California Workers' Compensation Glossary

A claims adjuster (also called an examiner) is the insurance company employee assigned to manage your workers' compensation claim from start to finish. The adjuster investigates the claim, decides whether to accept or deny it, authorizes or denies medical treatment, issues TD and PD payments, and negotiates settlements. Adjusters often handle dozens of claims simultaneously. While some adjusters are fair and efficient, others may delay payments, deny reasonable treatment, or undervalue claims. Having an attorney can help ensure the adjuster handles your claim properly.

Activities of Daily Living (ADLs) are fundamental self-care tasks that doctors evaluate to assess how a workplace injury affects a person's functional ability. Standard ADLs include bathing, dressing, eating, toileting, transferring (moving from bed to chair), and continence. In workers' compensation, limitations in ADLs support a higher impairment rating because they demonstrate the real-world impact of the injury. Doctors document ADL limitations in their medical-legal reports, and these limitations factor into the permanent disability rating.

California uses the AMA Guides to the Evaluation of Permanent Impairment (5th Edition) as the starting point for determining permanent disability ratings. Doctors use these standardized criteria to assign a Whole Person Impairment (WPI) percentage based on the worker's specific medical condition and limitations. The WPI is then converted into a California PD rating using the rating string formula. The AMA Guides cover virtually every body part and medical condition.

AOE (Arising Out of Employment) and COE (Course of Employment) are the two-part legal test used to determine whether an injury is covered by workers' compensation in California. AOE asks whether the injury was caused by the work itself, while COE asks whether the injury happened during the performance of job duties. Both elements must generally be satisfied for a claim to be compensable. Disputes over AOE/COE are among the most common reasons claims are denied, particularly for injuries that develop gradually or occur during break periods.

In California workers' compensation law, the "applicant" is the injured employee (or their dependents in death cases) who files a claim seeking benefits. Once an Application for Adjudication is filed with the Workers' Compensation Appeals Board (WCAB), the injured worker is formally referred to as the applicant throughout all legal proceedings. The opposing party is typically the employer and their insurance carrier, referred to as the "defendant."

An Application for Adjudication of Claim is the legal filing that formally opens a workers' compensation case at the Workers' Compensation Appeals Board (WCAB). It identifies the injured worker (applicant), the employer (defendant), the date and nature of the injury, and the body parts affected. Filing this application assigns a case number and a district office where the case will be heard. It must be filed within one year of the date of injury (or within one year of the last provision of benefits for delayed discovery cases).

Under California Labor Code sections 4663 and 4664, apportionment allows the insurance company to reduce your permanent disability award by attributing a percentage of your impairment to pre-existing conditions, prior injuries, or natural aging. For example, if you have a 40% PD rating but the doctor apportions 25% to a prior injury, you would only receive compensation for 30% PD. Apportionment is one of the most contested issues in workers' comp because it directly impacts the settlement amount. A skilled attorney can challenge unfavorable apportionment through additional medical evaluations.

Average Weekly Wage (AWW) is calculated by dividing the worker's total earnings by the number of weeks worked during a specific period (typically the 52 weeks before the injury). AWW directly determines the temporary disability (TD) rate, which is two-thirds of AWW, subject to state minimums and maximums. In 2026, the TD minimum is $265/week and the maximum is $1,764/week. AWW also affects the permanent disability advance rate. Tips, overtime, and concurrent employment may all be included in the AWW calculation.

A Compromise and Release (C&R) is a settlement agreement where the injured worker receives a one-time lump sum payment in exchange for closing the case entirely, including the right to future medical care for the work injury. C&Rs are common when the worker wants cash now and is willing to take on the risk of future medical costs. The settlement must be approved by a Workers' Compensation Judge. Unlike Stipulations, a C&R generally cannot be reopened later, even if the condition worsens. Many workers who receive a C&R use a portion to obtain medical insurance through Medicare or Medi-Cal.

A claims administrator is the organization responsible for administering workers' compensation claims on behalf of the employer. This can be the employer's insurance company, a third-party administrator (TPA) hired by a self-insured employer, or the State Compensation Insurance Fund. The claims administrator handles all aspects of the claim, including accepting or denying claims, paying benefits, authorizing treatment, and managing the litigation process. California law imposes strict timelines on claims administrators for claim acceptance, payment processing, and treatment authorization.

Cumulative trauma (CT) injuries develop gradually from repeated workplace exposures, such as typing causing carpal tunnel syndrome, lifting causing back injuries, or chemical exposure causing respiratory problems. Under California law, the date of a CT injury is the date the worker first suffered disability and knew (or should have known) it was caused by work. CT claims are common but often contested because insurers argue the condition is due to aging or non-work activities. Multiple employers may share liability if the CT spans different jobs.

The date of injury (DOI) is critical because it determines which employer is liable, what benefit rates apply, and when the statute of limitations begins. For specific injuries (single events), the DOI is usually obvious. For cumulative trauma injuries, the DOI is legally defined as the date the employee first suffered disability and either knew or should have known the disability was caused by employment. The DOI also determines which Workers' Compensation Judge has jurisdiction over the case.

Death benefits in California workers' compensation are paid to the dependents of a worker who dies as a result of a work-related injury or occupational disease. As of 2026, the maximum death benefit ranges from $250,000 to $390,000 depending on the number of dependents, plus a $10,000 burial allowance. Totally dependent minor children and a surviving spouse are typically the primary beneficiaries. If there are no dependents, a reduced benefit may be paid to the estate.

A deposition is a formal proceeding where a witness or party gives sworn testimony outside of court, typically at an attorney's office, with a court reporter transcribing every word. In workers' comp cases, depositions are commonly taken of the injured worker, treating physicians, QMEs, and sometimes coworkers or supervisors. The testimony can be used as evidence at trial. Medical-legal depositions of doctors are particularly important because the doctor's opinions on causation, disability, and treatment needs are central to the case outcome.

Discovery in workers' compensation is the pre-trial process through which both sides gather evidence to prepare their case. Common discovery methods include interrogatories (written questions), requests for production of documents (medical records, employment records), depositions, and subpoenas. The applicant's medical records, employment history, and tax returns are frequently requested. Discovery helps both sides evaluate the strengths and weaknesses of the case and often facilitates settlement negotiations.

A Declaration of Readiness to Proceed (DOR) is the formal document filed with the WCAB to request that a hearing or Mandatory Settlement Conference be scheduled. Either party (applicant or defendant) can file a DOR when they believe the case is ready for judicial intervention - typically after discovery is complete and settlement negotiations have stalled. The DOR specifies the issues in dispute and triggers the WCAB to set a conference date, usually within 30-60 days. It is the procedural mechanism that moves a stalled case forward.

The exclusive remedy doctrine means that in most cases, an injured worker cannot sue their employer in civil court for a workplace injury. Instead, workers' compensation benefits are the sole source of compensation from the employer. However, there are important exceptions: employees can pursue civil lawsuits against third parties (such as equipment manufacturers), and in rare cases involving employer fraud or intentional harm, the exclusive remedy bar may not apply. Additionally, Labor Code 132a provides a separate remedy for employer retaliation.

A Functional Capacity Evaluation (FCE) is a comprehensive, standardized physical test conducted by a trained evaluator (usually a physical or occupational therapist) to objectively measure what an injured worker can and cannot do physically. The evaluation typically takes 4-6 hours and tests lifting, carrying, standing, sitting, walking, bending, and grip strength. FCE results help determine work restrictions, permanent disability ratings, and whether the worker can return to their previous job. Insurance companies often request FCEs to verify disability claims.

A Findings and Award (F&A) is the formal ruling issued by a Workers' Compensation Judge (WCJ) after a contested trial. The document contains the judge's factual findings on issues such as injury, disability level, need for medical treatment, and apportionment. The award portion specifies the benefits the employer/insurer must pay. Either party can file a Petition for Reconsideration with the WCAB within 25 days if they disagree with the F&A.

California law entitles injured workers to receive all reasonable and necessary medical treatment for their work injury for life, unless they voluntarily give up this right through a Compromise and Release (C&R) settlement. Future medical care can include surgeries, medications, physical therapy, diagnostic imaging, and medical equipment. When settling by Stipulations, the right to future medical care remains open. When settling by C&R, the value of anticipated future medical treatment is calculated and included in the lump sum.

A hearing in workers' compensation is a formal proceeding before a Workers' Compensation Judge (WCJ) where evidence is presented and legal arguments are made on disputed issues. Hearings can address specific issues like temporary disability benefits, medical treatment authorization, or liens. They are less comprehensive than a full trial and typically focus on resolving one or two specific disputes. The WCJ may issue interim orders based on the hearing that provide relief while the overall case continues to develop.

Independent Bill Review (IBR) is a dispute resolution process established by California SB 863 that allows medical providers to challenge the amount an insurer pays for treatment. When a provider believes the insurer underpaid for authorized treatment, they can request IBR through the Division of Workers' Compensation. An independent reviewer then determines the correct payment amount based on the Official Medical Fee Schedule. IBR decisions are binding on both parties.

Independent Medical Review (IMR) is the process by which an injured worker can challenge a Utilization Review (UR) denial of medical treatment. When the insurer's UR doctors deny requested treatment, the worker or their doctor can request IMR through the Division of Workers' Compensation. An independent physician reviewer (not connected to the insurer) evaluates the medical records and treatment request and makes a binding decision. IMR decisions are based on the Medical Treatment Utilization Schedule (MTUS) and evidence-based medicine guidelines. IMR overturns UR denials in a significant percentage of cases.

Labor Code section 132a makes it a misdemeanor for an employer to discriminate against an employee for filing or threatening to file a workers' compensation claim, or for receiving a rating or settlement. Remedies include a penalty of up to $10,000, reimbursement of lost wages, reinstatement to the former position, and increased compensation of up to $250. Unlike a civil lawsuit, a 132a claim is filed with the WCAB and decided by a Workers' Compensation Judge.

In workers' compensation, a lien is a claim filed by a healthcare provider, attorney, or other entity asserting a right to payment from the proceeds of a workers' comp case. Medical providers commonly file liens when they treat an injured worker without upfront payment, expecting to be paid from the settlement or award. Liens must be resolved before a case can fully close. California has implemented lien filing fees and procedures to reduce fraudulent lien claims.

A life pension is awarded to injured workers who receive a permanent disability rating of 70% or higher. After the standard PD indemnity payments are exhausted, the life pension payments continue every two weeks for the rest of the worker's life. The amount is based on the PD rating percentage and the worker's age at the time of injury. Life pension payments are in addition to any permanent disability indemnity and are adjusted according to a statutory schedule. Workers rated at 100% PD receive the highest life pension rates.

Injured workers in California are entitled to mileage reimbursement for travel to and from medical appointments, pharmacy visits, and medical-legal evaluations related to their workers' comp claim. The reimbursement rate follows the IRS standard mileage rate. Workers may also be reimbursed for parking fees, bridge tolls, and other reasonable travel expenses. To receive reimbursement, workers should keep detailed records of all trips, including dates, destinations, and mileage.

Maximum Medical Improvement (MMI) is the medical determination that a worker's condition has plateaued and further treatment is unlikely to produce substantial improvement. MMI is functionally equivalent to being declared Permanent and Stationary (P&S) in California. Reaching MMI does not mean the worker is fully healed - it means the condition is as good as it will get. After MMI, the treating doctor writes a final report with permanent work restrictions, impairment ratings, and recommendations for ongoing maintenance care.

A Medical Provider Network (MPN) is a group of healthcare providers selected by the employer or insurer to treat injured workers. California law generally requires injured workers to treat within the MPN for the first 30 days. After 30 days, workers who pre-designated a personal physician before the injury can switch to that doctor. Within the MPN, workers have the right to choose their treating physician and can switch doctors up to three times. If the MPN does not have an appropriate specialist, the worker can treat outside the network.

A Mandatory Settlement Conference (MSC) is a pre-trial hearing before a Workers' Compensation Judge where both parties present their positions and attempt to negotiate a settlement. Each side submits a Pre-Trial Conference Statement outlining the issues in dispute, the evidence, and their settlement positions. The WCJ actively participates by evaluating the evidence and encouraging compromise. If the case does not settle at the MSC, the judge sets it for trial. MSCs resolve a significant majority of workers' comp cases without the need for trial.

Permanent and Stationary (P&S) is the point at which a treating physician determines that the injured worker's medical condition has reached a plateau and is not expected to materially improve or worsen with continued treatment. This is essentially synonymous with Maximum Medical Improvement (MMI). Once declared P&S, the doctor writes a final medical report assessing permanent disability, work restrictions, and future medical needs. This report is the foundation for settlement negotiations.

Permanent Disability (PD) refers to lasting physical or mental limitations caused by a work injury that remain after the worker reaches Maximum Medical Improvement. PD is expressed as a percentage from 0% to 100%, with higher percentages yielding larger compensation. The PD percentage is calculated from the doctor's Whole Person Impairment rating using the California rating schedule, factoring in the worker's occupation, age, and injury type. PD benefits are paid as bi-weekly indemnity payments (in Stipulations) or as a lump sum (in a C&R). A 100% PD rating entitles the worker to payments for life.

A Permanent Disability Advance (PDA) is a payment of permanent disability benefits that begins after temporary disability ends and before the case is formally settled. Under California law, the insurer must begin PDA payments within 14 days after the last TD payment if there is a reasonable expectation of permanent disability. PDA payments are typically made at the same rate as TD and are credited against the final PD settlement or award. These advances ensure injured workers continue receiving income while their case is being resolved.

Under California Labor Code section 5410, an injured worker can file a Petition to Reopen a previously closed case within five years of the date of injury. This is typically done when the worker's condition has worsened since the original settlement. However, cases settled by Compromise and Release (C&R) generally cannot be reopened because the worker traded future medical rights for a lump sum. Cases resolved by Stipulations with Request for Award can be reopened for new and further disability.

The Primary Treating Physician (PTP) is the single physician who has overall responsibility for managing the injured worker's medical care. The PTP writes PR-2 progress reports, requests authorization for treatment through Utilization Review, determines temporary disability status, and ultimately writes the final Permanent and Stationary report with impairment ratings. The PTP's opinions carry significant weight in the case. Injured workers have the right to change their PTP within the MPN.

A Qualified Medical Evaluator (QME) is a physician certified by the Division of Workers' Compensation Medical Unit to perform independent medical-legal evaluations. When there is a dispute about the nature or extent of an injury, a QME provides an impartial medical opinion. For unrepresented workers, the DWC assigns a panel of three QMEs; the worker picks one. For represented workers (those with attorneys), the parties may agree on an Agreed Medical Evaluator (AME) instead. QME reports are extremely influential in determining disability ratings and settlement values.

A rating string is the mathematical formula used in California to convert a doctor's Whole Person Impairment (WPI) percentage into a final Permanent Disability (PD) rating. The formula accounts for the worker's occupation group number, age at the time of injury, and the specific impairment. For example: "15.03.01.00 - 10 - [1.4]14 - FEC adj. 14 - 14% PD." The rating is performed by the Disability Evaluation Unit (DEU) of the Division of Workers' Compensation, or by a qualified rater.

Retroactive Temporary Disability (TD) refers to TD benefits that are owed for past periods when the injured worker was unable to work but did not receive timely payments. This commonly occurs when a claim is initially denied and later approved, or when there are delays in processing. California law imposes penalties on insurers who unreasonably delay TD payments, including a 25% self-imposed increase and potential penalties at trial. Workers should track all periods of work absence to ensure full retroactive payment.

The Return to Work Supplement (RTWS) is a $5,000 one-time payment available to injured workers who sustained permanent disability and have not returned to work within 60 days of receiving a permanent disability award. The supplement was established to help workers who face difficulty returning to employment after a workplace injury. To qualify, the worker must have a date of injury on or after January 1, 2013, and meet specific eligibility criteria. The RTWS is separate from and in addition to the SJDB Voucher.

A self-insured employer is a company that has received certification from the California Department of Industrial Relations to directly pay workers' compensation benefits rather than purchasing insurance from a carrier. Large employers like major corporations, school districts, and government entities often self-insure because they have the financial reserves to handle claims. Self-insured employers typically hire third-party administrators (TPAs) to manage claims. The claims process is the same for injured workers, but the employer bears the financial risk directly.

The Supplemental Job Displacement Benefit (SJDB) voucher is a $6,000 non-transferable voucher provided to injured workers who have permanent work restrictions that prevent them from returning to their pre-injury job, and whose employer does not offer modified or alternative work. The voucher can be used for education, retraining, or skill enhancement at accredited schools, and a portion can be applied to licensing, certification exam fees, and computer equipment. The SJDB applies to injuries occurring on or after January 1, 2013.

Stipulations with Request for Award (commonly called "Stips") is a settlement format where the injured worker and the insurance company agree on the permanent disability rating, and the worker receives PD indemnity payments every two weeks based on that rating. Unlike a Compromise and Release, Stipulations keep the right to future medical treatment open, meaning the insurer continues to pay for reasonable and necessary medical care for the work injury. Stipulations cases can also be reopened within five years if the condition worsens.

A subpoena in workers' compensation is a legal order issued to compel a witness to appear for deposition or trial testimony, or to require the production of documents such as medical records, employment files, or surveillance footage. Subpoenas can be issued to medical providers, employers, insurance companies, and other third parties. In California workers' comp, subpoenas are typically served through the WCAB and can be enforced through contempt proceedings if not complied with.

Temporary Disability (TD) benefits are tax-free payments made to injured workers who are temporarily unable to work while recovering from a work injury. TD is calculated at two-thirds of the worker's Average Weekly Wage, subject to state minimum and maximum rates. In 2026, the minimum TD rate is $265/week and the maximum is $1,764/week. TD payments are made every two weeks. There are two types: Total TD (TTD) for workers who cannot work at all, and Partial TD (TPD) for workers who can do some work at reduced hours or pay. TD generally lasts up to 104 weeks within five years of the injury.

A third-party claim is a separate civil lawsuit (distinct from workers' comp) filed against a party other than your employer whose negligence contributed to your injury. Common examples include claims against defective equipment manufacturers, property owners, or negligent drivers in work-related car accidents. Third-party claims can provide compensation for pain and suffering, which is not available through workers' comp. However, the workers' comp insurer typically has a lien on any third-party recovery.

A trial in workers' compensation is the final adjudicatory proceeding where a Workers' Compensation Judge hears testimony, reviews medical reports and other evidence, and issues a binding Findings and Award. Trials are held when the parties cannot reach a settlement. Unlike civil court trials, there is no jury - the WCJ is the sole decision-maker. Evidence is typically submitted through medical reports and depositions rather than live testimony. After trial, the WCJ has 30 days (extendable to 90) to issue a decision. The losing party may file a Petition for Reconsideration.

Utilization Review (UR) is the mandatory process by which an insurer evaluates whether medical treatment requested by the Primary Treating Physician is reasonable, necessary, and consistent with evidence-based medical guidelines (MTUS - Medical Treatment Utilization Schedule). UR doctors - who never examine the patient - review the treatment request and supporting medical records, then issue a decision to approve, modify, or deny. If treatment is denied, the injured worker can appeal through Independent Medical Review (IMR). UR decisions must be made within specific timeframes: 5 business days for prospective requests, 72 hours for concurrent requests, and 30 days for retrospective requests.

The Workers' Compensation Appeals Board (WCAB) is the judicial branch of the California Division of Workers' Compensation. It has district offices throughout the state where Workers' Compensation Judges hear cases. The WCAB also has a panel of commissioners who review appeals (Petitions for Reconsideration) from WCJ decisions. All disputed workers' comp claims in California are adjudicated through the WCAB system, not the civil court system.

The Workers' Compensation Insurance Rating Bureau (WCIRB) of California is a private, nonprofit organization that serves as the state's official advisory organization for workers' compensation insurance. The WCIRB collects and analyzes data on workplace injuries and insurance claims to calculate advisory pure premium rates that insurers use as a starting point for pricing policies. The WCIRB also assigns experience modification ratings (X-Mod) to employers based on their claims history, which directly affects their insurance premiums.

A Workers' Compensation Judge (WCJ) is a state-appointed judicial officer who presides over disputed workers' compensation cases at the local WCAB district office. WCJs conduct Mandatory Settlement Conferences (MSCs), preside over trials, review medical evidence, hear testimony, and issue Findings and Awards. They have significant discretion in evaluating medical reports and witness credibility. Their decisions can be appealed to the WCAB commissioners through a Petition for Reconsideration.

Whole Person Impairment (WPI) is the medical impairment rating assigned by a physician using the AMA Guides to the Evaluation of Permanent Impairment (5th Edition). WPI represents the percentage of function lost due to the injury relative to the whole body. For example, a significant back injury might receive a 15% WPI. This WPI percentage is the starting point for calculating the California Permanent Disability (PD) rating, which factors in the worker's occupation, age, and diminished future earning capacity.