Workers Comp Terms For Injured Workers
Below are common terms that you may encounter with a workers comp claim. These terms are for general information and not to be construed as a legal guide.
- Accepted claim
- Agreed medical evaluator
- Alternative work
- American Medical Association (AMA)
- Americans with Disabilities Act (ADA)
- AOE/COE (Arising out of and occurring in the course of employment)
- Appeals Board
- Applicant’s Attorney
- Application for adjudication of claim (application or app)
- Audit Unit
- Benefit notice
- California Labor Code Section 132a
- Claim form
- Claims adjuster
- Claims administrator
- Claims examiner
- Commission on Health and Safety and Workers’ Compensation (CHSWC)
- Compromise and release (C&R)
- Cumulative Trauma injury (CT)
- Date of injury
- Death benefits
- Declaration of readiness (DOR)
- Delay letter
- Denied Claim
- Description of employee’s job duties (RU-91)
- Determination and order (D&O)
- Disability Evaluation Unit (DEU)
- Disability management
- Disability rater
- Disability rating
- Discrimination claim (Labor Code132a)
- Division of Workers’ Compensation (DWC)
- Electronic Adjudication Management System (EAMS)
- Essential functions
- Ex parte communication
- Fair Employment and Housing Act (FEHA)
- Family and Medical Leave Act (FMLA)
- Final order
- Findings & award (F&A)
- Future earning capacity (FEC)
- Future medical
- Health care organization (HCO)
- In pro per
- Independent contractor
- Independent medical examiner (IME)
- Industrial Medical Council
- Information & Assistance (I&A) officer
- Injury and illness prevention program
- Impairment rating
- Mandatory settlement conference (MSC)
- Maximal medical improvement
- Mediation conference
- Medical care
- Medical-legal report
- Medical provider network (MPN)
- Medical treatment
- Medical treatment utilization schedule (MTUS)
- Medical Unit
- Modified work
- Nontransferable voucher
- Objective factors
- Off Calendar (OTOC)
- Offer of modified or alternative work form (RU-94)
- Offer of modified or alternative work (DWC form #AD 10133.53)
- Panel qualified medical evaluator (QME)
- Permanent and stationary (P&S)
- Permanent disability (PD)
- Permanent disability rating (PDR)
- Permanent disability rating schedule (PDRS)
- Permanent disability (PD) benefits
- Permanent disability advance (PDA)
- Permanent disability payments
- Permanent partial disability award
- Permanent partial disability (PPD) benefits
- Permanent total disability (PTD) benefits
- Personal physician
- Petition for reconsideration (Recon)
- Predesignated physician
- Primary treating physician(PTP)
- Proof of service
- P&S report
- Qualified injured worker (QIW)
- Qualified medical evaluator (QME)
- Qualified rehabilitation representative (QRR)
- Reconsideration of a summary rating
- Reconsideration Unit
- Regular work
- Rehabilitation consultant
- Rehabilitation counselor
- Rehabilitation Unit
- Schedule for rating permanent disabilities
- Serious and willful misconduct (S&W)
- Social Security disability benefits
- Specific injury
- State average weekly wage
- State disability insurance (SDI)
- Stipulated rating
- Stipulation with award
- Stipulations with request for award (Stips)
- Subjective factors
- Subpoena Duces Tecum (SDT)
- Summary rating
- Summary rating reconsideration
- Supplemental job displacement benefit (SJDB)
- Temporary disability (TD or TTD)
- Temporary partial disability (TPD) benefits
- Temporary total disability (TTD) benefits
- Transportation expenses
- Treating doctor
- Treating physician
- Uninsured Employers Fund (UEF)
- Utilization review (UR)
- Vocational & return to work counselor (VRTWC)
- Vocational rehabilitation (VR)
- Vocational rehabilitation maintenance allowance (VRMA)
- Wage loss (temporary partial disability)
- Workers’ Compensation Appeals Board (WCAB)
- Workers Compensation Insurance Rating Bureau (WCIRB)
- Work restrictions
- Workers’ compensation administrative law judge
- Workers’ compensation judge
Accepted claim: A claim in which the insurance company agrees your injury or illness is covered by workers’ compensation. Even if your claim is accepted there may be delays or other problems. Also called admitted claim.
Agreed medical evaluator (AME): If you have an attorney, an AME is the doctor your attorney and the insurance company agree on to conduct the medical examination that will help resolve your dispute. If you don’t have an attorney, you will use a qualified medical evaluator (QME). See QME.
Alternative work: A new job with your former employer. If your doctor says you will not be able to return to your job at the time of injury, your employer is encouraged to offer you alternative work instead of supplemental job displacement benefits or vocational rehabilitation benefits. The alternative work must meet your work restrictions, last at least 12 months, pay at least 85 percent of the wages and benefits you were paid at the time you were injured, and be within a reasonable commuting distance of where you lived at the time of injury.
American Medical Association (AMA): A national physician’s group. The AMA publishes a set of guidelines called “Guides to the Evaluation of Permanent Impairment.” If your permanent disability is rated under the 2005 rating schedule, the doctor is required to determine your level of impairment using the AMA’s guides.
Americans with Disabilities Act (ADA): A federal law that prohibits discrimination against people with disabilities. If you believe you’ve been discriminated against at work because you’re disabled and want information on your rights under the ADA, contact a U.S. Equal Employment Opportunity Commission office. For the EEOC office in your area, call 1-800-669-4000 or 1-800-669-6820 (TTY).
Appeals board: A group of seven commissioners appointed by the governor to review and reconsider decisions of workers’ compensation administrative law judges. Also called the Reconsideration Unit. See Workers’ Compensation Appeals Board.
Application for adjudication of claim (application or app): A form you file to open a case at the local Workers’ Compensation Appeals Board (WCAB) office if you have a disagreement with the insurance company about your claim.
Audit Unit: A unit within the Division of Workers Compensation (DWC) that receives complaints against claims administrators. These complaints may lead to investigations of the way the company handles claims.
California Labor Code section 132a: A workers’ compensation law that prohibits discrimination against you because you filed a workers’ compensation claim, and against co-workers who might testify in your case.
Claims adjuster: See claims administrator.
Claims administrator: The term for insurance companies and others that handle your workers’ compensation claim. Most claims administrators work for insurance companies or third party administrators handling claims for employers. Some claims administrators work directly for large employers that handle their own claims. Also called claims examiner or claims adjuster.
Claims examiner: See claims administrator.
Commission on Health and Safety and Workers’ Compensation (CHSWC): A state-appointed body that conducts studies and makes recommendations to improve the California workers’ compensation and workplace health and safety systems.
Compromise and release (C&R): A type of settlement in which you receive a lump sum payment and become responsible for paying for your future medical care. A settlement like this must be approved by a workers’ compensation judge.
Cumulative Trauma injury (CT): An injury that was caused by repeated events or repeated exposures at work. For example, hurting your wrist doing the same repetitive motion or losing your hearing because of constant loud noise.
Date of injury: When you got hurt or ill. If your injury was caused by one event, the date it happened is the date of injury. If the injury or illness was caused by repeated exposures (a cumulative injury), the date of injury is the date you knew or should have known the injury was caused by work.
Delay letter: A letter sent to you by the insurance company that explains why payments are delayed. The letter also tells you what information is needed before payments will be sent and when a decision will be made about the payments.
Description of employee’s job duties (RU-91): A form filled out jointly by you and the insurance company that helps your treating physician decide whether you will be able to return to your normal job and working conditions.
Disability Evaluation Unit (DEU): A unit within the DWC that calculates the percent of permanent disability based on medical reports. See disability rater.
Disability management: A process to prevent disability from occurring or to intervene early, following the start of a disability, to encourage and support continued employment. This is done early in the recovery process in severe injury cases such as spinal injuries. Usually a rehabilitation nurse is involved with you and your treating doctor and the progress of your medical treatment is reported to the insurance company.
Disability rater: An employee of the Division of Workers Compensation (DWC) Disability Evaluation Unit (DEU) who rates your permanent disability after reviewing a medical report or a medical-legal report describing your condition.
Disability rating: See permanent disability rating.
Division of Workers’ Compensation (DWC): A division within the state Department of Industrial Relations (DIR). The DWC administers workers’ compensation laws, resolves disputes over workers’ compensation benefits and provides information and assistance to injured workers and others about the workers’ compensation system.
Ergonomics: The study of how to improve the fit between the physical demands of the workplace and the employees who perform the work. That means considering the variability in human capabilities when selecting, designing or modifying equipment, tools, work tasks and the work environment.
Essential functions: Duties considered crucial to the job you want or have. When being considered for alternative work, you must have both the physical and mental qualifications to fulfill the job’s essential functions.
Fair Employment and Housing Act (FEHA): A state law that prohibits discrimination against people with disabilities. If you believe you’ve been discriminated against at work because you’re disabled and want more information on your rights under the FEHA, contact the state Department of Fair Employment and Housing at 1-800-884-1684. In some cases, the FEHA provides more protection than the federal Americans with Disabilities Act (ADA).
Family and Medical Leave Act (FMLA): A federal law that provides certain employees with serious health problems or who need to care for a child or other family member with up to 12 weeks of unpaid, job-protected leave per year. It also requires that group health benefits be maintained during the leave. For more information, contact the U.S. Department of Labor at 1-866-4-USA-DOL.
Findings & Award (F&A): A written decision by a workers’ compensation administrative law judge about your case, including payments and future care that must be provided to you. The F&A becomes a final order unless appealed.
Fraud: Any knowingly false or fraudulent statement for the purpose of obtaining or denying workers’ compensation benefits. The penalties for committing fraud are fines up to $150,000 and/or imprisonment for up to five years.
Independent contractor: There is no set definition of this term. Labor law enforcement agencies and the courts look at several factors when deciding if someone is an employee or an independent contractor. Some employers misclassify employees as an independent contractor to avoid workers’ compensation and other payroll responsibilities. Just because an employer says you are an independent contractor and doesn’t need to cover you under a workers’ compensation policy doesn’t make it true. A true independent contractor has control over how their work is done.
You are probably not an independent contractor IF the person paying you:
- Controls the details or manner of your work
- Has the right to terminate you
- Pays you an hourly wage or salary
- Makes deductions for unemployment or Social Security
- Supplies materials or tools
- Requires you to work specific days or hours
Industrial Medical Council (IMC): No longer in existence. See Medical Unit.
Information & Assistance Unit (I&A): A unit within the Division of Workers Compensation (DWC) that provides information to all parties in workers’ compensation claims and informally resolves disputes.
Information & Assistance (I&A) officer: A DWC employee who answers questions, assists injured workers, provides written materials, conducts informational workshops and holds meetings to informally resolve problems with claims.
Impairment rating: A percentage estimate of how much normal use of your injured body parts you’ve lost. Impairment ratings are determined based on guidelines published by the American Medical Association (AMA). An impairment rating is used to calculate your permanent disability rating but is different from your permanent disability rating.
Judge: See workers’ compensation administrative law judge.
Lien: A right or claim for payment against a workers’ compensation case. A lien claimant, such as a medical provider, can file a form with the local Workers’ Compensation Appeals Board to request payment of money owed in a workers’ compensation case.
Maximum Medical Improvement (MMI): Your condition is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Once you reach MMI, a doctor can assess how much, if any, permanent disability resulted from your work injury.
Medical care: See medical treatment.
Medical Provider Network (MPN): An entity or group of health care providers set up by an insurer or self-insured employer and approved by Division of Workers Compensations’ administrative director to treat workers injured on the job.
Medical treatment utilization schedule (MTUS): 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.
Medical Unit: 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).
Modified work: Your old job, with some changes that allow you do to it. If your doctor says you will not be able to return to your job at the time of injury, your employer is encouraged to offer you modified work instead of supplemental job displacement benefits or vocational rehabilitation benefits.
Nontransferable voucher: A document you get from the insurance company that must be completed by both you and the insurance company. This is the document used to provide payment for education under the supplemental job displacement benefit program.
Notice: See benefit notice.
Offer of modified or alternative work form (RU-94): A form you get from the insurance company if: you were injured before 2004 and; your treating physician says you probably will never return to your job or one like it and; your employer is offering modified or alternative work instead of vocational rehabilitation benefits.
Offer of modified or alternative work (DWC form #AD 10133.53): A form you get from the insurance company if: you were injured in 2004 or later and; your treating physician reports you have a permanent disability and; your employer is offering modified or alternative work instead of a supplemental job displacement benefit. This form also explains how your permanent disability payments may be lowered by 15 percent because your employer is returning you to work.
Panel qualified medical evaluator (QME): A list of three independent qualified medical evaluators (QMEs) issued by the DWC Medical Unit. You select any one of the three doctors for your evaluation. If you have an attorney, other rules apply.
Permanent and stationary (P&S): Your medical condition has reached maximum medical improvement. Once you are P&S, a doctor can assess how much, if any, permanent disability resulted from your work injury. If your disability is rated under the 2005 schedule you will see the term maximal medical improvement (MMI) used in place of P&S. See also P&S report.
Permanent Disability Rating (PDR): A percentage that estimates how much a job injury permanently limits the kinds of work you can do. It is based on your medical condition, date of injury, age when injured, occupation when injured, how much of the disability is caused by your job, and your diminished future earning capacity. It determines the number of weeks you are entitled to permanent disability benefits.
Permanent disability rating schedule (PDRS): A DWC publication containing detailed information used to rate permanent disabilities. One of three schedules will be used to rate your disability, depending on when you were injured.
Penalty: An amount of money you receive because something wasn’t done correctly in your claim. Paid by your employer or the insurance company, the penalty amount can be an automatic 10 percent for a delay in one payment to you, or a 25 percent penalty (up to $10,000) for an unreasonable delay.
Petition for Reconsideration: A legal process to appeal a decision issued by a workers’ compensation judge. Heard by the Workers’ Compensation Appeals Board Reconsideration Unit, a seven-member, judicial body appointed by the governor and confirmed by the Senate.
Physician: A medical doctor, an osteopath, a psychologist, an acupuncturist, an optometrist, a dentist, a podiatrist or a chiropractor licensed in California. The definition of personal physician is more limited. See personal physician.
You can predesignate your personal doctor of medicine (M.D.) or doctor of osteopathy (D.O.) if:
- your employer offers group health coverage.
- the doctor has treated you in the past and has your medical records.
- prior to the injury your doctor agreed to treat you for work injuries or illnesses.
- prior to the injury you provided your employer the following in writing:
A written notice stating that you want your personal doctor to treat you for a work-related injury or illness and your personal doctor’s name and business address.
Primary Treating Physician (PTP): The doctor having overall responsibility for treatment of your work injury or illness. This physician writes medical reports that may affect your benefits. Also called treating physician or treating doctor.
P&S report: A medical report written by a treating physician that describes your medical condition when it has stabilized. See also permanent and stationary.
Rating: See permanent disability rating.
Reconsideration: See petition for reconsideration.
Reconsideration Unit: See appeals board.
Rehabilitation counselor: See qualified rehabilitation representative.
Rehabilitation Unit: A unit within DWC that resolves vocational rehabilitation disputes, approves potential settlements of vocational rehabilitation services, and reviews and approves vocational rehabilitation plans for injuries that happened before Jan. 1, 2004.
Restrictions: See work restrictions.
Schedule for rating permanent disabilities: See permanent disability rating schedule.
Settlement: An agreement between you and the insurance company about your workers’ compensation payments and future medical care. Settlements must be reviewed by a workers’ compensation judge to make sure they are adequate.
Social Security disability benefits: Long-term financial assistance for totally disabled persons. These benefits come from the U.S. Social Security Administration. They are reduced by workers’ compensation payments you receive.
Specific injury: An injury caused by one event at work. Examples: hurting your back in a fall, getting burned by a chemical splashed on your skin, getting hurt in a car accident while making deliveries.
State average weekly wage: The average weekly wage paid in the previous year to employees in California covered by unemployment insurance, as reported by the U.S. Department of Labor. Effective 2006, temporary disability benefit increases are tied to this index.
State disability insurance (SDI): A partial wage-replacement insurance plan paid out to California workers by the state Employment Development Department (EDD). SDI provides short-term benefits to eligible workers who suffer a loss of wages when they are unable to work due to a non work-related illness or injury, or a medically disabling condition from pregnancy or childbirth. Workers with job injuries may apply for SDI when workers’ compensation payments are delayed or denied. Call 1-800-480-3287 for more information on SDI.
Stipulations with request for award (Stips): A settlement in which the parties agree on the terms of an award. It may include future medical treatment. Payment takes place over time. This document is provided to the judge for final review.
Subjective factors: The amount of pain and other symptoms described by an injured worker that a doctor reports as contributing to a worker’s permanent disability. Subjective factors are given very little weight under the 2005 rating schedule as the schedule relies mainly on objective findings.
Supplemental job displacement benefit (SJDB): A workers’ compensation benefit. If you were injured in 2004 or later, and have a permanent partial disability that prevents you from doing your old job, and your employer does not offer other work, you qualify for this benefit. It is in the form of a voucher that promises to help pay for educational retraining or skill enhancement, or both, at state-approved or state-accredited schools. Also called voucher.
Treating doctor: See primary treating physician.
Treating physician: See primary treating physician.
Vocational & return to work counselor (VRTWC): If you have a permanent disability, this is the person or entity that helps you develop a return to work strategy. They evaluate you, provide counseling and help you get ready to work. A VRTWC must have at least an undergraduate degree in any field and three or more years of full time experience.
Vocational Rehabilitation: A workers’ compensation benefit. If you were injured before 2004 and are permanently unable to do your usual job, and your employer does not offer other work, you qualify for this benefit. It includes job placement counseling to help you find another job. It may also include retraining and a vocational rehabilitation maintenance allowance.
Vocational rehabilitation maintenance allowance (VRMA): Payments to help you with living expenses while participating in vocational rehabilitation. See vocational rehabilitation.
Wage loss: See temporary partial disability benefits.
Workers’ Compensation Appeals Board (WCAB): Consists of 24 local offices throughout the state where disagreements over workers’ compensation benefits are initially heard by workers’ compensation judges. The WCAB Reconsideration Unit in San Francisco is a seven-member, judicial body appointed by the governor and confirmed by the Senate that hears appeals of decisions issued by local workers’ compensation judges.
Workers’ Compensation Insurance Rating Bureau (WCIRB): An agent of the state Department of Insurance and funded by the insurance industry, this private entity provides statistical and rating information for workers’ compensation insurance and employer’s liability insurance, and collects and tabulates information to develop pure premium rates.
Workers’ compensation administrative law judge: A DWC employee who makes decisions about workers’ compensation disputes and approves settlements. Judges hold hearings at local Workers’ Compensation Appeals Board (WCAB) offices, and their decisions may be reviewed and reconsidered by the Reconsideration Unit of the WCAB. Also called workers’ compensation judge.