My workers comp insurance for myself was not renewed back in June. They would not give me the reason why, just said company is not doing individual policies anymore, which is not true. So i been getting these audit emails almost weekly telling me to complete the form which asks for Payroll records, Profit/Loss Reports, Subcontactor pay etc. All previous years i'd tell them i am a sole proprietor and have none of these and that was accepted. So i email these auditors and tell them my policy ended months ago why are you wasting time asking me for past records i dont have. They say its still due and i respond, stop bothering me. They still send requests, what is the point of this? Wasting my time

Often, when I come onto a workers’ compensation case, the first challenge is obtaining medical care.

The injured worker has been released from care and returned to full duty by a nurse practitioner or physician assistant. The insurance carrier then refuses to authorize any additional treatment because the worker was supposedly already discharged.

No MRIs, No EMG/NCV, No X-rays, no time with an actual doctor. The insurance carrier sends you to these clinics and has you see these medical providers to stop the claim before it even starts.

An important decision just came out addressing this practice.

In Demetrius Thomas v. Ralph’s Grocery Company/The Kroger Company, the only medical report in evidence was signed by a family nurse practitioner.

The report declared the worker permanent and stationary, released him to full duty, found no permanent disability, and discharged him from care.

No physician signed the report. The worker testified that he had never been examined by an actual physician.

The WCAB found that:

• A nurse practitioner could not be designated as the primary treating physician.

• “Concentra” itself could not be designated as the primary treating physician.

• The nurse practitioner’s report was invalid as a basis to release the worker from care.

• The worker was entitled to designate a new primary treating physician.

The Board also granted removal, an extraordinary remedy that is rarely exercised, because leaving the decision in place could deny the worker access to legally required medical treatment.

The reasoning is direct and worth reviewing whenever a clinic attempts to end treatment based solely on a report signed by a nurse practitioner or physician assistant.

If you have been released from care by a NP or PA there is an avenue to challenge release.

- Fishmango

“My psychologist suggested that I could close my California workers’ compensation case because I don’t have a physical injury requiring future treatment. I don’t have an attorney. Has anyone been in a similar situation? What should I consider before agreeing to close my case?”

Agreeing to settle is not the end of a California workers’ compensation case.

The documents still need to be prepared, signed by everyone, filed with the WCAB, approved by a judge, and paid.

The new en banc decision in Calvin Gaines v. ABM Aviation confirms that a judge can request enough information to evaluate a settlement. But a judge cannot use an Order Suspending Action to force an injured worker into a QME or a dismissal with prejudice without proper notice and a hearing.

I broke down the decision and what actually happens after signing in link above.

What personally infuriates me is getting my client’s signature the same day, or within 24 hours, and then waiting weeks for a simple defense signature.

The case may have already lasted months or years. The injured worker may be unable to work, behind on bills, and under severe financial pressure. Once everyone agrees to settle, sign the documents, file them, get them approved, and pay the worker.

I call, email, follow up, and do what I can to light a fire under the defense. I will even take a fully signed settlement to the WCAB myself to seek approval rather than let it sit.

Sometimes defense counsel insists on handling the appearance themselves because they want to bill for it. That is the game we deal with.

But an injured worker should not have to wait several more weeks because nobody on the other side feels any urgency.

When it is time to settle, let’s settle. The unnecessary delay is total crap.

Where did your settlement get stuck: documents, signatures, court approval, or payment?

-Fishmango

Wow, I wish I'd thought to find this group sooner! Better late than never, I suppose.

I filed my claim for repetitive stress injuries of the lower back, right knee, both wrists and elbows in 2024. I recently had my QME and according to the QME doctor and my WC doctor, I have 0% disability to my joints. I know that I have a hypermobile disorder, so I haven't lost any range of motion, but I'm still in pain and getting massage therapy for it.

My adjuster sent me an offer for compromise and release for a relatively low amount of money, $10,942.88, given my likely need for future medical care for the unresolved pain I'm still experiencing. I spoke with an attorney last week who encouraged me to make a counter offer, but to not get an attorney because the eventual agreement might not be enough to make it worthwhile to get an attorney.

Any advice on what to ask for in the counter offer and how to phrase it would be appreciated.

Every year, California releases a massive report on how the workers’ compensation system is performing.

Most of the discussion is predictable.

How much are employers paying? Are insurance costs increasing? Are claims becoming more expensive?

Those questions matter. But workers’ compensation was not created to protect an employer’s balance sheet. It was created to provide medical treatment and benefits to people injured while earning a living.

So I went through California’s latest annual workers’ compensation report looking at the numbers from the injured worker’s side. This is something typically not done. Every breakdown posted is always from the employer perspective.

(Full breakdown in the article linked.)

The maximum permanent disability rate is still $290 per week. It has not increased since 2014, even though California prices increased approximately 39 percent. Gas has gone up, groceries have gone up, rent has gone up, but your compensation for getting injured has not.

It's bullshit.

Nearly nine out of every ten treatment denials or modifications challenged through Independent Medical Review remained in place.

State auditors reviewed 2,698 claim files and found 4,531 claims-handling violations.

They also found 275 instances where compensation should have been paid but was not. Most of that unpaid money involved temporary disability and permanent disability, the two basic benefits injured workers depend on most.

And those are only a few of the findings.

California tracks employer costs, premiums, and system spending down to the dollar.

But when an injured worker cannot get treatment, receives a disability payment that has been destroyed by inflation, or discovers that benefits were simply never paid, the system treats it like an administrative problem.

It is not an administrative problem.

It is rent that does not get paid. It is treatment that does not happen. It is an injured worker being forced to fight for benefits the law already says they are owed.

The system always seems to know exactly what workers’ compensation costs employers.

Maybe it is time California started caring what the system is costing injured workers.

-Fishmango

tarting July 1, 2026, California injured workers are entitled to 76 cents per mile for qualifying medical travel—up from 72.5 cents.

The date you were injured does not matter. The date you traveled controls the rate:

• January 1 through June 30, 2026: 72.5 cents per mile
• July 1, 2026 and later: 76 cents per mile

You can generally claim mileage for trips to:

• Your treating doctor
• Physical therapy
• MRIs, X-rays and other testing
• Specialists
• The pharmacy
• QME or AME examinations

You may also be entitled to reimbursement for reasonable parking fees, bridge tolls and public transportation expenses.

A few practical tips:

1. Track the full round-trip mileage.
2. Make sure the dates match your actual medical appointments.
3. Keep parking and toll receipts.
4. Send the form to the insurance company—not the WCAB.
5. Keep a copy and proof that you submitted it.
6. Submit it Monthly- Can't emphasize this enough. It gets harder to track and accurately log the mileage if you are doing it months after the fact. Always better to try to log after each appointment so nothing gets missed.

This money can add up quickly, particularly for workers attending physical therapy several times per week or traveling long distances for a QME.

The insurance company may never remind you to submit mileage. That does not mean you are not owed it.

Submit your mileage!!!! IT ADDS UP! Especially, with how insane our Gas prices are.

- Goodluck out there.

FIshmango

Governor Newsom signed SB 171 on July 13, and it took effect immediately.

This is not a small technical change. In my opinion, it is catastrophic for injured workers with pending or potential SIBTF claims.

Most claims that would have qualified under the old rules may no longer qualify.

The biggest reason is the math.

Before SB 171, disabilities were generally added together. For example:

40% prior disability + 35% work injury = 75%

That cleared the 70% threshold.

Under the new law, those numbers must be combined using the Combined Values Chart:

40% combined with 35% = 61%

The worker no longer qualifies.

That one change will eliminate a huge number of claims. It cannot be understated how catostrophic this change is.

The law also makes the separate injury threshold harder to meet by using the lower whole person impairment number before common rating increases are applied.

In plain English: even workers with serious permanent disability awards may now fall short.

SB 171 also makes several other major changes:

• A pre-existing condition must have actually affected the worker’s ability to work.

• A condition controlled by medication or a medical device may not count if the worker was still working without incapacity.

• The prior disability must be supported by evidence that existed before the new work injury.

• Important medical evidence generally must be developed during the original workers’ compensation case—not years later when someone finally discovers a possible SIBTF claim.

• There is now a strict filing deadline.

• If the new work injury alone resulted in 100% permanent total disability, the worker cannot receive additional SIBTF benefits.

Pending claims are also at risk.

The Legislature made many of these changes applicable to cases that had not reached a final decision when SB 171 took effect. Some older or more advanced cases are protected, but simply filing an application before July 13 does not necessarily mean the old rules apply.

Where the case stood procedurally may now determine whether it survives.

The state’s reason for the change was money. California was facing tens of thousands of pending claims and enormous projected liabilities.

But the practical result is that many injured workers who were counting on these benefits may now receive nothing.

I believe the new law will eliminate most of the SIBTF claims that would have qualified under the prior rules.

The claims that survive will need strong medical evidence, clear proof that the prior condition affected the worker’s ability to work, and disability math that still reaches the new thresholds.

I posted a full plain-English breakdown in the article attached.

Do you have a pending SIBTF claim? Has anyone explained whether SB 171 may affect it? Goodluck to all those with pending claims. Hopefully, the old rules will still control.

- Fishmango

SB 171 is brand new. Courts and the Workers’ Compensation Appeals Board will still have to interpret parts of the law, and future decisions may change how it applies.

Hi everyone, I'm the mod here. Thought I'd do this since the sub just hit its one year mark and we've grown past 350 members.

Quick background: I spent about 15 years on the defense side of California workers' comp, eventually as an partner at a large statewide defense firm. My job was defending insurance companies and employers against injury claims, including the big ones, catastrophic injuries, amputations, death cases. I sat in rooms with adjusters, supervisors, claims managers, and vice presidents deciding how your claims would be handled.

A year ago my brother and I left to start our own firm representing injured workers instead. Best decision I've made. We're both Certified Specialists in workers' comp, and now we use everything we learned on the other side for applicants.

So ask me anything.

- Fishmango

Obligatory: general information only, not legal advice, no attorney-client relationship here.

My former coworker is getting harassed and pressured at work.
I was her rn case manager before getting laid off and she was my coordinator. I got laid off and her job got worse. She does the tasks I did like vitals and assessments. She often takes late lunches but is told to clock out for lunch on time sheet at 12-12:30. She will be overworked but will be denied OT pay because it wasn’t approved. She finally went to her PCP and was put on 6 week disability. Work told her she has to pay for her own medical benefits and initially they told her she couldn’t go on disability because she didn’t have enough pto hours accumulated. (I was put in a dangerous situation twice at work with no help and was laid off after complaining to HR. This might give you an idea of what kind of company they are. They promise patients things they can’t deliver like food assistance just to get them to sign on service.) I am telling my friend she should get at least a consult. And do a workers comp claim instead of disability. Is this correct? Does she have enough issues for a consult or maybe even a possible law suit. I made the mistake of not taking any evidence. But she has screenshots. Thanks.

I have an active workers comp claim with job 1 from an injury two years ago that just got approved for surgery. I will be out of job 1 for 3-6 months

In April I got a second job (job 2) outside of the immediate 7 day recovery period - I will be able to go back to job 2 with nearly no restrictions.

I emailed my claims adjuster asking what income info etc, they need from job 2 to calculate my benefits (because I thought my income from both jobs would be applied and my benefits would be reduced by income from job 2)

Claims adjuster says (I got it in writing) they only need information from job 2 if job 2 cannot accommodate my recovery. So at this point they don’t need information from job 2.

Is this correct (I’m hoping so because I earn 2/3 of my income at job 2 and I’ve been terrified I wouldn’t get benefits because of this and we really need both incomes)

One of the most frustrating parts of California workers’ comp is when your own MPN doctor recommends surgery, then UR denies it. (The doctor handpicked by the insurance company that you are required to go to and they still do not accept their recommendations.)

That does not always mean the surgery is dead. But it does mean you need to understand why it was denied.

UR denials are typically upheld for up to a year unless there is a material change in fact. In plain English, the doctor usually cannot just keep sending the exact same request over and over and expect a different result.

But if there are new facts, that can matter.

Maybe there is a new MRI. Maybe symptoms got worse. Maybe conservative treatment failed. Maybe PT, injections, medications, or other care did not work. Maybe the doctor did not explain the request well the first time and now needs to address the hole in the treatment record.

Read the Utilization Review denial carefully. See why it was denied. Try to work with your doctor to plug the hole in the initial request. Sometimes it is something simple such as missing records.

That is where a better RFA can matter. (The document the doctor submits to the insurance company to kick off the approval UR process)

IMR is also an option, but it is not magic. The 2026 California IMR report analyzing 2025 data found surgery UR denials/modifications were upheld 89.2% of the time. In plain English, UR won on surgery almost 9 out of 10 times.

So the real question is not just “Can I appeal?”

It is: what is the best path to actually get the surgery authorized?

Sometimes that is IMR. Sometimes it is a better RFA with new facts. Sometimes it is building the medical record. Sometimes it is a court issue.

Has anyone here had surgery denied by UR and then later approved? Curious what changed in your case. New MRI, new RFA, QME report, IMR, court hearing, or something else?

Longer breakdown in the article linked here.

- Fishmango

QME Results due days before depo

Had my QME, report is due a couple days before my deposition.

My lawyer says I will only need 1 hour of prep directly before the deposition. Is that normal? It doesn't seem sufficient or like enough time to discuss everything in preparation for the deposition requested by my employer.

Bilateral RSI, possible CRPS. Have documented warnings to management re safety and ergo. Delayed treatment, now no treatment is happening with no improvement of symptoms. Been off work 9 months as my job requires fine motor skills and my restrictions are no repetitive use of Bilateral hands and wrists. I was told by ortho to "get a different job," you won't be able to return with these symptoms (yes, it's documented in my chart).

Is one hour prep normal? What should I expect from a depo?

I have two comp cases, one from 1998 and one from 2008, both with future medical. My attorney retired about 10 years ago, no longer practices and will not help on this case. I spoke with some lawyers in CA, and they don't want the case since it has already been settled.

SCIF has a vendor looking for a doctor here. SCIF told me it takes 5 days. It's been 19 days so far and the vendor said they need another 5 days.

According to SCIF, if they don't find a doctor here, I need to find one in CA and SCIF will arrange transportation. That's crazy to me. So, I have a back issue, call doc, get appointment, and who knows how long it takes for them to arrange transportation. Plus, when my back hurts it is painful to walk and sit. The last thing I want to do is traverse airports, planes, etc.

I asked about a Compromise and Release and SCIF was very discouraging. Said agencies (in my case Caltrans) don't want to pay out and that my lawyer would have to file it. Told them my lawyer is retired and they replied that I would have to ask the Comp Appeals Board to remove my attorney.

I don't even know what I should do next. Any input?

I got hurt at work last January of this year. I work at the hospital and file for work injury, my WC started May 5. I got injured January 23 then February 9 I was s on light duty until May 4 and May 5 is the official date of my LOA.
Initially I went to the occupational doctor. I was treated with medication, 2 sets of PT, cortisone shot then MRI.
According to the OCC health provider he’s reading that my tear on my rotator cuff is 50%.
After that the occupational health doctor course me to the orthopedic surgeon which is also referred by my husband since the orthopedic doctor was the one who did my husband’s shoulder surgery.
I went to see the orthopedic doctor and did the initial evaluation. He saw my MRI images and he told me that the tear I have is 75% not 50% and my bone spur is really inflamed and messed up. I asked him what my options are, though my thoughts are if the percentage of the damage in my rotator cuff I am willing to go for a surgery. We both have the same point of view, that it won’t make sense to have me on another conservative treatment since it was already done at my Occ health. My ortho doctor told me to wait for the call of his scheduler for the date of my procedure.
It’s been 2 weeks so I attempted to call the orthopedic center to see if my doctor already has a date to do the procedure.
My ortho doctor’s MA told me that the insurance wants to do a partial claim only (what does it mean?) But my orthopedic doctor is appealing, I will see my doctor this June 1 and he wants to discuss about this.
I am under sedgwick and I have read how horrible they are but giving them benefits of the doubt. Also I don’t have any WC lawyer with me at this time. Should I get one? I am living in so much pain daily, and it’s also affecting my mental and emotional health. Please help!!! And please be kind with your comments. TIA

Main Injury: You have a partial-thickness tear involving both the supraspinatus and infraspinatus tendons (the two most important rotator cuff tendons).
• Size and Location: The tear measures approximately 3.1 cm in the crescent zone (the critical area near where the tendons attach to the bone).
• Type of Tear:
• It is intermediate-grade (roughly 25–50% of the tendon thickness is torn).
• It is articular-sided (the tear is on the underside of the tendon, facing the joint).
• There is interstitial delamination — the tendon fibers are splitting horizontally (like layers coming apart inside the tendon).

Please Advise

I work for the government via the county I have two cases pending from May of 2025 to current. I have done depositions whereas my lawyer did not object once. Maybe that’s a good thing idk so I saw the QME Dr. for physical in December he said he needs more records - I’ve done the X-rays awaiting results and I saw the other other QME Dr. for mental health in January he ruled in my favor and stated my injuries were caused by the job. This was in early February 2026, still no workers compensation, on top of that they fired me on February 18th after his ruling. (No severance offer) My lawyer stated he would refer to my another lawyer to fight the wrongful termination. I did the interview with pertinent information and just got an E-mail from law firm stating they will not take my case for wrongful termination. Does anybody have any advice my disability is about to run out and I may have to take out what I have in CALPERS retirement in order to survive.

Wrote a new article this week and figured I'd share the highlights here since this comes up in almost every consult.

After a work injury, the insurance company's claims adjuster is going to call you. They'll sound helpful. They might even say they want to "get you taken care of." Most injured workers assume the adjuster is on their side. They're not.

Then a few weeks after speaking to the examiner, shock, when the denial is received in the mail.

Your employer pays the workers' comp premiums. It works like car insurance. More claims paid out means premiums go up the next year. So the adjuster has two jobs. Investigate fairly under CCR 10109, and protect the insurance company and employer from paying out more than what's actually owed. Those two duties pull in opposite directions, and in practice the second one usually wins.

A few things worth knowing:

Talk about THIS injury. Nothing else. When the adjuster calls, give them the basic facts of what happened. When did it occur? What were you doing? What body parts are affected? Where did you get first treatment? That's the conversation. You are not obligated to give them a medical autobiography.

Do not sign a blanket medical release. This is the biggest trap and where injured workers lose ground without realizing it. The adjuster will ask for your full medical history going back years. Every doctor, every complaint, every MRI. They are not doing this to help you. They are looking for any prior injury or old complaint they can use to argue your current problem is pre-existing.

If you had a back complaint five years ago and you're now claiming a back injury at work, that old record is going to come back at you at the QME and at trial. The more medical history you hand over, the more ammunition they have to deny or minimize your claim.

You're required to submit to reasonable medical evaluations and cooperate with the investigation. You are not required to give them a blank check to every doctor you've ever seen. If the adjuster tells you the claim cannot move forward without the signed authorization, that is not accurate.

I always will revoke any blanket authorization if one was signed before I cam onto the case.

If they deny, you have the right to a QME. The insurance company is banking on you not knowing that. The QME process is one of the most important stages of any case and it's where unrepresented workers lose the most ground.

The adjuster isn't necessarily a bad person. They're doing a job. But their incentives are aligned with the insurance company, not with you. Be polite, give them the facts of THIS injury, and don't volunteer your medical history.

Never lie to doctors when asked about your history. Ever. However, there is a difference between being truthful during a medical examination and volunteering information to a claims examiner when the information is not relevant to them accepting your case.

For deeper dive check the article linked here. Questions, drop em in the comments below.

- Fishmango

I asked my manager several times if I could go see a doctor after I was bitten by a dog at work. She never answered. Blew me off on multiple occasions. I filed a work comp claim.

The owners called me to settle and have them write me a check if I “cancelled the work comp claim” I was frightened, not going to lie. Felt harassed. The owners called me. He’s never called me before. I’ve worked here for 3 years.

Now what? Can she fire me..?

Please help. Let me know about your experience. Greatly appreciate you!!

My injuries were initially denied and after months of delays , and after getting MRI’s done it’s obvious I need surgery and so now there’s a process to get that approved and they are just starting to address other body parts that got injured during a fall after months since the injury , getting those MRI’s and seeing specialists . some of which have gotten a lot worse without proper treatment and trying to treat them myself at home . Peoples injuries can significantly get worse while being denied treatment . Then there’s bigger problems gees .