended from failure to act, coupled with conscious failure to act to end of averting injury. Helme v. Great Western Milling Co. (Cal. App. 1919), 43 Cal. App. 416, 185 P. 510, 1919 Cal. App. LEXIS 745. Willful misconduct may involve a violation of law or ordinance. It may involve a violation of a safety order. See Labor Code Section 4553
SERIOUS MEDICAL CONDITION:
A SERIOUS CHRONIC CONDITION is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the employer or its claims administrator in consultation with the injured employee and the terminated provider and consistent with good professional practice. Completion of treatment under this paragraph shall not exceed 12 months from the contract termination date.
SERVICE CONNECTED RETIREMENT:
A SERVICE CONNECTED RETIREMENT is a regular retirement which is usually based upon time worked and age.
A SETTLEMENT is an agreement between an injured worker and the claims administrator about the workers’ compensation payments and future medical care that will be provided to the worker. Settlements must be reviewed by a workers’ compensation administrative law judge to determine whether they are adequate to compensate the injured worker for the injury
SETTLEMENT NEGOTIATIONS are when the parties meet in an attempt to resolve a workers’ compensation case. Settlement Negotiations are a fundamental part of the litigation process. Settlement Negotiations can take place at any time. Even when a matter is set for Trial, pursuant to the Policy and Procedure Manual, the Workers’ Compensation Judge should allow for a minimal amount of time for settlement negotiations.
SHELTERED WORK ENVIRONMENT:
A SHELTERED WORK ENVIRONMENT is generally not considered as part of the open labor market. It is usually provided for handicapped individuals in a protected environment under an institutional program. Common types of Sheltered Work Environments are sheltered workshops which may engage in manufacturing, assembly, reconditioning, repair, and other operations. It could be homebound employment. This is work that is done at home by individuals under public or institutional programs designed to provide them with paid employment. Pay for the work is usually on a piece-rate basis. The employer delivers raw materials to the individual’s home and picks up finished merchandise.
SIGNIFICANT PANEL DECISION:
A SIGNIFICANT PANEL DECISION is one in which the Workers’ Compensation Appeals Board identified for dissemination in order to address new or recurring issues of importance to the workers’ compensation community. Significant Panel Decisions have been reviewed by each of the commissioners, who agree that the decision merits general dissemination.
SKIN CONDITION PRECLUDING OUTSIDE WORK:
SKIN CONDITION PRECLUDING OUTSIDE WORK contemplates the individual must perform work predominantly indoors, permitting some exposure to sunlight.
SKIN CONDITION PRECLUDING WET WORK:
SKIN CONDITION PRECLUDING WET WORK contemplates the individual must avoid more than incidental co
SKYLARKING is the same as Horseplay. See Horseplay.
SOCIAL SECURITY is a Federal Government program which provides for retirement benefits. Retirement benefits can be an “age” retirement. This means that you reach the age and are claiming regular benefits. Currently, the age range for regular Social Security benefits can be claimed is as early as age 62 or as late as age 70. Social Security offers some additional programs There is Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI.) Financial assistance for disabled persons. These benefits are administered by the US Social Security Administration. They may be reduced by workers’ compensation payments that the injured worker receives.
SOCIAL SECURITY DISABILITY INSURANCE:
SOCIAL SECURITY DISABILITY INSURANCE are payable to disabled individuals through the Social Security Administration. Many state workers’ compensation statutes have specific provisions that dictate whether an injured employee may receive both workers’ compensation benefits and SSDI benefits at the same time. Generally, if both benefits are appropriate for the same individual, a complex calculation will be performed to “offset” the benefits so that the individual does not receive more money than they are entitled to from both programs
SOCIAL SECURITY NUMBER:
The SSN is an identification number issued by the Social Security Administration, and used instead of a Medicare ID (HICN or MBI) when the Medicare ID is not present.
SPECIAL MISSION EXCEPTION:
The SPECIAL MISSION EXCEPTION applies to the Going and Coming Rule. The employee’s conduct is ‘special’ if it is ‘extraordinary in relation to routine duties, not outside the scope of employment.’ Schreifer v. Industrial Acc. Com. (1964) 29 Cal. Comp. Cases 103.
A SPECIFIC INJURY is one occurring as the result of one incident or exposure which causes disability or need for medical treatment. See Labor Code Section 3208.1
A settlement in which the agreed-on funds are paid from an initial deposit and subsequent deposits on a regular basis for a given amount of time.
The person who sends a WCMSA application to CMS. This may be someone acting on the claimant’s behalf.
SUBSEQUENT INJURIES BENEFITS TRUST FUND:
The SUBSEQUENT INJURIES BENEFITS TRUST FUND is a source of additional compensation to injured workers who already had a disability or impairment at the time of injury. For benefits to be paid from the SIBTF, the combined effect of the injury and the previous disability or impairment must result in a permanent disability of at least 70 percent. The fund enables employers to hire disabled workers without fear of being held liable for the effects of previous disabilities or impairments. SIBTF benefit checks are issued to injured workers by the SIBTF Claims Unit after benefits are awarded by the Workers’ Compensation Appeals Board.
SUBSEQUENT INJURIES FUND:
The SUBSEQUENT INJURIES FUND is also known as the Subsequent Injuries Benefits Trust Fund which is a source of additional compensation to injured workers who already had a disability or impairment at the time of injury. For benefits to be paid from the SIBTF, the combined effect of the injury and the previous disability or impairment must result in a permanent disability of at least 70 percent. The fund enables employers to hire disabled workers without fear of being held liable for the effects of previous disabilities or impairments. SIBTF benefit checks are issued to injured workers by the SIBTF Claims Unit after benefits are awarded by the Workers’ Compensation Appeals Board.
SUBSTANTIAL WORK is a restriction which contemplates the individual has lost approximately 75% of pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling, and climbing or other activities involving comparable physical effort
A SUMMARY RATING is done for unrepresented workers where no application of adjudication is filed. A Summary rating may be issued on QME panel reports or treating physician reports.
A SUPERVISING ATTORNEY is one who assist a non-attorney representative.
SUPPLEMENTAL MEDICAL-LEGAL EVALUATION:
A SUPPLEMENTAL MEDICAL-LEGAL EVALUATION means an evaluation which (A) does not involve an examination of the patient, (B) is based on the physician’s review of records, test results or other medically relevant information which was not available to the physician at the time of the initial examination, or a request for factual correction pursuant to Labor Code section 4061(d), (C) results in the preparation of a narrative medical report prepared and attested to in accordance with Section 4628 of the Labor Code, any applicable procedures promulgated under Section 139.2 of the Labor Code, and the requirements of Section 10606 and (D) is performed by a qualified medical evaluator, agreed medical evaluator, or primary treating physician following the evaluator’s completion of a comprehensive medical-legal evaluation.
SUPPLEMENTAL SECURITY INCOME:
SUPPLEMENTAL SECURITY INCOME is a Federal Government program which is designed to help the aged, blind, and disabled people who have little or not income, and it provides cash to meet basic needs for food, clothing, and shelter.
SPECIAL INVESTIGATION UNIT:
The SPECIAL INVESTIGATION UNIT is a Unit with an Insurance Company that investigates fraud. From time to time, if fraud is suspected, a claim may be referred to the Unit within the Insurance Company. California licensed insurers are required by California Insurance Code Sections 1875.20-24 and California Code of Regulations, Title 10, Sections 2698.30 -.43 to establish and maintain Special Investigative Units that identify and refer suspected insurance fraud to California Department of Insurance.
SPECIAL NEEDS TRUST:
A SPECIAL NEEDS TRUST is a trust which is usually considered to be used in a settlement if the Injured is receiving needs based Medicaid or SSI they qualify for a Special Needs Trust. The Trust is intended to protect the Injured Worker and prevent the cessation of Medicaid and/or SSI benefits.
A STATE AUDITOR is an employee of the Audit Unit of the State of California and they 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.
STATE DISABILTIY INSURANCE:
STATE DISABILITY INSURANCE is a State of California program which provides short-term Disability Insurance (DI) and Paid Family Leave (PFL) wage replacement benefits to eligible workers who need time off work. Individuals may be eligible for Disability insurance if the person is unable to work due to non-work-related illness or injury, pregnancy, or childbirth.
STATEMENT OF DUTIES:
The STATEMENT OF DUTIES is the same as a Job Description. See Job Description.
A STATUS CONFERENCE is a hearing before the WCAB. The purposes of a Status Conference is the opportunity for the parties to meet before the WCAB to discuss disputed issues that need assistance in resolution. A Status Conference does not cut off discovery.
STATUTE OF LIMITATIONS:
The STATUTE OF LIMITATIONS is the time period upon which an injured worker must file their claim. Failure to due so may most likely bar their claim from seeking benefits. There are various Statutes of Limitations within workers’ compensation. Labor Code Section 5405 provides in pertinent part that an application for workers’ compensation benefits must be filed within one year from the date of injury. Section 5412 provides: “The date of injury in cases of occupational diseases or cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his present or prior employment.”
STIPULATIONS WITH REQUEST FOR AWARD:
A STIPULATION WITH REQUEST FOR AWARD is a type of settlement in which an injured work resolves their case yet preserves their rights for future benefits. These future benefits may include the right to reopen to claim additional TTD, PD, and additional body parts. It may also leave the right to open to pursue a death claim. Also, future medical care can be part of a stipulated award. This means that the claims administrator will agree to continue paying for medical care for the injury.
A STRUCTURED SETTLEMENT is a settlement in which the parties spread out the payments over a period of time. Most of the time, they are done set a up a guaranteed payment stream. Some payment streams can be guaranteed for a set period of time. Some payment streams can be guaranteed for the life of the injured worker. Structures can be done in any shape or form. They are usually done through the purchase of an Annuity from an Insurance Company.
SUBJECTIVE FACTORS are the reported complaints of the injured Worker. It refers to the symptoms and pain reported by the Injured Worker. This is in contrast to OBJECTIVE FACTORS. A medical-legal report should list the Injured Worker’s Subjective Factors of disability.
A SUBMISSION designates the time that a trial has been taken in by the Workers’ Compensation Judge in order to make a decision. Cases can be submitted no longer than 90 days. See Labor Code Section 123.5. In otherwords, unless a case is withdrawn from submission, the Workers’ Compensation Judge should issue a decision within 90 days from the date of submission.
A SUBPOENA is discovery tool permitted in workers’ compensation. The WCAB has full subpoena powers. They have the power to order contempt with respect to issues of non-compliance. It is a means by which a party with a Workers’ Compensation Case can secure the production of records or documents from, and compel the attendance at depositions by, persons or entities who are not parties to the action or proceeding. In workers’ compensation proceedings, subpoenas for these purposes may also be served on opposing parties. It is common that parties will use a copy service to obtain records by subpoena.
SUBROGATION is a legal means by which an insurance company can recover their costs for handling a case from a third party responsible for the injury. When insurance carrier that pays compensation for which employer is liable is subrogated to employer’s rights and may enforce such rights in its own name, remedies open to employer. In other words, where an employer is required to provide financial benefits to a worker because of disability brought about by a third party’s negligence. The subrogation rights come into play. The statutory subrogation rights attach to the claim of “the employee, or any other person to whom a claim for compensation accrues, against any person liable for damages as a result of the injury of the employee.
SUBROSA is refers to the filming of a Claimant unbeknownst to them. Subrosa film is usually taken by a Private Investigator at the behest of the Claims Administrator.
SUBSEQUENT INJURIES FUND:
The SUBSEQUENT INJURIES FUND is a source of additional compensation to injured workers who already had a disability or impairment at the time of injury. For benefits to be paid from the SIBTF, the combined effect of the injury and the previous disability or impairment must result in a permanent disability of at least 70 percent. The fund enables employers to hire disabled workers without fear of being held liable for the effects of previous disabilities or impairments. SIBTF benefit checks are issued to injured workers by the SIBTF Claims Unit after benefits are awarded by the Workers’ Compensation Appeals Board. Application for subsequent injuries fund benefits is the required for SIBTF benefits.
SUBSTANTIAL EVIDENCE is a legal term concerning judicial review of Workers’ Compensation Appeals Board decisions. Reviewing courts are bound by the factual findings and decision of the WCAB if supported by substantial evidence.
SUBSTITUTION OF ATTORNEYS:
SUBSTITUTION OF ATTORNEYS is a form which is used by a party to replace their counsel. The form is available at the Department of Industrial Relations website.
SUBSTITUTION OF ATTORNEYS:
SUBSTITUTION OF ATTORNEYS is a form which is used by a party to replace their counsel. The form is available at the Department of Industrial Relations website.
SUMMARY OF EVIDENCE:
A SUMMARY OF EVIDENCE is a document generated by the WCJ. Where testimony is taken, the WCJ shall ensure that all witnesses are clearly identified for the reporter, and that names are spelled out and titles identified. The WCJ shall provide a fair and unbiased summary of the testimony given by each witness, and clearly identify direct and cross examination, redirect and re cross-examination, and examination by the WCJ. Where motion pictures are presented as evidence, the Summary of Evidence shall include a brief summary of the contents of the motion pictures.
A SUMMARY RATING is a document issued by the Disability Evaluation Unit that generates a permanent disability rating from analyzing a doctor’s report. Summary ratings are given out after all qualified medical evaluator (QME) exams and after treating doctor exams, when requested. A Summary Rating can be contested.
SUPPLEMENTAL SECURITY INCOME:
SUPPLEMENTAL SECURITY INCOME is a Federal Government program which is designed to help the aged, blind, and disabled people who have little or not income, and it provides cash to meet basic needs for food, clothing, and shelter.
SUITABLE GAINFUL EMPLOYMENT:
SUITABLE GAINFUL EMPLOYMENT in workers’ compensation means that employment or self-employment which is reasonably attainable and which offers an opportunity to restore the employee as soon as practicable and near as possible to maximum self-support, due consideration being given to the employee’s qualifications, interests and incentives, pre-injury earnings and future earning capacity, and the present and future labor market.” California Administrative Code, Title 8, § 10,003(c)
A TAKE NOTHING refers to a case in which the WCJ finds that the Applicant is barred from receiving any benefits on their workers’ compensation claim. Examples of “take nothing”s are as follows: a finding the medical reporting does not support industrial causation; a finding that the activity during which the Applicant was injured was not in the course and scope of employment; a finding that the case was barred by the Statute of Limitation because it was not timely filed. TAKE NOTHINGs can refer to 132a claims, Serious and Willful and Misconduct Claims, and Lien Claims.
TELEPHONIC NURSE CASE MANAGER:
See NURSE CASE MANAGER
TEMPORARY DISABILITY are when an employee is injured on the job and can’t return to work, he is temporarily totally disabled and entitled to receive TTD benefits during his convalescence. TTD benefits are generally paid weekly at the rate of two-thirds of the employee’s AWW, subject to a maximum or minimum rate. For example, an employee who usually makes $600 per week would be entitled to receive $400 per week for the period that he is temporarily and totally disabled. TTD benefits may be discontinued after the claimant reaches MMI.
TEMPORARY PARTIAL DISABILITY BENEFITS:
TEMPORARY PARTIAL DISABILITY BENEFITS is when an employee returns to work following an on-the-job injury but hasn’t achieved MMI and is earning less than his preinjury AWW, he is entitled to TPD benefits. Typically, TPD benefits are payable at two- thirds of the difference between what the employee earned at the time of the injury and his current earnings. TPD is perhaps the least common type of workers’ comp benefit.
TEMPORARY TOTAL DISABILITY BENEFITS:
TEMPORARY TOTAL DISABILITY BENEFITS are when an employee is injured on the job and can’t return to work, he is temporarily totally disabled and entitled to receive TTD benefits during his convalescence. TTD benefits are generally paid weekly at the rate of two-thirds of the employee’s AWW, subject to a maximum or minimum rate. For example, an employee who usually makes $600 per week would be entitled to receive $400 per week for the period that he is temporarily and totally disabled. TTD benefits may be discontinued after the claimant reaches MMI.
A TERMINAL ILLNESS/CONDITION is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of treatment shall be provided for the duration of a terminal illness.
TESTIMONY in workers’ compensation is different than in Civil Court. While It is testimony under oath, just like in Civil Court, there is some flexibility. Workers’ compensation law has noted that [n]o informality in any proceeding or in the manner of taking testimony shall invalidate any order, decision, award, or rule made…. No order, decision, award, or rule shall be invalidated because of the admission into the record, and use as proof of any fact in dispute, of any evidence not admissible under the common law or statutory rule of evidence and procedure. Evidence (particularly certain types of hearsay) is admissible in compensation proceedings which would not normally be admissible in civil proceedings over objection. See Martinez v. Associated: (1979) 44 C.C.C. 1012.
A THIRD OPINION is an opinion that an injured worker who is treating in a MPN can obtain. Regulations provide that if the covered employee disagrees with either the diagnosis or treatment prescribed by the second opinion physician, the injured employee may seek the opinion of a third physician within the MPN. See Regular Section §9767.7.
THIRD PARTY ADMINISTRATOR:
A THIRD PARTY ADMINISTRATOR is a company that processes claims on behalf of an employer. Many times, a large company may be self- insured for workers’ compensation claims but may outsource the administration of its claims to a Third Party Administrator. Public Sector employees may employ a TPA to adjust claims as well.
THIRD PARTY CLAIM:
A THIRD PARTY CLAIM is a civil lawsuit which arose out of the events that caused the industrial work injury. The Civil Lawsuit is a lawsuit against a party other than the employer. For example, the injured worker may have been rear-ended by another vehicle. The Injured Worker can file a lawsuit against the driver of the vehicle that rear-ended them.
THIRD PARTY CREDIT:
A THIRD PARTY CREDIT concerns the recovery from a Third Party Claim. The appeals board is empowered to and shall allow, as a credit to the employer to be applied against his liability for compensation, such amount of any recovery by the employee for his injury, either by settlement or after judgment, as has not theretofore been applied to the payment of expenses or attorneys’ fees, pursuant to the provisions of Sections 3856, 3858, and 3860 of this code, or has not been applied to reimburse the employer
TOTAL is a slang workers’ compensation term for an Injured Worker being totally permanently disabled or 100 percent disabled.
TRANSPORTATION EXPENSES in workers’ compensation claims relate to three different events. Transportation Expenses are applicable with respect to medical treatment, medical evaluations, and deposition.
TRANSPORTATION REIMBURSEMENT refers to the various reimbursable expenses that pertain to travel related to workers’ compensation cases. Some events in the workers’ compensation process provide for reimbursement to the injured worker. This includes going to medical evaluations and treatment as well as going to a deposition.
A TREATING DOCTOR is an injured worker’s primary treating physician (PTP) or other physician who treats the injured worker and whose findings are incorporated into the PTP’s medical reports.
A TREATING PHYSICAN is an injured worker’s primary treating physician (PTP) or other physician who treats the injured worker and whose findings are incorporated into the PTP’s medical reports.
Per the AMA Guides, TREATMENT is the action and manner of treating an individual either medically or surgically. Treatment may also include modalities recommended by a health care provider. Treatment under the Labor Code is Medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury shall be provided by the employer. In the case of his or her neglect or refusal reasonably to do so, the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment and (b) As used in this division and notwithstanding any other law, medical treatment that is reasonably required to cure or relieve the injured worker from the effects of his or her injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27. See Labor Code Section 4600.
Request for authorization (i.e., compensation for) of medical treatment submitted by the treating physician to the UR claims administrator on a request for authorization form (DWC Form RFA).
A TRIAL is a hearing before an assigned Trial Judge. A trial occurs whenever the parties are unable to resolve an issue or issues, and it is appropriate to try the issues. A trial may include oral testimony, objections, and rulings. They shall be taken down in shorthand by a competent phonographic reporter. The WCAB is not be bound by the common law or statutory rules of evidence and procedure, it may make inquiry in the manner, through oral testimony and records, which is best calculated to ascertain the substantial rights of the parties and carry out justly the spirit and provisions of the division of the Labor Code which pertains to Workers’ Compensation. Generally, trials should not be set for more than a full day. For good cause shown, however, a trial may be set for two or more consecutive days. More than one day may be required, for example, when it is clear that, based on the complexity of the issues and/or number of witnesses presented, the trial cannot reasonably be completed in one day. A WCJ shall not set a trial for more than one day without the approval of the PWCJ.
TRIAL PRIORITIES are the basis for upon which a Trial Judge employs to determine which case should proceed to trial. Trial Judge’s Calendars frequently have multiple cases schedule for hearing. According to the Policy and Procedure Manual of the WCAB, the priorities are as follows as to which cases are to be heard first. 1. Cases set for Expedited Hearing; 2. Cases which are returned to the calendar for cross-examination of the disability evaluation specialist; 3. Continued cases in which testimony has been received (The judges are encouraged to have these cases set on the first available opening in their calendar with notice waived.); 4. Cases in which the applicant is not working and is receiving no benefits and/or in which the applicant or any witnesses have traveled from out of state or a significant distance within the state to appear; 5. Cases that were previously set for trial but did not commence; 6. Cases in which no benefits have been furnished but the applicant is working; and 7. All other cases
An Undocumented Worker refers to workers who do not have the proper papers to be eligible to work in the United States. One example is a person who does not possess a Green Card from the Federal Government. Although they are undocumented, they are allowed to pursue workers’ compensation claims in California.
UNINSURED EMPLOYERS BENEFITS TRUST FUND:
The UNINSURED EMPLOYERS BENEFITS TRUST FUND is possible source of workers’ compensation benefits for an injured worker whose employer is illegally uninsured in California. These benefits are administered by the state Division of Workers’ Compensation.
UNINSURED EMPLOYERS FUND:
The UNINSURED EMPLOYERS FUND or UEBTF is an agency for the State of California which administers claims when the employers are illegally uninsured for workers’ compensation when the employer fails to pay benefits.
UNDERINSURED MOTORIST is part of a car insurance policy which covers limited costs for bodily injury if you are in an accident with a driver who does not have enough insurance to pay for damages.
UNINSURED MOTORIST BODILY INJURY:
The UNINSURED MOTORIST BODILY INURY pays for injuries to the insured and any person in their car when there is an accident with an uninsured driver who is at fault. The limits are the same as your liability coverage limits.
UPPER EXTREMITY IMPAIRMENT:
An UPPER EXTREMITY IMPAIRMENT is used within the AMA guides to address impairment within the upper extremities. The upper extremities refer to hands, wrists, elbows, and shoulders. An Upper Extremity Impairment has a lesser value than a Whole Person Impairment.
UTILIZATION REVIEW (UR):
UTILIZATION REVIEW is a process by which Claims Administrators approve (authorize) or deny medical treatment. The process involves guidelines that are employed to conduct the procedure. Determinations of Utilization Review as subject to the Independent Medical Review procedure.
UTILIZATION REVIEW (UR) DECISION:
Decision by the claims administrator to approve, modify, or deny a medical treatment request made by the injured worker’s treating physician. Only a physician may modify or deny a medical treatment request. Unless the decision is based on the treating physician’s failure to provide requested information, the UR decision is required to be based on medical evidence (see MTUS).
Venue is the location at which the Workers’ Compensation Case is filed. If the case is not under ADR, the case will have a venue at a Local/District WCAB office. This Local/District office will be where the hearings on the case will be heard. Further, filings on the case will be at that particular location as well. The location of the venue can be based upon the following: the place of the employee or dependent’s residence at the time of filing; the place where the injury allegedly occurred or, for cumulative trauma or industrial disease claims, where the last alleged injurious exposure occurred; or the place where the employee’s attorney maintains his or her principal place of business.
A Venue Authorization is a form signed by the Injured Worker authorizing their Attorney to choose the venue where their Application for Adjudication will be filed. If the Application is filed based upon the Authorization, it will be filed at the Local/District Office which the Applicant’s Attorney has designated.
A letter that confirms a WCMSA does not need to be reviewed. CMS will not issue such letters.
VERY HEAVY LIFTING:
VERY HEAVY LIFTING contemplates the individual has lost approximately 25% of pre-injury capacity for lifting. (A statement “inability to lift 50 pounds” is not meaningful. The total lifting effort, including weight, distance, endurance, frequency, body position and similar factors should be considered with reference to the particular individual.)
VERY HEAVY WORK:
VERY HEAVY WORK contemplates the individual has lost approximately 25% of pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort.
A VOCATIONAL COUNSELOR in workers’ compensation can be used as part of the Voucher. Out of the voucher, $600, may be used to pay for the services of a licensed placement agency or vocational counselor.
In Workers’ Compensation Law, VOCATIONAL EXPERTs are allowed in workers’ compensation cases. Vocational Experts have experience with the areas of vocational rehabilitation, vocational capacity, earnings capacity, lost earnings. Their opinions are preferred to be in a written report. If there is good cause, their testimony may be received before the WCAB. Vocational Experts will usually provide testimony as to an Injured Worker’s ability to compete in the open labor market as well as participate in vocational rehabilitation services.
A VOLUNTARY AUDIT refers to an audit form for an employer concerning wages paid and classifications of workers.
A VOUCHER for Employees injured on or after Jan. 1, 2013, with injuries that result in permanent partial disability, and whose employer does not offer other regular, modified or alternative work, may also qualify for the SJDB voucher. The offer must be made within 60 days after receipt by the claims administrator of the Physician’s Return-to-Work & Voucher Report (Form DWC-AD 10133.36) The voucher amount is $6000 for all levels of permanent disability and can be used for training at a California public school or any other provider listed on the state’s eligible training provider list. It can also be used to pay licensing or certification and testing fees, to purchase tools required by a training course, to purchase computer equipment of up to $1,000 and to reimburse up to $500 in miscellaneous expenses. Up to 10 percent, or $600, may be used to pay for the services of a licensed placement agency or vocational counselor. No more than 10 percent of the value of the voucher can be used for vocational & return to work counseling.
WAGE LOSS refers to one’s loss of wages after an injury has occurred. Wage Loss may be relevant with respect to a number of workers’ compensation issues. One issue where Wage Loss is of import is when an Injured Worker is Partially Temporarily Disabled. See Partially Temporarily Disabled. Wage Loss may be an issue with respect to a Labor Code Section 132a discrimination case.
The term WALK-THROUGH refers to the procedure when a party takes a moving document to the WCAB for an action by a Judge when the matter is not on calendar. Walk-through documents may only be filed at the district office having venue over the case, or one of the cases, pursuant to Rule 10280(g). Walk-through documents may include a Compromise and Release, Stipulations with Request for Award, Petition for Deposition Attorney Fees, or Petition to Compel Attendance at Medical Examination or Deposition.
A WALK-THROUGH JUDGE is a Judge assigned at a Local WCAB Office to handle walk-through documents. Each Local WCAB has their own walk-through procedures.
A WCAB PANEL refers to the Panel of Commissioners who are assigned to make the disposition on a Petition.
The WCMSAP may be used to submit and view WCMSA proposals, to communicate about the review approval process, and to submit re-review requests. It can also be used to submit annual attestations, or for professional administrators, detailed transaction records; and to view the status and balance of an established WCMSA.
WEIGHT OF THE EVIDENCE:
The WEIGHT OF THE EVIDENCE refers the analysis that either a Workers’ Compensation Judge or an Evaluating Physician employs to make a decision concerning an issue or fact. In doing so, consideration is made concerning credible evidence. There are many qualities to evidence which may impact its probative value.
WESTERN GROWERS is a caselaw decision that stands for legal concepts relating to claims involving multiple dates of injury. The caselaw notes that, in any given situation, there can be more than one injury, either specific or cumulative or a combination of both, arising from the same event or from separate events. The number and nature of the injuries suffered are questions of fact for the Workers’ Compensation Judge or the Workers’ Compensation Appeals Board. See Western Growers Ins. Co. v. W.C.A.B. (1993) 16 Cal. App. 4th 227. It is not uncommon when there is the possibility of two cumulative trauma injuries that the matter is referred to as a WESTERN GROWERS situation.
WHOLE PERSON IMPAIRMENT:
Per the AMA Guides, WHOLE PERSON IMPAIRMENT is the percentages that estimate the impact of the impairment on the individual’s overall ability to perform activities of daily living. Ironically, in the AMA Guides definition, work is to be excluded in such an assessment.
WILLFUL MISCONDUCT refers to an affirmative defense that can act as a bar to an injured worker’s right to obtain compensation. Willful Misconduct refers to an injured worker who, at the time of injury, engaged in willful misconduct. See Labor Code Section 5705.
WITNESS STATEMENTS are statements of witnesses that are taken by a party, their agent or their attorney (including statements taken by a private investigator.)
WORK PRODUCT is legal work generated as a result of an attorney representing a client. See Attorney Work Product Work Product is generally considered as privileged information.
WORK RESTRICTIONS are limits which are placed upon a worker. In Workers’ Compensation, work restrictions are placed upon injured workers due to limitations that are caused by injury and/or illness. Work Restrictions are usually assigned by doctors. Work Restrictions may address an injured worker’s physical limitations or are designed to prevent or protect the worker from further injury. Work Restrictions therefore are termed as either actual or prophylactic.
WC is a government program set up to provide wage replacement and medical benefits to workers injured on the job.
WORKERS’ COMPENSATION APPEALS BOARD:
The WORKERS’ COMPENSATION APPEALS BOARD consists of both a Main Office and Local Offices. The Main Office located in San Francisco. It is considered the Reconsideration Unit and essentially handles the appeals from the Local Offices. The Main Office consists of a group of seven Commissioners, who are appointed by the Governor, and who review and reconsider decisions. Also, there are Local Offices plus satellites throughout the state where disagreements over workers’ compensation benefits are initially heard by Workers’ Compensation Judges.
WORKERS’ COMPENSATION INSURANCE RATING BUREAU:
The WORKERS’ COMPENSATION INSURANCE RATING BUREAU is a private company that works with the State of California Department of Insurance and is funded by the insurance industry. They collect data and evaluate it concerning measuring the cost of providing workers’ compensation benefits to injured workers. They perform other functions which also include collecting workers’ compensation insurance coverage information to assist injured workers, insurers and others identify which insurer wrote a workers’ compensation policy for a specific employer.
WORKERS’ COMPENSATION JUDGE:
A WORKERS’ COMPENSATION JUDGE is an employee of the State of California who works for the Division of Workers’ Compensation. Their role is to make decisions concerning workers’ compensation disputes. If necessary, they will hold Trials and take in both testimony and evidence to make a record. They will also make decisions on the cases. Also, they act as the “finder of fact.” Therefore, at the WCAB there are no juries. Also, they approved settlements. Judges hold hearings at the Local WCAB offices. Their decisions are subject to review and reconsideration by the WCAB Reconsideration Unit.
WORKERS’ COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT:
A WCMSA is set up to ensure that all future medical and drug or pharmacy expenses for a work-related injury otherwise payable by Medicare are covered by a WC settlement.
WORKERS’ COMPENSATION REVIEW CONTRACTOR:
WCRC is responsible for reviewing WCMSA proposals and issuing final determinations.
In Workers’ Compensation, WRIT DENIED refers to an action from the Appellate Courts when they refuse to hear an aggrieved party’s appeal aka Petition for Review. This means that, if no further action is taken, the underlying decision remains in force. Both the Court of Appeal and the Supreme Court can deny writs. Writ Denied cases are reported in the California Compensation Cases.
WRONGFUL DISCHARGE – A Synonymous Term With Wrongful Termination. See WRONGFUL TERMINATION
WRONGFUL TERMINATION refers to a termination of an employment that was in violation of law. In Workers’ Compensation Law, a wrongful termination charge would be pursuant to Labor Code Section 132a which provides that “[a]ny employer who discharges..[an] employee because he or she has filed or made known his or her intention to file a claim for compensation with his or her employer or an application for adjudication, or because the employee has received a rating, award, or settlement is guilty of a misdemeanor and the employee’s compensation shall be increased by one-half, but in no event more than ten thousand dollars ($10,000), together with costs and expenses not in excess of two hundred fifty dollars ($250). Any such employee shall also be entitled to reinstatement and reimbursement for lost wages and work benefits caused by the acts of the employer. Wrongful termination may also refer to a termination that was in violation of any other laws. This could include a termination that was due to race, skin color, national origin, gender disability, religion or age.