Permanent Disability Benefits

Permanent Disability Benefits

Most workers recover from their job injuries. But some continue to have medical problems. If your treating doctor says you will never recover completely and will always be somewhat limited in your ability to work, you have a permanent disability. This means you are probably eligible for permanent disability (PD) benefits.

PD benefits are payments that help make up for limitations in your ability to work in the future. However, you don’t have to lose your current job to be eligible for PD benefits.

PD benefits are limited. If you lose income, PD benefits may not cover all the income lost. If you experience loses unrelated to your ability to work, PD benefits will not cover those losses.

Your Treating Doctor’s P & S Report

When you reach a point where your medical condition is not improving and not getting worse, your condition is called permanent and stationary (P&S). When this happens, your treating doctor writes a P & S report.

The P & S report should describe:

  • Specific medical problems, like how much you can move the injured parts of your body and how much pain you have. These are called objective and subjective factors.
  • Limits on the work you can do. These are called work restrictions.
  • Medical care that you may need in the future for your injury.

Your treating doctor sends the P & S report to the claims administrator. (This person handles workers’ compensation claims for your employer and usually works for the employer’s insurance company.)

Important! The P & S report will affect future benefits. You have a right to receive a copy of it. Request in writing that the claims administrator or your doctor gives you copies of all medical reports.

Your treating doctor must use special language to describe your disability. If you have questions, ask the doctor. Read the P & S report carefully, make sure it’s complete and see if you agree with the doctor’s conclusions. Information left out could result in loss of some benefits.

Q. I don’t agree with the P & S report. What can I do?

A. Sometimes different doctors have different opinions about a worker’s disability. You have a right to questions or disagree with the P & S report. Taking the following steps may help your case.

First, you can send a letter to the claims administrator stating that you disagree with the P & S report. In some cases, you must do this within a specific number of days after you received the report (20 days if you have an attorney, 30 days if you don’t).

Second, you can get a medical opinion from another doctor. This could be either:

  • A QME (qualified medical evaluator) – a doctor certified by the state IMC (Industrial Medical Council) and selected by either you, your attorney, or the claims administrator. -or-
  • An AME (agreed medical evaluator) – a doctor agreed upon by your attorney and the claims administrator.

If you don’t have an attorney, the claims administrator must send you the instructions on how to contact the IMC and select a QME. If you have an attorney either will agree upon an AME with the claims administrator or will select a QME. The QME or AME will examine you and write a medical-legal-report describing your condition.

Important! You or your attorney should choose the QME or AME carefully. The medical-legal report will affect your benefits. In most cases, you won’t be allowed to see another QME or AME.

For more information about medical evaluations, call the IMC @ (800) 794-6900. Also see the Department of Industrial Relations web site: www.dir.ca.gov.

Q. If the claims administrator doesn’t agree with the P&S report, can he or she send me to a QME or AME?

A. Yes. Here is how the QME or AME is selected:

  • If you don’t have an attorney, you will be examined by a QME. The claims administrator must let you select the QME.
  • If you have an attorney, the claims administrator either will agree upon an AME with your attorney or will select a QME.

Rating of Your Disability

Next, your disability is rated. A rating is a percentage that estimates how much your injury affects your ability to work. It determines the amount of your PD benefits.

Ratings are based on four factors:

  1. Your medical condition (described in P & S report or medical-legal report)
  2. Your date of injury
  3. Your age of injured
  4. Your occupation (based on job you performed before injury).

A rating of 100% means that you have a permanent total disability—for example, if you lose the use of both hands. Ratings of 100% are very rare. A rating of between 1% and 99% means you have a permanent partial disability. Most injured workers’ ratings are between 5% and 30%.

You, your attorney, or the claims administrator can ask a state Disability Rater to rate your disability. (If you were examined by a QME and don’t have an attorney, a state Disability Rater will automatically rate your disability.) Also, the claims administrator and your attorney may estimate or try to predict a rating that a Referee (workers’ compensation judge) would consider appropriate.

The "Schedule for Rating Permanent Disabilities" is used to rate disabilities based on four factors. There are two schedules, depending on your date of injury. To see the schedule that applies to you, contact a state Information & Assistance officer.

Q. I don’t agree with the rating by the claims administrator. What can I do?

A. You have a right to question or disagree with the rating. Different people reviewing the same medical report will sometimes rate a worker’s disability differently.

You can negotiate with the claims administrator over the correct rating of your disability. You can request a rating by a state Disability Rater and use this rating in your negotiations. If you and the claims administrator can’t agree on the rating of your disability, you can request that a Referee decide on the correct rating.

Q. I don’t agree with the rating by the state Disability Rater. What can I do?

A. If you don’t have an attorney, you can ask the state Division of Worker’s Compensation (DWC) to review the rating. They will determine if mistakes were made in the medical evaluation process or the rating process. This is called the reconsideration of your rating. You can also present your case to a Referee.

To get help in requesting reconsideration or presenting your case to a Referee, contact a state Information & Assistance officer.

If you have an attorney, he or she can present your case to a Referee. Workers with attorneys cannot request reconsideration.

Determining PD Payments

PD benefit amounts are set by law. The claims administrator will determine how much to pay you based on three factors.

  1. Rating(s) of your disability
  2. Your date of injury
  3. Your wages before you were injured.

Receiving PD Payments

If you have a partial disability, you are eligible to receive the total amount of your PD benefits spread over a fixed number of weeks. If you have a permanent total disability, you are eligible to receive a fixed level of PD payments for the rest of your life.

If you were receiving temporary disability benefits (TD), the first PD payment if due within 14 days after the final TD payment. If you weren’t receiving TD, you could receive the first PD payment within 14 days after your treating doctor says your condition is permanent and stationary.

After the first payment, PD benefits must be paid every 14 days. They end when you reach the maximum amount allowed by law or when you settle your case and receive a lump sum.

Notices About PD Payments

The claims administrator must keep you up to date by sending letters that explain:

  • How PD payment amounts were determined
  • When you will receive PD payments
  • Why PD payments will be delayed
  • Why PD payments won’t be paid.

Q. Is the claims administrator required to pay a penalty for delays in PD payments?

A. Yes. If the claims administrator sends a payment late, he or she must pay you an additional 10% of the payment. This is true even if there was a reasonable excuse for the delay and even if the claims administrator sends a letter explaining the delay.

You could be awarded a substantial extra payment if there was no reasonable excuse for the delay.

Settlement Offers

After your disability is rated, the claims administrator usually asks you to settle your case. A settlement is an agreement between you and the claims administrator. There are two different ways to settle your case:

1. Stipulation with Requests for Award ("Stips")

  • Payments. You can the claims administrator agree on when and how long you’ll continue to receive PD payments. You also agree on how much each payment will be.
  • Medical care. The claims administrator agrees to keep paying for medical care for your injury, as long as care is needed.
  • Possible additional benefits. If your condition gets worse, you have a right to request additional workers’ compensation benefits. Usually this request must be made within five years after the date of your injury.

2. Compromise and Release ("C&R")

  • One payment. The claims administrator agrees to pay you a lump sum. This covers both the PD payments you haven’t received yet, the estimated cost of future medical care for your injury, and all other benefits except vocational rehabilitation. (Vocational rehabilitation benefits cannot be included in a C&R unless certain conditions are met.)
  • No further medical care. Because the lump sum covers the estimated cost of future medical care, the claims administrator will no longer pay your doctor. This becomes your responsibility.
  • No additional benefits. You don’t have the right to request additional workers’ compensation benefits if your condition gets worse.

If you and the claims administrator agree on a settlement, a Referee (workers’ compensation judge) must approve it.

Q. What if I don’t agree with the claims administrator’s settlement offers?

A. You are not required to accept the claims administrator’s offers. You can negotiate a settlement. If you can’t reach an agreement with the claims administrator, you can present your case to a Referee. The Referee will decide what benefits you will receive. This decision is called a Findings and Award. It will be sent to you in writing.

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