WORKERS’ COMPENSATION GLOSSARY OF TERMS

Workers' compensation is the oldest social insurance program. While this glossary was created for the state of California, many of these terms are applicable in all states. Use this glossary of terms to better understand workers' compensation.

California only: California has a no-fault system, which means that injured employees need not prove the injury was someone else's fault in order to receive workers' compensation benefits for an on-the-job injury. 

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W

accepted claim/admitted claim. A workers’ compensation claim in which the claims administrator agrees that the worker’s injury or illness is covered by workers’ compensation. Even if a claim is accepted, however, there may be delays or other problems.

agreed medical evaluation (AME). A doctor who is selected by agreement between the injured workers’ attorney and the claims administrator to conduct a medical examination and prepare a medical-legal report to help resolve a dispute.

AOE/COE - Arising Out of Employment, and in the Course Of Employment or caused by a worker’s job and occurring while working. An injury or illness must be AOE/COE to be covered by workers’ compensation.

applicant: The injured worker.

applicants’ attorney (A/A). A lawyer who represents injured workers in their workers’ compensation cases.

application for adjudication of claim (application or app) : A form (PDF) 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.

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. Visit the California Department of Safety and Health website for additional information. 

California Labor Code.  Access Workers' Compensation sections in the California Labor Code.

date of injury (DOI). If the injury was caused by one event (a specific injury), this is the date of the event. If the injury was caused by repeated exposures (a cumulative injury), this is the date that the worker knew of should have known that the injury was caused by work. death benefits. Money paid to qualified surviving dependents of a worker who dies from a work-related illness or injury. 

declaration of readiness (DOR). A form (PDF) used to request a hearing before a workers' compensation judge when you're ready to resolve a dispute.

defense attorney (DA). The employer or the employer's insurance carrier’s legal representative.

delay letter. A letter sent by the claims administrator to the injured worker that explains why payments are delayed, what information is needed before payments will be sent, and when a decision will be made about the payments.

denied claim. A workers’ compensation claim in which the claims administrator believes that the worker’s injury or illness is not covered by workers’ compensation and has notified the worker of this decision.

description of employee’s job duties Form RU-91. A form (PDF) 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.

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.

employee claim form for workers’ compensation benefits (California). A form to report a work injury or illness to your employer.

employer’s report of occupational injury or illness form (CA Form 5020). A form the employer completes to report a work injury to their carrier.

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. 

field nurse case managers. A nurse assigned to the case, by the insurance company, to attend medical evaluations with the injured worker.

hearing. A legal proceeding or event where a workers’ compensation administrative law judge holds a meeting to discuss issues or receives information from different persons in order to make a decision about a dispute or a proposed settlement.

information & assistance (I&A) Officer. An employee of the state Division of Workers’ Compensation who answers questions, assists injured workers, provides written materials, conducts informational workshops, and holds meetings to informally resolve problems with claims. Most of their services are designed to help workers who do not have an attorney.

information &assistance Unit (I&A): A unit within DWC that provides information to all parties in workers' compensation claims and informally resolves disputes. For additional information visit the California Department Division of Workers' Compensation Information and Assistance website.

maximum medical improvement (MMI) report. A medical report written by a treating physician that describes the injured worker’s medical condition when it has stabilized.

medical care. All medical treatment necessary to cure or relieve the effects of a work-related injury or illness will be paid either by the employer or the insurance company providing coverage. This includes physician services, hospitalization, physical restoration, dental care, prescriptions, X-rays, laboratory services, and all other necessary/reasonable care ordered by the treating doctor(s). Injured workers are entitled to receive all medical care reasonably required to cure or relieve the effects of the injury, with no deductible or co-payments by the injured worker

medical-legal report. A report written by a doctor that describes an injured worker’s 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. A workers’ compensation benefit, offered to the injured worker, that is "reasonably required to cure or relieve from the effects of the injury."

modified job (mod work). If the treating physician reports that the injured worker will never be able to return to the same job duties that they had at the time they were injured, the employer is permitted to offer the injured worker a modified job. 

objective factors. Measurements, direct observations, and test results that a treating physician, a QME, or an AME describes as contributing to an injured worker’s permanent disability.

permanent and stationary (P&S) report. A medical report written by a treating physician that describes the injured worker’s medical condition when it has stabilized.

permanent disability (PD) benefits. Money paid if an injury or illness results in a permanent impairment that reduces the injured workers ability to compete in the open labor market. The amount the employee will receive depends on the extent of the disability. Other factors that are considered when calculating PD include the date of the injury, the age when injured, and occupation. PD benefit amounts are set by law. 

permanent disability (PD) rating. The numerical assessment of a physician's description of an injured worker's permanent disability. This is derived by applicant of the functions in the permanent disability rating manual to the language used by the physician to describe the disability, usually involving workers' compensation terms.

primary treating physician (PTP). The doctor who is responsible for managing the overall care of the injured worker and who writes medical reports that affect the worker’s benefits.

qualified injured worker (QIW). An injured worker who probably will never be able to return to his or her usual job and working conditions, and who probably could find a suitable job after receiving vocational rehabilitation services.

qualified medical evaluator (QME). A doctor who is selected by either the injured worker, the worker’s attorney, of the claims administrator to conduct a medical examination and prepare a medical-legal report to help resolve a dispute. QMEs are certified by the state Industrial Medical Council.

specific injury (SP). An injury that was caused by one event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.

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 (800) 480-3287 for more information on SDI or visit the California Employment Development Department website.

stipulations with request for award (Stips). A type of settlement where the claims administrator usually agrees to continue paying for medical care for the injury, after agreeing to a particular level of permanent disability.

telephonic Nurse Case Manager (TCM). A nurse, assigned to the case by the insurance carrier, to contact the doctor to get updated medical and work status, or to assist with getting a treatment plan.

temporary disability (TD). Paid if a physician verifies that an injured employee cannot work because of work-related illness or injury. TD benefits are not paid for the first three days of work missed unless the employee is off more than fourteen days or hospitalized. The amount of TD compensation is determined by law and is two-thirds of the employee’s wages. Payments must be made every two weeks for as long as the employee is eligible. TD benefits stop when the employee returns to work or treating physician releases the employee for work or says that the injury has reached a point of maximum improvement. 

temporary total disability benefits (TTD). Payments to a worker who 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. A medical mileage expense form (PDF) is available from the California Division of Workers' Compensation.

transportation reimbursement. Paid by the insurance carrier or employer for the reasonable cost of transportation incurred while obtaining medical care and rehabilitation. The injured worker is entitled to round trip mileage from his or her home or work to the place of treatment, examination, or rehabilitation.

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. 

work restrictions. A doctor’s description of clear and specific limits on an injured worker’s job tasks, usually designed to protect the worker from further injury.

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 administrative law judge. An employee of the state Division of Workers’ Compensation who makes decisions about disputes and approves settlement. The administrative law judges hold hearings at Workers’ Compensation Appeals Board (WCAB) offices, and their decision may be reviewed and reconsidered by the Appeals Board. Also called "Workers’ Compensation Judge."

Sources

• California Workers’ Compensation Handbook, Stanford D. Herlick., 2001 Edition.
• State of California, Workers’ Compensation Web page.
• Workers’ Compensation, Laws of California, 2003 Edition.

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