If you have suffered from a work-related injury and/or illness, then you are legally entitled to seek financial recompense via workers’ compensation, disability benefits, or both. There are various sources of disability benefits, each with their respective pros and cons that depend heavily on the particulars of your case. If you are located in the Long Beach area and need legal assistance in this type of case, then call The Workers Compensation Attorney Group right away.

What are Workers’ Compensation and Disability?

Workers’ compensation is an insurance program that is mandated by the state of California for employers to provide benefits and compensation to workers who have suffered from occupational illnesses and/or injuries. The exact programs and laws will vary from state to state, thereby necessitating that you retain an attorney who is particularly familiar with the program.

Workers’ compensation may cover the following expenses:

  1. Medical bills
  2. Missed wages
  3. Continuing care
  4. Vocational training
  5. Funeral expenses
  6. Costs incurred by repetitive injuries 
  7. Disability 

Determining the exact makeup of your workers’ compensation benefits package will depend on a variety of factors, including the specifics of your case. Consequently, it is absolutely vital that you retain legal representation that is well versed in these types of cases and who can provide you with effective and far-reaching legal guidance to maximize your potential benefits.

Disability, on the other hand, can come from a number of different sources and is not limited to only work-related injuries or illnesses. It does not, however, cover medical care or long-term care expenses. It is merely designed to replace a portion of the claimant’s income when an injury, disability, or illness prevents them from working.

What Are the Different Sources for Disability Benefits?

There are four primary sources through which you may be entitled to disability payouts, depending on the specifics of your case and your medical condition. They are:

  1. Workers’ compensation
  2. Social Security Disability Insurance (SSDI)
  3. Private insurance
  4. State disability insurance (SDI)

SSDI is by far the most common source for disability benefits, though in some cases patients may work through a private insurance company. Usually, this private coverage offers short-term disability benefits for up to six (6) months following the date of injury or diagnosis of illness. In most cases, however, private insurance is less desirable than these other sources of disability benefits for a variety of reasons that are detailed below.

Remember that under state insurance laws, any employee in the state of California is entitled to go through workers’ compensation because every employer is legally required to provide this type of coverage. Even if you think you may be exempt from this coverage, it is always prudent to consult with a workers’ compensation attorney to ensure that this applies to your case.

In terms of workers’ compensation versus SSDI, the crucial difference revolves around the concepts of permanent versus temporary disability. In other words, SSDI does not offer any kind of temporary disability benefits whereas regular workers’ compensation does. Because SSDI provides these permanent benefits, it is not easy to get approved for, thereby necessitating experienced legal representation in order to secure them.

To be eligible for SSDI, you need to have suffered from the disability for at least one (1) year or have a fatal condition. Once you are approved for these SSDI benefits, then you are entitled to continue receiving them until you recover from your ailment, die from the ailment, or reach retirement age and then transition your SSDI benefits into retirement benefits. SSDI is strictly developed for permanent cases and is used as a way to partially replace a claimant’s pre-injury income.

Please note that it is entirely possible to be approved for both workers’ compensation and SSDI. This usually occurs in cases where the injury and/or illness has been severe and permanently disabling.

Private Insurance Disability vs Workers’ Compensation and SSDI

There is no question, however, that some sources of disability benefits are inferior to other sources. When compared to workers’ compensation or SSDI, private insurance has serious limitations in its efficacy and applicability in giving proper disability payouts. Furthermore, as a means of offsetting their own costs, unscrupulous employers will use unsavory tactics to convince an injured employee to settle on private insurance disability rather than pursue a workers’ compensation case.

When compared to workers’ compensation or SSDI, private insurance disability is severely limited in the following ways:

  1. It is subject to income tax, whereas workers’ compensation is not (SSDI is not taxable for anyone making less than two thousand eighty-three dollars ($2,083) per month).
  2. Disability payouts via private insurance are quite limited in how long they can be distributed, with most tapping out at about six (6) months after the date of injury or diagnosis of illness. Both workers’ compensation and SSDI, however, can distribute permanent payouts.
  3. Private insurance disability benefits are generally much lower than SSDI or workers’ compensation. In most cases, they pay out less than fifty percent (50%) of your pre-injury salary.
  4. Private insurance disability benefits do not usually cover additional costs that have been incurred, such as vocational training, lost wages, or funeral expenses.
  5. Furthermore, if you suffer from only a partial disability, then workers’ compensation can pay out benefits to offset your loss in wages. The standard is usually two-thirds (2/3) of your pre-injury income.
  6. Private insurance will usually cover only a portion of medical expenses, whereas workers’ compensation will cover all medical bills and ongoing care expenses.
  7. Disability insurance kicks in after a period of time, known as the “exclusionary period”, before which you will have to live off whatever savings you may have. Workers’ compensation, on the other hand, will retroactively settle any outstanding bills or expenses that you may have accrued in the initial time following your work-related injury and/or illness.

Furthermore, if you have any disputes with the private insurance company regarding your claims being rejected, then you must go through their internal review system (which is almost always biased against you). Once you have exhausted this avenue, you must then go through the traditional judicial process in civil courts (usually on the federal level). Workers’ compensation cases, on the other hand, have a dedicated administrative process that is overseen by presiding judges who serve the district offices through which your case would be handled.

Consequently, we counsel all our clients to pursue workers’ compensation and/or SSDI rather than settle for the inferior quality of private insurance disability benefits. Furthermore, workers’ compensation and SSDI are not mutually exclusive programs; many of our clients end up qualifying for both.

Denial of Workers’ Compensation vs Denial of Disability

Depending on the specifics of your injury and/or illness, you may be rejected for workers’ compensation, disability, or both. There are some common reasons why you may be denied from either of these

You do not necessarily have to have been injured at your actual place of work in order to qualify for workers’ compensation benefits; the injury and/or illness simply must be related to your occupation. There are, however, various reasons why your claim may be rejected, including:

  1. Your injury did not occur at work.
  2. You failed to notify your employer within the necessary timeframe.
  3. You were under the influence of drugs and/or alcohol.
  4. Your actions violated the code of conduct set forth by your employer.
  5. Your employer disputes your account of what transpired.
  6. You did not file your application within the necessary timeframe.
  7. You did not receive medical treatment by an approved health care practitioner.
  8. You did not seek out or receive any medical treatment.
  9. You had a preexisting condition that was merely exacerbated by the injury.

Some of these are specific to workers’ compensation claims and will differ from the reasons why your disability claim may be rejected. For example, where your injury occurred has absolutely no bearing on your disability denial or approval because your eligibility for disability is completely independent of your occupation or employment.

Furthermore, you do not need to notify an employer or be subject to a specific timeframe in order to be eligible for disability. It is important to note that a work-related injury may still be subject to disability coverage; it is merely not entirely dependent on the parameters of your employment as it exists independently of any work coverage (unlike workers’ compensation). This also means that an employer’s code of conduct does not apply to your disability claim.

On the other hand, there a number of reasons why your disability claim may be rejected. The most common include:

  1. Your disability is not permanent or severe enough.
  2. Your income is too high.
  3. You have been convicted of a crime.
  4. You failed to follow the terms of your medical treatment.
  5. The Social Security Administration (SSA) cannot communicate with you.
  6. You failed to cooperate with the application process.
  7. Your disability is caused by drug and/or alcohol addiction.
  8. You filed your disability application fraudulently.

Of these eight (8) common reasons, the first four (4) are specific to disability denials. For example, reason number 1) refers only to disability denials because workers’ compensation coverage does not make a determination about the severity of the work-related injury and/or disease. Remember that workers’ compensation covers short-term disability in addition to long-term disability, meaning that these benefits are available nearly immediately following your injury or illness. Workers’ compensation may also pay long-term or even permanent benefits, but it is not limited to those scenarios.

This is in sharp contrast to SSDI coverage, which by its very nature is granted only in severe situations when the claimant has lost most or even all of their ability to work. It cannot be used for any kind of injury or illness that is temporary in nature. Consequently, SSDI is generally much more difficult to get than either short-term or long-term workers’ compensation, although securing any of these benefits is always best done under the guidance of a workers’ compensation attorney.

Maximum Income in Workers’ Compensation and Disability

Your level of income has no bearing on the status of your workers’ compensation; there is no maximum or minimum that determines whether or not your benefits are approved. In fact, the level of financial compensation in your workers’ compensation will be determined by your pre-injury income and is usually two-thirds (⅔) of that which you were earning before.

In order to receive disability (SSDI), however, there is a concept known as “substantial gainful activity” (SGA). If you are working above this SGA limit at the time of your disability application, then you are considered to be above the level that necessitates permanent disability coverage. This SGA limit is set by federal standards and, as of 2018, is one thousand one hundred eighty dollars ($1,180) per month for people who are not blind.

However, SGA does not always consist of paid work. To better understand the concept, it is best to break it down as follows:

  1. Substantial - Any work or activity that is considered “substantial” means that you are undertaking significant mental and/or physical activities. Even volunteer work can be considered substantial if it is a type of work that requires you to devote considerable mental or physical acuity, commitment, and/or focus. This is also true of any part-time work.
  2. Gainful - This refers to any type of work that is paid. However, even if you are not being paid, the SSA may conclude that your work is still “gainful” if you are undertaking work that people are usually paid for.

It is also important to note that SGA does not apply to “passive income”. This is any money that you receive for work that you are not actively doing, such as investments or retirement funds.

Remember that workers’ compensation is different from SSDI in that there is no causal relationship between your level of income and whether or not you are approved for workers’ compensation benefits. SSDI, on the other hand, is heavily determined by the level and type of income.

Failure to Follow Medical Treatment in Workers’ Compensation and Disability

It is vital that you follow any and all medical direction that you receive throughout the course of your treatment. Workers’ compensation and disability may both be denied on the basis that you are not following your clinician’s orders, although there is much greater leeway with disability claims. In fact, the SSA recognizes a number of legitimate excuses for not following your medical treatment, including:

  1. You suffer from a mental illness that is so severe that you are incapable of following direction or adhering to a treatment regimen.
  2. You have a real and legitimate fear of surgery that is so intense that you may actually suffer deleterious physical effects if you undergo a procedure. This fear must be fully documented and explained by the clinician treating you.
  3. Your clinician prescribed some form of treatment that another clinician disagreed with.
  4. You have a physical disability (such as blindness or paralysis) that renders you incapable of following your medical treatment without some form of assistance.
  5. You do not have the money to pay for treatment.
  6. Your religious beliefs prevent you from receiving medical treatment.

The SSA recognizes some legitimate excuses that workers’ compensation would not recognize, most notably 1) through 3) on the list. All the other reasons would, in almost every case, be recognized as a legitimate excuse under both workers’ compensation and SSDI.

Furthermore, suffering from chronic and severe mental illness may even qualify some claimants for SSDI benefits. This is rarely the case with workers’ compensation, where you would have to establish that your mental illness was a direct result of your occupation. Remember that workers’ compensation is given only to injuries or illnesses that were caused exclusively by your work; it is possible to have mental illness exacerbated by a work environment, although it is fairly unlikely that it was entirely caused by it.

Additionally, your workers’ compensation would likely not recognize your fear of surgery as a legitimate reason to not follow your medical treatment. They would likely consider this to be a failure to comply and deny your claims.

Finally, your medical treatment under workers’ compensation is almost exclusively determined by clinicians who are determined by the insurance provider. These are known as qualified medical examiners (QMEs) and agreed medical evaluators (AMEs). Unlike SSDI cases, where your primary care physician (PCP) can oversee the overall process of securing your disability benefits, your workers’ compensation case has to go almost entirely through these QMEs and/or AMEs. 

If you feel you have been unfairly denied either workers’ compensation or disability (SSDI) benefits, then The Workers Compensation Attorney Group can help you in your case.

Workers’ Compensation vs State Disability Insurance (SDI)

There are ways to apply for temporary disability benefits. These are usually used when your condition is still in a state of flux and you have not stabilized yet following your injury and/or illness. Furthermore, there are state coverage programs in five (5) states that offer temporary disability insurance (also known as “state disability insurance” or SDI):

  1. California
  2. New Jersey
  3. New York
  4. Hawaii
  5. Rhode Island

The decision to apply for this SDI is up to you and should depend on the particulars of your case, your overall medical prognosis, and what your legal counsel advises you. It is important to note, however, that SDI is strictly temporary, whereas workers’ compensation can be either temporary or permanent (depending on your case). Furthermore, there have been numerous cases of unscrupulous employers pushing their injured employees off onto SDI plans in order to avoid paying the premiums for the workers’ compensation settlement. 

There are a number of different district offices you may contact, depending on what kind of claim you intend on making. In the state of California, this SDI program is overseen by the Employment Development Department (also known as the EDD). They have an office located in Los Angeles at 888 S Figueroa Street, #200 and a contact number at (213) 337-4003.

Furthermore, if you seek out workers’ compensation benefits, overseen by the California Department of Industrial Relations (DIR), then their regional office is located in Los Angeles at 320 West 4th Street and they have a contact number at (213) 576-7335. Your claims will be evaluated by an impartial workers’ compensation court whose acting and presiding judge is the Honorable David Brotman.

Finally, if you wish to apply for SSDI, overseen by the Social Security Administration (SSA), then their regional office is located in Los Angeles at 611 West 6th Street and their contact number is (213) 251-7005. They also have a national toll-free number at (800) 325-0778.

As you can see, residents of California have all four potential sources of disability benefits available to them. This can quickly prove overwhelming, however, so it is best that you seek out a worker’s compensation attorney as soon as possible. The Workers Compensation Attorney Group can guide you every step of the way and help you determine whether workers’ compensation, disability, or both will be best suited for you.

How to Maximize My Combined Workers’ Compensation and Disability Benefits

It is important to note that if you are approved for both workers’ compensation and SSDI, then you must plan accordingly as your SSDI payments may be reduced based on your workers’ compensation payouts. This potential reduction only applies if your combined monthly income of workers’ compensation and SSDI is greater than eighty percent (80%) of your pre-injury average income.

There are, however, three (3) potential ways to maximize your combined workers’ compensation and disability benefits:

  1. Make exclusions for certain kinds of expenses – Before your gross workers’ compensation amount is calculated, the Social Security Administration (SSA) will deduct dependent payments, rehabilitation costs, legal fees, and any medical expenses not covered by Medicare. Consequently, maintaining meticulous records about your expenses and various bills will allow you to claim exclusions of all these various expenses. 
  2. Choose monthly payments over a lump-sum workers’ compensation settlement – In many cases, you will be offered a single lump-sum settlement amount from workers’ compensation. It is absolutely vital that you have a workers’ compensation attorney draft what is known as an “amortization provision” that will allow you to break up this lump-sum payment into monthly payments, thereby increasing your SSDI payments. Please note that this provision cannot be added to an existing workers’ compensation agreement, so it must be drafted before the final settlement is reached and then included in the original settlement documents. Furthermore, a federal circuit judge has ruled that this settlement cannot be spread out over a claimant’s entire life but limited exclusively to their working life. In other words, there are potential complications that must be handled by an experienced workers’ compensation attorney to handle these details before the settlement is finalized.
  3. Shifting SSDI to retirement benefits – The decrease in workers’ compensation does not apply if you are receiving retirement benefits through the SSA. In order to maximize these benefits, claimants as young as sixty-two (62) can look into the legal possibility of filing for early retirement.

Our team at The Workers Compensation Attorney Group can ensure that we will draft a legal strategy that conforms specifically to the parameters of your case and that you will be able to maximize your benefits, whether it be from workers’ compensation, disability, or both.

Find A Workers’ Compensation Attorney Near Me

Navigating these various intricacies is a tall order for even the shrewdest person, so let us take the wheel and guide you through this complex process. Contact The Long Beach Workers Compensation Attorney Group at 714-716-5933 right away and get your free consultation