How Workers’ Compensation Payments for Injured Employees in California Are Calculated

Learn about the many types of workers’ compensation benefits available in California, as well as how much they pay.

If you’ve been injured or become ill on the job in California, you’ve probably got a lot of questions, particularly regarding the benefits available via workers’ compensation—and what you need to do to get them. This essay covers those fundamental benefit concerns.

Can You Get Workers’ Comp in California for COVID-19?

Long-standing California law states that you cannot receive workers’ compensation for an infectious illness unless your job involves a special risk of exposure that is greater than the risk in the general population and you can provide medical evidence that you contracted the disease as a result of a specific exposure or incident at work. However, according to a statute implemented in reaction to the pandemic, getting COVID-19 while working as a first responder, in specific healthcare positions, or at a workplace with a coronavirus epidemic makes it simpler to qualify for workers’ compensation. In these circumstances, unless the employer or its insurer shows otherwise, workers’ compensation will conclude that the sickness is work-related if you test positive within 14 days of providing services at your employer’s workplace. (Find out more about obtaining workers’ compensation payments in California for COVID-19.)

Medical Care and Benefits

Your employer’s insurance company should begin paying benefits for your medical care after you disclose the injury to them and submit a workers’ compensation claim. Even if your claim is eventually denied, the insurance company is legally liable for up to $10,000 of your medical bills while it is being processed. Furthermore, if the insurer does not reject your claim within a specific amount of time after you submit it, the law presumes that you are entitled to benefits. (California Labor Code 5402 (2020).)

You are entitled to reimbursement for any medical care that is “reasonably necessary to cure or alleviate” the consequences of the injury under California workers’ compensation legislation, with no deductible or out-of-pocket expense to the employee. This covers doctor’s expenses, hospital costs, prescription medications, medical supplies and equipment, acupuncture therapy, and up to 24 sessions with a chiropractor, physical or occupational therapist, or both. If your employer has established a medical provider network (MPN) for workers’ compensation treatment, you may be required to see a doctor inside that network. There are few exceptions to this rule, such as if you need emergency care or have already chosen your regular primary care physician as your treating doctor. (Labor Code sections 4600, 4600.3, and 4604.5 (2020).)

You may be required to get permission (through a procedure called as “utilization review”) before receiving any therapy advised by your doctor (other than emergency care). In the first 30 days after an accident, the regulations for pre-authorization are more liberal. (California Labor Code 4600(d)(5), 4610 (2020).)

Benefits for Temporary Disability

If your doctor determines that you will be unable to perform any element of your job for an extended period of time due to a work-related accident or sickness, you are eligible to temporary disability (TD). Unless you’re out of work for more than 14 days or are hospitalized, the payments won’t start until you’ve missed three days. There is no waiting time for temporary incapacity if you are eligible for one of the COVID-19 presumptions (described above) and do not have any coronavirus-related sick leave available. (See California Labor Code sections 3212.87, 3212.88, and 4652 (2020).)

TD benefits are only intended to compensate a portion of your lost pay. Generally, you’ll earn two-thirds of your normal weekly income while you’re regarded temporarily handicapped and unable to execute the required responsibilities of your job—though there are maximum and minimum amounts. The pre-tax gross amount you were making at the time of the injury, including overtime, the market value of employment benefits, and pay from several occupations, is your typical weekly wage. (Labor Code Sections 4453(c)(2), 4454, and 4653 (2020).)

The maximum and minimum temporary disability payments are altered each year since they are connected to the statewide average weekly earnings. In 2020, the highest weekly wage is $1,299.43, while the lowest is $194.91. However, for persons who were wounded before 2020, these sums will be different; for two years after the injury, you’re locked into the maximum TD payment that applied to your injury date. If you are still eligible for TD payments after two years, the amount will be adjusted to reflect the current higher rate.

If your doctor says you may work but only for a restricted number of hours, you may be eligible for partial temporary disability benefits. You’ll be entitled to two-thirds of your weekly pay loss, which is determined as the difference between your typical weekly salary (up to the limit described above) and your part-time earnings. (Labor Code Section 4657 (2020).)

Temporary disability payments may be stopped and restarted, for example, if you returned to work but then had a flare-up of pain or required surgery. Whether you get these advantages continually or occasionally, there is a time limit on how long they will last. Even if you haven’t entirely healed, you can’t obtain temporary disability payments for more than 104 weeks within five years after being wounded, unless you have HIV, hepatitis B or C, or certain kinds of lung illness. (Labor Code Section 4656 (2020).)

Benefits for Permanent Disability

If your physicians find that your accident or disease has left you with persistent limits that hinder your capacity to work, you may be eligible to permanent disability compensation. This will not occur until your treating doctor declares that your medical condition is permanent and immobile, which means that you are not likely to improve in the following year, with or without further therapy. Then, based on your profession, age, and limitations, you’ll be assigned a permanent disability rating (stated as a percentage). (See our article on permanent disability compensation in California workers’ comp cases for more information on how the rating process works and how it is used to decide how much you earn in benefits.)

Supplemental Job Displacement Compensation

In California, you may be entitled for additional job displacement if your employer does not give you regular, modified, or alternate employment after 60 days of getting a medical report indicating that your injury resulted in partial PD. This benefit consists of a $6,000 voucher that you may use to pay for training or other fees related to obtaining the skills and certification required to join a new area of employment.

Benefits on Death

If you are a surviving dependant of an employee who died as a result of a work-related accident, you are entitled to a death benefit. The death benefit amount is determined by the number of survivors who are eligible for benefits as well as the date of the initial injury. (Learn more about California workers’ compensation death payments, including eligibility and how benefits are calculated.)

When Benefits Are Withheld or Delayed

If your employer’s insurance carrier refuses to pay any of the above-mentioned benefits, you have the right to appeal that decision. In addition, if the insurance company fails to pay you benefits on time, you may be eligible to recover a penalty. The mechanism for settling issues with insurance companies, on the other hand, may be complicated. An expert workers’ compensation attorney can assist you in navigating the system and obtaining the benefits you are entitled to.