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Supplemental Job Displacement Nontransferable Training Voucher Form (Form DWC-
AD 10133.57 - Mandatory Form) For injuries occurring on or after 1/1/04
You have been determined eligible for this nontransferable, Supplemental Job Displacement Voucher. This voucher may be used for the payment of tuition, fees, books, and other expenses required by a state approved or accredited school that you enroll in for the purpose of education related retraining or skill enhancement, or both.
The state approved or accredited school will be reimbursed upon receipt of a documented invoice for tuition, fees, books and other required expenses required by the school for retraining or skill enhancement. If you pay for the eligible expenses, you may be reimbursed for these expenses upon submission of documented receipts. No more than 10 percent of the value of this voucher may be used for vocational or return to work counseling. If you decide to voluntarily withdraw from a program, you may not be entitled to a full refund of the voucher amount utilized.
Please present this original letter to the state approved or accredited school and/or the Vocational & Return to Work Counselor of your choice, chosen from the list developed by the Division of Workers' Compensation's Administrative Director, in order to initiate your training and return to work counseling. A list of Vocational & Return to Work Counselors is available on the Division of Workers' Compensation's website www.dir.ca.gov or upon request. The school and/or counselor should contact me regarding direct payment from your supplemental job displacement benefit.
Injured Employee Information: Upon completing the voucher form the injured employee must return the form with receipts and documentation to the claims administrator immediately for reimbursement. (The claims administrator must complete Nos. 1-8 of this voucher form prior to sending it to the injured employee.)
1. Injured Employee Name __________
2. Address __________ __________ __________ __________ __________ City __________State __________ Zip Code __________
3. Claim Number __________Phone Number __________
Claims Administrator
4. Name __________
5. Claims Mailing Address __________
6. City __________State __________ __________Zip Code __________
7. Claims Representative __________Phone Number __________ __________
8. $ __________ is available to the injured employee based on _____% of Permanent Partial Disability Award
The injured employee must complete Nos. 9-19 and sign and date this voucher form.
(VRTWC) Vocational Return to Work Counselor (if any)
9. Name __________Phone Number __________ __________
10. Address __________
11. City __________State __________ __________ Zip Code __________
12. Funds used for vocational and return to work counseling $________ (10% maximum of voucher value)
Training Provider Details (Attach additional pages for each provider if necessary.)
13. Provider Name __________
14. Provider Address __________Phone Number __________ __________
15. City __________State __________ __________ Zip Code __________
16. Provider approval number __________
17. Expiration Date ___________________
18. Provider Contact Name __________
19. Training Cost _________________
Injured Employee Signature __________Date __________
Note to Claims Administrator: Upon receipt of voucher, receipts and documentation from the employee, reimbursement payments to the employee or direct payments to VRTWC and training providers must be made within 45 calendar days.
Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.
s 10133.58. State Approved or Accredited Schools.
(a) This section shall only apply to injuries occurring on or after January 1, 2004.
(b) Private providers of education-related retraining or skill enhancement selected to provide training as part of a supplemental job displacement benefit shall be:
(1) approved by the Bureau for Private Postsecondary and Vocational Education (www.bppve.ca.gov), or a California state agency that has an agreement with the Bureau for the regulation and oversight of non-degree-granting private postsecondary institutions;
(2) accredited by one of the Regional Associations of Schools and Colleges authorized by the United States Department of Education; or
(3) certified by the Federal Aviation Administration.
(c) Any training outside of California must be approved by an agency in that state similar to the Bureau for Private Postsecondary and Vocational Education.
Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.
s 10133.59. The Administrative Director's List of Vocational Return to Work Counselors.
(a) This section shall only apply to injuries occurring on or after January 1, 2004.
(b) The Administrative Director shall maintain a list of Vocational & Return to Work Counselors (VRTWC) who perform the work of assisting injured employees. A VRTWC who meets the qualifications specified in Section 10133.50(a)(15) must apply to the Administrative Director to be included on the list throughout the year. The list shall be reviewed and revised on a yearly basis, and shall be made available on the website www.dir.ca.gov or upon request.
(c) The injured employee may select a Vocational & Return to Work Counselor whenever the assistance of a Vocational & Return to Work Counselor is needed to facilitate an employee's vocational training or return to work in connection with the Supplemental Job Displacement Benefit set forth in this Article.
(d) The injured employee shall be responsible for providing the VRTWC with any necessary medical reports. However, a claims administrator shall provide a VRTWC with any medical reports, including permanent and stationary medical reports, upon an employee's written request and a signed release waiver.
(e) The VRTWC shall communicate with the injured employee regarding the evaluation.
Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.
s 10133.60. Termination of Claims Administrator's Liability for the Supplemental Job Displacement Benefit.
(a) For injuries occurring on or after January 1, 2004, the claims administrator's liability to provide a supplemental job displacement voucher shall end if either (a)(1) or (a)(2) occur:
(1) the claims administrator offers modified or alternative work to the employee, meeting the requirements of Labor Code s4658.6, on DWC-AD Form 10133.53 "Notice of Offer of Modified or Alternative Work";
(A) If the claims administrator offers modified or alternative work to the employee for 12 months of seasonal work, the offer shall meet the following requirements:
1. the employee was hired on a seasonal basis prior to injury; and
2. the offer of modified or alternative work is on a similar seasonal basis to the employee's previous employment;
(2) the maximum funds of the voucher have been exhausted.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4658.1, 4658.5, 4658.6 and 5410, Labor Code; and Henry v. WCAB(1998) 68 Cal.App.4th 981.
s 10134. Attorney Fee Disclosure Statement Form.
Note: Authority cited: Sections 133 amd 5307.3, Labor Code. Reference: Section 4906(e), Labor Code.
s 10135. Required Use of Form.
Every attorney or his/her agent who consults with an injured worker or dependent is required to furnish the attorney fee disclosure statement form set forth in Section 10134 of this Article to the injured worker or dependent at the initial consultation.
Note: Authority cited: Section 133 and 5307.3, Labor Code. Reference: Section 4906(e), Labor Code.
s 10135.1. Service of Form.
Within 15 days of the employee's and attorney's execution of the disclosure form, a copy of the disclosure form shall be mailed to the employer or, if known, to the employer's insurer or third-party administrator.
Note: Authority cited: Section 133 and 5307.3, Labor Code. Reference: Section 4906(e), Labor Code.
s 10136. Filing the Request.
(a) The Administrative Director shall establish a uniform expedited hearing calendar in all offices of the Division of Workers' Compensation.
(b) An applicant is entitled to an expedited priority hearing and decision upon the filing of an Application for Adjudication of Claim and Request for Expedited Hearing, DWC Form 4, showing a bona fide dispute as to:
(1) entitlement to medical treatment;
(2) entitlement to temporary disability payments or amount;
(3) appeal from a decision and order of the rehabilitation unit, enforcement thereof, or termination; or
(4) liability for benefits among employers;
(c) The request for expedited hearing must be on the form set forth in Section 10137, DWC Form 4, and must be filed with an Application for Adjudication of Claim.
(d) Within two (2) days of receipt of the Request for Expedited Hearing, the Request shall be reviewed for compliance with Subdivision (b).
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Section 5502(b), Labor Code.
s 10137. Form.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Section 5502(b), Labor Code.
s 10150. Disability Evaluation Unit.
The Disability Evaluation Unit, under the direction and authority of the Administrative Director, will issue permanent disability ratings as required under this subchapter utilizing the Schedule for Rating Permanent Disabilities adopted by the Administrative Director. The Disability Evaluation Unit will prepare the following kinds of rating determinations:
(a) Formal rating determinations
(b) Summary rating determinations
(c) Consultative rating determinations
(d) Informal rating determinations.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4660, 4662, 4663 and 4664, Labor Code.
s 10151. Schedule for Rating Permanent Disabilities.
Note: Authority cited: Sections 4660, 133, 4061, 5307.3 and 5307.4, Labor Code. Reference: Sections 124 and 4061, Labor Code.
s 10152. Disability, When Considered Permanent.
A disability is considered permanent when the employee has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4062, 4062.01, 4062.1, 4660, 4662, 4663 and 4664, Labor Code.
s 10154. Permanent Disability Rating Determinations, Kinds.
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 124. 4061, 5452, 5701 and 5703.5, Labor Code.
s 10156. Formal Rating Determinations.
A formal rating determination will be prepared by the Disability Evaluation Unit when requested by the Appeals Board or a Workers' Compensation Judge on a form specified for that purpose by the Administrative Director. The form will provide for a description of the disability to be rated, the occupation of the injured employee, the employee's age at the time of injury, the date of injury, the formula used, and a notice of submission in accordance with Appeals Board Rules of Practice and Procedure.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4660, 4662, 4663, 4664 and 5701, Labor Code.
s 10158. Formal Rating Determinations As Evidence.
Formal rating determinations prepared by disability evaluators shall be deemed to constitute evidence only as to the relation between the disability or impairment standard(s) described and the percentage of permanent disability.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4660, 4662, 4663 and 4664, Labor Code.
s 10160. Summary Rating Determinations, Comprehensive Medical Evaluation of Unrepresented Employee.
(a) The Disability Evaluation Unit will prepare a summary rating determination upon receipt of a properly prepared request. A properly prepared request shall consist of:
(1) A completed Request for Summary Rating Determination, DEU Form 101;
(2) A completed Employee's Disability Questionnaire, DEU Form 100;
(3) A comprehensive medical evaluation of an unrepresented employee from a Qualified Medical Evaluator.
(b) The insurance carrier or self-insured employer shall provide the employee with an Employee's Disability Questionnaire (DEU Form 100) prior to the appointment scheduled with the Qualified Medical Evaluator. The employee will be instructed in the form and manner prescribed by the Administrative Director to complete the questionnaire and provide it to the Qualified Evaluator at the time of the examination.
(c) The insurance carrier, self-insured employer or injured worker shall complete a Request for Summary Rating Determination (DEU Form 101), a copy of which shall be served on the opposing party. The requesting party shall send the request, including proof of service of the request on the opposing party, to the Qualified Medical Evaluator together with all medical reports and medical records relating to the case prior to the scheduled examination with the Qualified Medical Evaluator. The request shall include the appropriate address of the Disability Evaluation Unit. A listing of all of the offices of the Disability Evaluation Unit, with each office's area of jurisdiction, will be provided, upon request, by any office of the Disability Evaluation Unit or any Information and Assistance Office.
(d) When a summary rating determination has been requested, the Qualified Medical Evaluator shall submit all of the following documents to the Disability Evaluation Unit at the location indicated on the DEU Form 101 and shall concurrently serve copies on the employee and claims administrator:
1. Request for Summary Rating Determination of Qualified Medical Evaluator's Report (DEU Form 101) as a cover sheet to the evaluation report;
2. Employee's Disability Questionnaire (DEU Form 100);
3. Comprehensive medical evaluation by the Qualified Medical Evaluator, including the Qualified Medical Evaluator's Findings Summary Form (IMC Form 1002)..
(e) No request for a summary rating determination will be considered to be received until the DEU Form 100, the DEU Form 101, and the comprehensive medical evaluation have been received by the office of the Disability Evaluation Unit having jurisdiction over the employee's area of residence. In the event an employee does not have a completed Employee's Disability Questionnaire (DEU Form 100) at the time of his or her appointment with a Qualified Medical Evaluator, the medical evaluator shall provide this form to the employee for completion prior to the evaluation. Any requests received on or after April 1, 1994 without all the required documents will be returned to the sender.
(f) Any request for the rating of a supplemental comprehensive medical evaluation report shall be made no later than twenty days from the receipt of the report and shall be accompanied by a copy of the correspondence to the evaluator soliciting the supplemental evaluation, together with proof of service of the correspondence on the opposing party.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4062, 4062.01, 4062.1, 4062.2, 4062.5, 4064, 4067, 4660, 4662, 4663 and 4664, Labor Code.
s 10160.1. Summary Rating Determinations, Report of Primary Treating Physician for Unrepresented Employee.
For injuries on or after January 1, 1994, the insurance carrier, self-insured employer or the employee may request a summary rating of the primary treating physician's report prepared in accordance with Section 9785.5. The request may be made by completing a Request for Summary Rating Determination of Primary Treating Physician's Report (DEU Form 102) and sending the request to the Disability Evaluation Unit together with a copy of the primary treating physician's report. A copy of the request form and a copy of the primary treating physician's report must be served concurrently on the non-requesting party, including a proof of service on the non-requesting party.
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 124, 4061, 4061.5, 4062, 4062.1, 4062.2, 4062.5, 4064 and 4067, Labor Code.
s 10160.5. Summary Rating Determinations, Represented Employees.
(a) For injuries on or after January 1, 1991 and before January 1, 1994, the Disability Evaluation Unit will prepare a summary rating determination in cases where the injured worker is represented only if requested by a party. A summary rating determination will be prepared only upon receipt of a properly prepared request. A properly prepared request shall consist of:
(1) A completed Request for Summary Rating Determination (DEU Form 101);
(2) An evaluation by a Qualified Medical Evaluator or Agreed Medical Evaluator.
(b) The requesting party shall complete a Request for Summary Rating Determination (DEU Form 101) and submit it together with all medical reports and medical records concerning the case to the medical evaluator. The medical evaluator shall send the completed medical evaluation report together with the Request for Summary Rating Determination to the office of the Disability Evaluation Unit designated by the Administrative Director and specific on the Request for Summary Rating Determination (DEU Form 101) and shall simultaneously serve the party or parties requesting the evaluation.
(c) Notwithstanding the provisions of subdivision (b), a party may request a summary rating determination following receipt of a medical report prepared by a Qualified Medical Evaluator or Agreed Medical Evaluator on a represented case. The party shall send the Request for Summary Rating Determination (DEU Form 101) and the medical report to the DEU office designated by the Administrative Director and shall simultaneously serve the other party.
(d) If a case is settled prior to receipt of a summary rating which has been requested, the requesting party shall notify the DEU office to which the request was directed.
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 124, 4061, 4062, 4062.1, 4062.2, 4062.5, 4064 and 4067, Labor Code.
s 10161. Forms.
(a) Employee's Disability Questionnaire (DEU Form 100) (revised 4/05).
(b) Request for Summary Determination of Qualified Medical Evaluator's Report (DEU Form 101) (revised 4/05).
(c) Request for Summary Determination of Primary Treating Physician's Report (DEU Form 102)
STATE OF CALIFORNIA Division of Workers' Compensation Disability Evaluation Unit DEU Form 100 (Rev. 4/05)
EMPLOYEE'S DISABILITY QUESTIONNAIRE This form will aid the doctor in determining your permanent impairment or disability. Please complete this form and give it to the physician who will be performing the evaluation. The doctor will include this form with his or her report and submit it to the Disability Evaluation Unit, with a copy to you and your claims administrator.
_____ From a list of doctors provided by the State of California, Division of Workers' Compensation _____ Other (explain) __________ __________ __________ __________
How does this injury affect you in your work? Have you ever had a disability as a result of another injury or illness? If so, when? __________
REQUEST FOR SUMMARY RATING DETERMINATION of Qualified Medical Evaluator's Report State of California Division of Workers' Compensation Disability Evaluation Unit DEU Form 101 (Rev. 4/05) DEU Use Only INSTRUCTIONS TO THE CLAIMS ADMINISTRATOR: 1. Use this form if employee is unrepresented and has not filed an application for adjudication.
2. Complete this form and forward it along with a complete copy of all medical reports and medical records concerning this case to the physician scheduled to evaluate the existence and extent of permanent impairment or disability.
3. Send the EMPLOYEE'S DISABILITY QUESTIONNAIRE, DEU FORM 100 to the employee in time for the medical evaluation.
4. This form must be served on the employee prior to the evaluation. Be sure to complete the proof of service.
INSTRUCTIONS TO THE PHYSICIAN:
1. If the employee is unrepresented, review and comment upon the Employee's Disability Questionnaire, (DEU Form 100), in your report. (If the employee does not have a completed Form 100 at the time of the appointment, please provide the form to the employee.)
2. Submit your completed medical evaluation and, if the employee is unrepresented, the DEU Form 100, to the Disability Evaluation Unit district office listed below.PLEASE USE THIS FORM AS A COVER SHEET FOR SUBMISSION TO THE DISABILITY EVALUATION UNIT.
3. Serve a copy of your report and the Form 100 upon the claims administrator and the employee.
Date of first medical report indicating the existence of permanent impairment or disability: Last date for which temporary disability indemnity was paid:
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4062, 4062.01, 4062.1, 4062.2, 4062.5, 4064, 4067, 4660, 4662, 4663 and 4664, Labor Code.
s 10161.1. Reproduction of Forms.
The Request for Summary Rating Determination (DEU Form 101), the Employee's Permanent Disability Questionnaire (DEU Form 100), and the Request for Summary Rating Determination of the primary treating physician (DEU Form 102) may be reproduced by automated office equipment or other means as long as the content is identical to the specified form.
s 10162. Summary Rating Determinations, Apportionment.
In cases where the injured worker is not represented and a Qualified Medical Evaluator's formal medical evaluation indicates apportionment of the permanent disability, a summary rating determination will not be made until a Workers' Compensation Judge has reviewed the medical evaluation to determine if the apportionment is inconsistent with the law. The determination of the Workers' Compensation Judge will not be admissible in any judicial proceeding.
Upon receipt of a formal medical evaluation which apportions the disability, the Disability Evaluation Unit will transmit the medical evaluation to the Presiding Workers' Judge of the office of the Appeals Board designated by the Disability Evaluation Unit, with a request to review the apportionment to determine whether it is inconsistent with the law. The Workers' Compensation Judge will make the determination and respond to the Disability Evaluation within 45 days.
If the Workers' Compensation Judge refers the medical report back to the Qualified Medical Evaluator for correction or clarification, the Qualified Medical Evaluator shall provide a response to the Workers' Compensation Judge within 30 days of the referral. If no response is received, the Workers' Compensation Judge will make a determination whether the apportionment is inconsistent with the law, and a summary rating determination will be made.
In cases where the injured worker is represented and an Agreed Medical Evaluator or Qualified Medical Evaluator apportions the permanent disability, the Disability Evaluation Unit will issue a summary rating determination "Before Apportionment."
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 124 and 4061, Labor Code.
s 10163. Apportionment Referral.
STATE OF CALIFORNIA Department of Industrial Relations Department of Workers'
Compensation DISABILITY EVALUATION UNIT
Date: __________ TO: Presiding Workers' Comp. Judge, __________
(Office) __________ FROM: Disability Evaluation Unit, __________
(Office) __________
SUBJECT: DEU File: Employee: QME: Date of Report:
The attached formal medical evaluation report indicates that part or all of the permanent disability may be subject to apportionment pursuant to Labor Code Section 4663 and/or Labor Code Section 4664. Please determine whether the apportionment is inconsistent with the law.
If you believe the apportionment is inconsistent with the law, you may refer the report back to the medical evaluator for correction or clarification. If you receive no response from the medical evaluator within 30 days from your request, please make your determination based on the original report.
After checking the appropriate space, sign and date the bottom of this form and return it with the medical report to the DEU office listed above. Thank you.
The apportionment: IS CONSISTENT __________ or IS NOT CONSISTENT __________with the law.
__________, Workers' Compensation Judge (Signature)
__________ (Date)
NOTE: This memorandum is an administrative document and is not admissible in any judicial proceeding.
DEU Form 105 (Rev 12-04)
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4062, 4062.01, 4062.1, 4062.2, 4062.5, 4064, 4067, 4660, 4662, 4663 and 4664, Labor Code.
s 10164. Summary Rating Determinations, Reconsideration If Employee Is Unrepresented.
(a) Requests for reconsideration of the summary rating determination must be filed with the Administrative Director in writing within 30 days of receipt of the summary rating determination. The request shall clearly specify the reasons the summary rating determination should be reconsidered and shall be accompanied by a copy of the summary rating, a copy of the comprehensive medical evaluation, proof of service on the other party and any other information necessary to support the request. Reconsideration of a summary rating may be granted by the administrative director for one or more of the following reasons:
(1) the summary rating was incorrectly calculated,
(2) the comprehensive medical evaluation failed to address one or more issues;
(3) the comprehensive medical evaluation failed to completely address one or more issues;
(4) the comprehensive medical evaluation was not prepared in accordance with required procedures, including the procedures of the Industrial Medical Council promulgated under paragraph (2) or (3) of subdivision (j) of Section 139.2.
Requests for reconsideration which are not based on one of the above reasons will be denied.
(b) The Administrative Director shall not accept or consider, as a basis for a request for reconsideration, a supplemental or follow-up evaluation which was requested by a party after a summary rating determination has already been issued to the parties.
(c) If the Administrative Director determines that an additional evaluation from another Qualified Medical Evaluator is necessary, the matter shall be referred to the Executive Medical Director of the Industrial Medical Council for the provision of another Qualified Medical Evaluator.
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 124 and 4061, Labor Code.
s 10165. Service of Summary Rating Determination and Notice of Options Following Permanent Disability Rating.
Within the time specified in Labor Code section 4061(h), the Office of Benefit Determination shall serve the permanent disability rating determination on the employee and employer by first class mail. At the same time, the employee shall also be served with the Notice of Options Following Permanent Disability Rating.
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 124 and 4061, Labor Code.
s 10165.5. Notice of Options Following Disability Rating (DEU Form 110).
STATE OF CALIFORNIA Department of Industrial Relations Division of Workers' Compensation DISABILITY EVALUATION UNIT
NOTICE OF OPTIONS FOLLOWING DISABILITY RATING
This is a disability rating determination (Rating) prepared by the State of California Disability Evaluation Unit within the Division of Workers' Compensation. It describes your percentage of disability. This percentage is based on your limitations as reported by the doctor, your potential loss of future earning capacity, your age, and the type of work you were doing at the time of your injury. If the rating indicates that you have some permanent disability, you should automatically begin to receive permanent disability payments. Payments are made in installments, every two weeks, for the number of weeks shown on the rating, less any permanent disability payments made to you prior to the rating.
If the rating is not disputed by you or your employer, you do not have to take any action to receive your benefits. We do want you to know that you may have two options you may want to consider. They are:
1) STIPULATED FINDINGS AND AWARD; 2) COMPROMISE AND RELEASE;
1) STIPULATED FINDINGS AND AWARD
If you and the employer, carrier or agent accept the rating, written agreements may be submitted to the Workers' Compensation Appeals Board (WCAB) requesting that an Award be made without the need for a hearing. We recommend this option when the rating is not disputed, and you have a need for future medical care. A Workers' Compensation Judge will review the stipulations and issue an award.
ADVANTAGES
wA stipulated award is a quick, easy way to settle your case while protecting your rights; wThere is no need to take time off work to go to a hearing; wThe Division of Workers' Compensation will review the settlement to protect your rights at no cost to you, there is no need to hire a lawyer; wIf your condition worsens, you can apply for additional payments anytime within five years from the date of your injury; wIf you need additional medical care or you are to receive a life pension (rating of 70% or more), your rights to future benefits can be fully protected and a judge can enforce the award if there later becomes a problem. wYou may request a lump sum payment of all or part of your permanent disability if you can show a financial need or hardship. However, a Workers' Compensation Judge must first be convinced that it would be in your best interest.
DISADVANTAGES
wYou normally will not receive a lump sum payment, but will receive your benefits in payments every two weeks.
2) COMPROMISE AND RELEASE
A Compromise and Release Agreement is a settlement which 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 is paid in one lump sum to you. It must be reviewed and approved by a Workers' Compensation Judge.
ADVANTAGES
wYou may receive more money than you would receive under a Stipulated Findings and Award because you are giving up your future rights in exchange for money.
wIf the employer, or insurance company disputes the rating, a Compromise and Release will assure you receive an agreed amount of money now rather than risk getting nothing or a lesser amount later.
wYou will receive your benefits in one lump sum.
DISADVANTAGES
wA Compromise and Release usually permanently releases the employer from all future responsibilities. After your case has been resolved by a Compromise and Release Agreement, you cannot ask for more medical treatment at your employer's expense, nor can you claim additional benefits if your disability or condition becomes worse. Also, if you later die as result of the injury, your dependents would not be entitled to death benefits.
wOnce a Workers' Compensation Judge has approved your Compromise and Release, the settlement is final and it cannot be set aside except in very rare circumstances.
If you would like more information, you can receive recorded information free of charge, by calling 1-800-736-7401 or you may contact your local Information and Assistance officer (listed in the state government section of your telephone book under Department of Industrial Relations, Division of Workers' Compensation). You may also consult an attorney of your choice.
SPECIAL NOTICE TO UNREPRESENTED INJURED WORKERS
If you disagree with the rating because you believe that the rating was improperly calculated or that the doctor failed to address any or all issues or failed to properly rate your impairment, you may request administrative review of the rating within 30 days of receipt of the rating, from the Administrative Director of the Division of Workers' Compensation. In some cases, you may be entitled to an additional medical evaluation or a different medical specialist. Your request should include a copy of the rating and a copy of the report from the doctor. A copy of the request must be sent to your claims adjustor.
If you have questions about whether to request administrative review of your rating or whether another medical evaluation is appropriate, you should contact the local Information and Assistance Officer listed in the state government section of your telephone book under Department of Industrial Relations, Division of Workers' Compensation. They can tell you how to file the request if you decide to do so.
DEU FORM 110 (Rev 12/04)
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 124, 4061, 4062, 4062.01, 4062.1, 4062.2, 4062.5, 4064, 4067, 4660, 4662, 4663 and 4664, Labor Code.
s 10166. Consultative Rating Determinations.
(a) The Disability Evaluation Unit will prepare consultative rating determinations upon request of the Workers' Compensation Appeals Board, Workers' Compensation Judges, Settlement Conference Referees, Arbitrators, Workers' Compensation Judges Pro-Tempore and Information & Assistance Officers.
(b) Consultative rating determinations may be requested for the purpose of determining the ratable significance of factors, reviewing proposed Compromise and Release Agreements for adequacy, determining commuted values, resolving occupational questions or any other matters within the expertise of the disability evaluators. These rating determinations are the "informal ratings" referred to in subsection (k) of section 10301 of the Workers' Compensation Appeals Board Rules of Practice and Procedure. Consultative Rating Determinations will not be admissible in judicial proceedings.
(c) The Disability Evaluation Unit may also prepare consultative rating determinations upon receipt of reasonable requests from employers, injured workers or their respective representatives. A request is not considered reasonable where an insurance carrier or self-insurer seeks a consultative rating determination for the purpose of terminating its self-insurer seeks a consultative rating determination for the purpose of terminating its liability or for negotiating a Compromise and Release settlement where the injured worker has no representative. Consultative rating determinations shall not to be used as a substitute for summary rating determinations.
(d) In all cases the person making a request for a consultative rating determination will provide the Disability Evaluation Unit with the occupation and age of the injured worker at the time of injury.
(e) No consultative rating determination will be provided on cases in which an application for adjudication of claim has been filed with the Appeals Board without prior written authorization of the Appeals Board, a Workers' Compensation Judge, Settlement Conference Referee, Arbitrator, Workers' Compensation Judge Pro-Tempore, or Information & Assistance Officer. In cases where an application has been filed, the disability evaluator may require that any request for consultative rating determination be accompanied by the Appeals Board file.
Note: Authority cited: Sections 133, 5307.3 and 5307.4, Labor Code. Reference: Sections 123.6, 123.7, 124, 5275, 5451, 5502, 5701 and 5703.5, Labor Code.
s 10167. Informal Ratings.
An informal rating will be prepared by the Disability Evaluation Unit upon the request of both the employee and/or his/her representative and the employer, or at the request of an Information and Assistance Officer providing the necessary information. Such requests shall be submitted on forms and in a manner prescribed by the Administrative Director. Informal ratings shall be issued only in those instances where an Application for Adjudication of Claim has not been filed with the Appeals Board. All medical reports pertaining to the case must be submitted with the request.
The Disability Evaluation Unit may request the employee to submit to a medical examination as provided for under Labor Code Sections 4050, 4600, and 5703.5.
The Disability Evaluation Unit will issue the informal rating on a form prescribed for that purpose by the Administrative Director, which will contain a statement that the informal rating is not: a) a finding, award, order or decision of the Appeals Board, and b) evidence as to the existence of the factors of disability.
Where the informal rating indicates a life pension, or provision for future medical treatment appears indicated, the Disability Evaluation Unit will forward a copy of the rating to an Information and Assistance Officer for the purpose of obtaining a stipulated award, or other action as may be appropriate.
Self-ratings prepared by the employer are not acceptable substitutes for informal ratings prepared by the Disability Evaluation Unit.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Section 4061, Labor Code.
s 10168. Records, Destruction of.
(a) The Disability Evaluation Unit's copies of requests for, and instructions on formal rating determinations, together with the disability evaluator's work notes shall be destroyed by the unit two years after the date of issuance of the formal rating determination by the disability evaluator.
(b) Requests for summary rating determinations and informal ratings, the documents and reports pertaining thereto, the rating and work notes of the disability evaluators, shall be destroyed by the unit two years after issuance of the summary or informal rating, unless there is evidence of on-going activity.
The approval of the Department of Finance, as required by the provisions of Government Code section 14755, is recognized.
Note: Authority cited: Sections 133, 135 and 5307.3, Labor Code. Reference: Sections 135 and 4061, Labor Code; and Section 14755, Government Code.
s 10169. Commutation Tables and Instructions.
Table 1 ( "Present Value of Permanent Disability at 3% Interest") as issued in January 2001, Table 2 ( "Present Value of Life Pension at 3% Interest for a Male") as issued in July 2001, Table 3 ( "Present Value of Life Pension at 3% Interest for a Female") as issued in July 2001, and "Commutation Instructions" as issued in January 2001, are hereby incorporated by reference in their entirety as though they were set forth below. The tables and instructions are available from any office of the Division of Workers' Compensation and may be accessed and printed from the Division's homepage at www.dir.ca.gov.
Note: Authority cited: Sections 133, 5100, 5101, 5307.3 and 5307.4, Labor Code. Reference: Sections 5100 and 5101, Labor Code.
s 10169.1. Commutation of Life Pension and Permanent Disability Benefits.
(a) Determinations of the present value of a life pension under Labor Code Section 5101(b) shall be made in accordance with the Commutation Instructions contained in Section 10169, and shall be based on the actuarial data contained in Section 10169, Table 2 ( "Present Value of Life Pension at 3% Interest for a Male") or Table 3 ( "Present Value of Life Pension at 3% Interest for a Female").
(b) Determinations of the present value of permanent disability indemnity under Labor Code Section 5101(b) shall be made in accordance with the Commutation Instructions contained in Section 10169, and shall be based on the actuarial data contained in Section 10169, Table 1 ( "Present Value of Permanent Disability at 3% Interest").
(c) The Administrative Director shall periodically revise Tables 2 and 3 of Section 10169 to incorporate revisions to the "U. S. Life Tables" and "Actuarial Tables Based On The U. S Life Tables" issued by the United States government following each decennial census.
Note: Authority cited: Sections 133, 5100, 5101, 5307.3 and 5307.4, Labor Code. Reference: Sections 5100, 5100.5, 5100.6 and 5101, Labor Code.
s 10175. Definitions.
As used in this subchapter:
(a) "Employer" means any person defined as an employer in Section 3300 of the Labor Code who has secured the payment of workers' compensation benefits as required by Section 3700 of the Labor Code.
(b) "Exclusive provider of care option" means an option chosen by an employee under Section 10180 under which medical, surgical, and hospital treatment for both occupational and non occupational injuries and illness are provided to the employee through one health care service plan.
(c) "Health care service plan" means any of the following which offer a managed care product:
(1) A health care service plan licensed under Section 1353 of the Health and Safety Code (Knox-Keene Health Care Service Plan Act);
(2) A disability insurer authorized to transact health insurance or disability income insurance pursuant to Part 2 of Division 2 of the Insurance Code.
(3) An insurer authorized to transact workers' compensation insurance in California, including the State Compensation Insurance Fund.
(4) The state or an employer who has secured a certificate of consent to self-insure from the Director of Industrial Relations pursuant to Labor Code Section 3700.
(5) Multi-employer collectively bargained employee welfare benefit plans or an employee welfare benefit plan sponsored by a recognized exclusive bargaining agent for State employees.
(d) "Managed care product" means a system of medical care which provides for all of the following:
(1) All medical and health care services required under Section 4600 of the Labor Code in a manner that is timely, effective, and accessible to the employee. This shall include making available to an employee, within 5 days of a request, the services of any type of physician, as defined in Section 3209.3 of the Labor Code, including a chiropractor, following an initial visit with the employee's primary care physician, when treatment for an occupational injury or illness falls within the scope of practice of the requested type of physician.
(2) Appropriate case management, including direction of injured employees to appropriate medical service providers within a network for all non emergency services.
(3) Appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service, and mechanisms to identify and correct quality deficiencies.
(4) Adequate methods of quality assurance, peer review and service utilization review to prevent inappropriate or excessive treatment, and exclusion from participation those providers who violate treatment standards.
(5) Expertise in providing medical reports necessary for the prompt, proper administration of compensation, including those required under Sections 9785 and 10978.
(6) A procedure for resolving disputes concerning the provision of health care services under the plan, which shall be equivalent to that specified in Section 1368 of the Health and Safety Code.
(7) A program involving cooperative efforts by the employees, the employer, physicians, and other participants to promote employee wellness, workplace health and safety, and early return to work.
(8) Adequate mechanisms to assure coordinated case management goals and incentives among all providers of workers' compensation for employees with occupational injuries and diseases.
(e) "Principal place of business" means the location at which the majority of the employer's employees are employed.
(f) "Small employer" means an employer who on at least 50 percent of its working days during the calendar quarter preceding submission of the proposal under which the employer participates in the pilot project employed not more than fifty (50) employees.
(g) "Traditional health benefit plan" means a plan of medical coverage for non occupational injuries and illness provided by the employer, through a contract between the employer and a health care provider, or through a purchasing cooperative specifically authorized by state law.
(h) "Traditional workers' compensation provider" means a health care provider chosen pursuant to Labor Code Section 4600 or 4601.
Note: Authority cited: Sections 133, 4612, and 5307.3, Labor Code. Reference: Section 4612, Labor Code.
s 10176. Eligible Employers and Employees.
(a) Employers whose principal place of business is in any of the following counties may participate in the pilot project:
(1) Los Angeles;
(2) San Diego;
(3) Santa Clara;
(4) Sacramento.
(b) Employees of employers eligible to participate in the pilot project who are employed in counties other than those enumerated in subdivision (a) are not precluded from participation in the project.
(c) Nothing in this section shall be construed to prohibit participation by employers whose principal place of business is not within one of the four counties listed in subdivision (a) above if the employer is specifically authorized to do so by statute.
Note: Authority cited: Sections 133, 4612, and 5307.3, Labor Code. Reference: Section 4612, Labor Code.
s 10177. Eligible Applicants.
(a) Pilot project plan proposals may be submitted to the administrative director by any one or combination of the following entities or authorized agents thereof:
(1) Employers
(2) Heath care service plans
(3) Health insurance purchasing cooperatives specifically authorized under state law.
Note: Authority cited: Sections 133, 4612, and 5307.3, Labor Code. Reference: Section 4612, Labor Code.
s 10178. Pilot Project Proposal Requirements.
(a) Proposals submitted to the administrative director for final approval shall include all of the following:
(1) A description of the manner in which health care services are to be provided, including the administrative and organizational structure, how each component of the managed care product will be provided, and the standards and procedures under which an employee who selects the exclusive provider of care option will be permitted to change health care service plans.
(2) The business name and tax identification number of the employer or employee, the approximate number and occupations of participating employees, the health care service plan or provider of health care services, and any other parties required in the operation of the proposal. The proposal shall include signed authorization from all necessary parties, other than the employees, confirming their commitment to the plan. In the case of a proposal under which only small employers will participate, the proposal may specify the method by which employers will be selected to participate in lieu of identifying and obtaining commitments from participating employers and identifying the approximate number and occupations of participating employees.
(3) The method whereby employees will be informed of their rights and options under the proposal, including the right to obtain a decision from the Workers' Compensation Appeals Board in the case of disputes over compensation for injuries compensable under Division 4 (commencing with Section 3200) of the Labor Code. Materials to be used for this purpose shall be submitted with the proposal. Materials shall include a description of the dispute resolution process, a description of dependent coverage, a description of the method and frequency of employee choice of health care provider and a description of any other incentives offered to employees by employers to participate in the plan.
(4) The dispute resolution process under the exclusive provider of care option, including the process made available to employees to voluntarily resolve issues subject to the jurisdiction of the appeals board, as well as the process for resolving disputes which are not subject to the jurisdiction of the appeals board.
(5) A description of how dependents will be covered under the proposal, and if co-payments, premium shares, deductibles, or other charges are to be assessed against employers or dependents for non occupational injuries and illness, the amount of such charges and how these charges will be determined and segregated in a manner to assure compliance with subdivision (a) of Section 3751 of the Labor Code.
(6) The method and frequency of employee choice as to whether the employee will receive medical care under an exclusive provider of care option.
(7) A description of any incentives offered by an employer to employees to encourage participation in the exclusive provider of care option.
(8) Verification of agreement to participate executed by an authorized representative of each exclusive or certified bargaining agent which represents employees of the employer.
(9) The method by which any workers' compensation liability of the employer incurred during the pilot project will be paid after an employee's or employer's participation in the pilot project terminates.
(10) An agreement to provide the administrative director, in the form and manner prescribed by the Administrative Director, with information necessary to evaluate the plan and compliance with this subchapter. (continued)