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Here are commonly used terms for insurance policy or claim documents. We hope these definitions better help you understand your claim situation.
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.
ACOEM: American College of Occupational and Environmental Medicine. Until the state Division of Workers’ Compensation (DWC) adopts medical treatment guidelines, the guidelines published by ACOEM, called “Occupational Medicine Practice Guidelines,” are the guidelines used in most cases to decide the type and amount of treatment you’ll receive for a work injury or illness.
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).
AOE/COE (Arising out of and occurring in the course of employment): Your injury must be caused by and happen on the job.
Applicant: The party -- usually you -- that opens a case at the local Workers’ Compensation Appeals Board (WCAB) office by filing an application for adjudication of claim.
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.
Applicants’ attorney: A lawyer that can represent you in your workers’ compensation case. Applicant refers to you, the injured worker.
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.
Apportionment: A way of figuring out how much of your permanent disability is due to your work injury and how much is due to other disabilities.
Audit Unit: A unit within the DWC that receives complaints against claims administrators. These complaints may lead to investigations of the way the company handles claims.
Benefit notice: A required letter or form sent to you by the insurance company to inform you of benefits you may be entitled to receive. Also called notice.
Cal/OSHA: A unit within the state Division of Occupational Safety and Health (DOSH). Cal/OSHA inspects workplaces and enforces laws to protect the health and safety of workers in California.
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.
Carve-out: Carve-out programs allow employers and unions to create their own alternatives for workers' compensation benefit delivery and dispute resolution under a collective bargaining agreement.
Claim form: The form used to report a work injury or illness to your employer.
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.
Commutation: An order by a workers’ compensation judge for a lump sum payment of part or all of your permanent disability award.
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 injury (CT): An injury that was caused by repeated events or repeated exposures at work. For example, hurting your wrist doing the same motion over and over 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.
Death benefits: Benefits paid to surviving dependents when a work injury or illness results in death.
Declaration of readiness (DOR or DR): A form used to request a hearing before a workers’ compensation judge when you’re ready to resolve a dispute.
Defendant: The party –- usually your employer or its insurance company -- opposing you in a dispute over benefits or services.
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.
Denied claim: A claim in which the insurance company believes your injury or illness is not covered by workers’ compensation and has notified you of the decision.
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.
Determination and order (D&O): A decision by the DWC Rehabilitation Unit on a vocational rehabilitation dispute.
Disability: A physical or mental impairment that limits your life activities. A condition that makes engaging in physical, social and work activities difficult.
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 DWC Disability Evaluation Unit who rates your permanent disability after reviewing a medical report or a medical-legal report describing your condition.
Disability rating: See permanent disability rating.
Discrimination claim (Labor Code132a): A petition filed if your employer has fired or otherwise discriminated against you for filing a workers’ compensation claim.
Dispute: A disagreement about your right to payments, services or other benefits.
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.
Electronic Adjudication Management System (EAMS): A computer based system to simplify and improve the Division of Workers’ Compensation case management process.
Employee: A person whose work activities are under the control of an individual or entity. The term employee includes undocumented workers and minors.
Employer: The person or entity with control over your work activities.
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.
Filing: Sending or delivering a document to an employer or a government agency as part of a legal process. The date of filing is the date the document is received.
Final order: Any order, decision or award made by a workers’ compensation judge that has not been appealed in a timely way.
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.
Future medical: On-going right to medical treatment for a work-related injury.
Health care organization (HCO): An organization certified by the Department of Industrial Relations to provide managed medical care within the workers’ compensation system.
Hearings: Legal proceedings 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.
In pro per: An injured worker not represented by an attorney.
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 probably are not an independent contractor when 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 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.
Injury and illness prevention program (IIPP): A health and safety program employers are required to develop and implement. This program is enforced by Cal/OSHA.
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.
Mandatory settlement conference (MSC): A required conference to discuss settlement prior to a trial.
Maximal 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.
Mediation conference: A voluntary conference held before an I&A officer to resolve a dispute if you are not represented by an attorney.
Medical care: See medical treatment.
Medical-legal report: A report written by a doctor that describes your medical condition. These reports are written to help clarify disputed medical issues.
Medical provider network (MPN): 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.
Medical treatment: Treatment reasonably required to cure or relieve the effects of a work-related injury or illness. Also called medical care.
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.
Objective factors: Measurements, direct observations and test results a treating physician, QME or an AME says contribute to your permanent disability.
Off calendar (OTOC): A WCAB case in which there is no pending action.
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.
Party: Normally this includes the insurance company, your employer, attorneys and any other person with an interest in your claim (doctors or hospitals that have not been paid).
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 (PD): Any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached.
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.
Permanent disability (PD) benefits: Payments you receive when your work injury permanently limits the kinds of work you can do or your ability to earn a living.
Permanent disability advance (PDA): A voluntary lump sum payment of permanent disability you are due in the future.
Permanent disability payments: A mandatory bi-weekly payment based on the undisputed portion of permanent disability received before and/or after an award is issued.
Permanent partial disability award: A final award of permanent partial disability made by a workers’ compensation judge or the Workers’ Compensation Appeals Board.
Permanent partial disability (PPD) benefits: Payments you receive when your work injury partially limits the kinds of work you can do or your ability to earn a living.
Permanent total disability (PTD) benefits: Payments you receive when you are considered permanently unable to earn a living.
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.
Personal physician: A doctor licensed in California with an M.D. degree (medical doctor) or a D.O. degree (osteopath), who has treated you in the past and has your medical records.
Petition for reconsideration (Recon): A legal process to appeal a decision issued by a workers' compensation judge. Heard by the Workers' Compensation Appeals Board Reconsideration Unit, a sevenmember, 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.
Pre-designated physician: A physician that can treat your work injury if you advised your employer in writing prior to your work injury or illness and certain conditions are met. See pre-designation.
Pre-designation: The process you use to tell your employer you want your personal physician to treat you for a work injury. You can pre-designate 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 and; prior to the injury you provided your employer the following in writing:
(1) Notice that you want your personal doctor to treat you for a work-related injury or illness and
(2) 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.
Proof of service: A form used to show that documents have been sent to specific parties.
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.
Qualified injured worker (QIW): Entitled to vocational rehabilitation benefits. This benefit applies only if you were injured before Jan. 1, 2004.
Qualified medical evaluator (QME): An independent physician certified by the DWC Medical Unit to perform medical evaluations.
Qualified rehabilitation representative (QRR): A person trained and able to evaluate, counsel, and place disabled workers in new jobs. Also called rehabilitation counselor.
Rating: See permanent disability rating.
Reconsideration: See petition for reconsideration.
Reconsideration Unit: See appeals board.
Reconsideration of a summary rating: A process used when you don’t have an attorney and you think mistakes were made in your permanent disability rating.
Regular work: Your old job, paying the same wages and benefits as paid at the time of an injury and located within a reasonable commuting distance of where you lived at the time of your injury.
Rehabilitation consultant: A DWC employee who oversees vocational rehabilitation procedures, makes decisions about vocational rehabilitation benefits and helps resolve disputes.
Rehabilitation counselor: See qualified rehabilitation representative (QRR).
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.
Serious and willful misconduct (S&W): A petition filed if your injury is caused by the serious and willful misconduct of your employer.
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.
Stipulated rating: Formal agreement on your permanent disability rating. Must be approved by a workers’ compensation judge.
Stipulation with award: A settlement of a case where the parties agree on the terms of an award. This is the document the judge signs to make the award final.
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 measurements.
Subpoena: A document that requires a witness to appear at a hearing.
Subpoena Duces Tecum (SDT): A document that requires records be sent to the requester.
Summary rating: The percentage of permanent disability calculated by the DWC Disability Evaluation Unit.
Summary rating reconsideration: A procedure used if you object to the summary rating issued by the DWC Disability Evaluation Unit.
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 stateapproved or state-accredited schools. Also called voucher.
Temporary disability (TD or TTD): Payments you get if you lose wages because your injury prevents you from doing your usual job while recovering.
Temporary partial disability (TPD) benefits: Payments you get if you can do some work while recovering, but you earn less than before the injury.
Temporary total disability (TTD) benefits: Payments you get if you cannot work at all while recovering.
Transportation expenses: A benefit to cover your out-of-pocket expenses for mileage, parking and toll fees related to a claim. Usually a reimbursement.
Treating doctor: See primary treating physician.
Treating physician: See primary treating physician.
Uninsured Employers Fund (UEF): A fund, run by the DWC, through which your benefits can be paid if your employer is illegally uninsured for workers’ compensation.
Utilization review (UR): The process used by insurance companies to decide whether to authorize and pay for treatment recommended by your treating physician or another doctor.
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 (VR): 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.
Voucher: See supplemental job displacement benefit and nontransferable voucher.
Wage loss (temporary partial disability): 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.
Work restrictions: A doctor’s description of the work you can and cannot do. Work restrictions help protect you from further injury.
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.
Workers’ compensation judge: See workers’ compensation administrative law judge.
The information contained here is general in nature and is not intended as a substitute for legal advice.
Changes in the law or the specific facts of your case may result in legal interpretations different than those presented here.
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