Commonly Used Workers' Comp Terms

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.

 

AOE/COE (Arising out of and occurring in the course of employment): Your injury must be caused by and happen on the job.

 

Apportionment: A way of figuring out how much of your permanent disability is due to other disabilities.

 

Claims administer, Claims Adjuster, Claims Examiner: 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.

 

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.

 

Delay Notice: 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.

 

Findings and 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.

 

Future Medical Care (FMC): On-going right to medical treatment for a work-related injury.

 

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.

 

In pro per: An injured worker not represented by an attorney.

 

Independent Medical Review (IMR): An informal process to resolve medical treatment issues through an independent third party contracted by DWC. Only an injured worker can request IMR if their medical treatment request has been denied, modified or delayed.

Information & Assistance Officer (I&A): A DWC employee who answers questions, assists injured workers, provides written materials, conducts informational workshops and holds meetings to informally resolve problems with claims.

A unit within DWC that provides information to all parties in workers’ compensation claims and informally resolves disputes.

 

Mandatory Settlement Conference (MSC): A required conference to discuss settlement prior to a trial.

 

Maximum Medical Improvement (MMI): Your condition is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Once you reach MMI, a doctor can assess how much, if any, permanent disability resulted from your work injury.

 

Med-Legal Exam: 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.

 

Modified Work/Duties: 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.

Off Calendar (OTOC): A WCAB case in which there is no pending action.

 

Panel Qualified Medical Evaluator (PQME/QME): A list of three independent qualified medical evaluators (QMEs) issued by the DWC Medical Unit. You select any one of the three doctors for your evaluation. If you have an attorney, other rules apply.

 

 

Permanent and Stationary (P&S): Your medical condition has reached maximum medical improvement. Once you are P&S, a doctor can assess how much, if any, permanent disability resulted from your work injury. If your disability is rated under the 2005 schedule you will see the term maximal medical improvement (MMI) used in place of P&S. See also P&S report.

 

Permanent Disability (PD): Any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached.

 

Permanent Disability Advances (PDAs): A voluntary lump sum payment of permanent disability you are due in the future.

 

Permanent Disability 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 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.

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.

Request for Authorization (RFA): A form that the treating doctor uses to notify the claims administrator of needed medical services.

 

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.

 

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.

 

Stipulation 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.

 

Subpoena: A document that requires a witness to appear at a hearing.

 

Subpoena Duces Tecum: A document that requires records be sent to the requester.

 

Supplemental Job Displacement Voucher (SJDV): 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. For injuries that occurred between Jan. 1, 2004 and Dec. 31, 2012, the benefit is in the form of a voucher that promises to help pay for educational retraining or skill enhancement, or both, at state-approved or state-accredited schools. For injuries that occur on or after Jan1. 2013, the voucher can be used for training at a California public school or any other provider listed on the state’s eligible training provider list. It can also be used to pay licensing or certification and testing fees, to purchase tools required by a training course, to purchase computer equipment of up to $1,000 and to reimburse up to $500 in miscellaneous expenses. Up to 10 percent, or $600 may be used to pay for the services of a licensed placement agency or vocational counselor.

 

Temporary Disability (TD): Payments you get if you lose wages because your injury prevents you from doing your usual job while recovering.

 

Temporary Partial Disability (TPD): Payments you get if you can do some work while recovering, but you earn less than before the injury.

 

Temporary Total Disability (TTD): _Payments you get if you cannot work at all while recovering.

 

Uninsured Employers Benefit Trust Fund (UEBTF or 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: The process used by insurance companies to decide whether to authorize and pay for treatment recommended by your treating physician or another doctor.

 

Whole Person Impairment (WPI): For injuries on or after Jan. 1, 2013 all cases with permanent residuals will be increased by a WPI factor of 1.4.

 

Work Restrictions: A doctor’s description of the work you can and cannot do. Work restrictions help protect you from further injury.

Workers’ Compensation 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 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.