Filing a workers’ comp claim can feel overwhelming, especially when you’re unsure how long you have to wait for a decision. You may be asking yourself, What is the 90-day rule for workers’ comp in California, and how does it protect injured workers?
The 90-day rule in California workers’ comp means your claim is automatically accepted if your employer or insurer doesn’t approve or deny it within 90 days of filing. During this time, they must still cover up to $10,000 in medical treatment. The 90-day rule is a key part of California’s workers’ compensation system, which governs claim processing, benefit eligibility, and the rights of injured workers.
With decades of experience helping California workers get the benefits they deserve, I know how crucial timely claim processing and decisions are during recovery.
In this article, I’ll explain how the 90-day rule works, what happens if your claim goes unanswered, and how to ensure you receive the care and compensation you’re entitled to.
Introduction to Workers’ Compensation in California
Workers’ compensation in California is a vital safety net designed to protect employees who suffer work related injuries or illnesses. This state-mandated program ensures that injured workers receive essential support, including medical treatment, temporary disability benefits to cover lost wages during recovery, and permanent disability benefits if the injury results in lasting impairment.
To access these workers compensation benefits, employees must promptly file a workers compensation claim with their employer, who is legally required to carry workers compensation insurance. Navigating the claims process can be complex, especially when dealing with medical care and benefit calculations.
That’s why many injured workers turn to an experienced workers compensation attorney for guidance, ensuring they receive the full range of benefits they’re entitled to under California law. Whether you’re dealing with a sudden accident or a condition that developed over time, the workers compensation system is there to help you recover and regain financial stability.
What Does the 90-Day Rule Mean in Workers’ Compensation?
The 90-day rule refers to California Labor Code Section 5402, which states that if a claim is not denied within 90 days, it is presumed accepted. The workers compensation claim process in California is governed by the compensation 90 day rule, which sets strict deadlines for claim processing and ensures both employees and employers comply with legal requirements. This means:
- The employer or insurer has 90 calendar days from the date the injury claim form (DWC-1) is submitted to approve or deny the claim.
- Employer’s responsibilities include responding to the claim within the 90-day period, posting required notices, and maintaining proper workers’ compensation insurance.
- If no action is taken within that period, the claim is automatically accepted by law, and the insurance company becomes liable for paying the associated benefits.
- During this 90-day window, the insurance company is required to authorize up to $10,000 in medical treatment, even while the claim is pending.
This rule ensures timely investigation and protects employees from being left without medical care or wage replacement, making the workers compensation 90 day rule a key legal guideline in California.
Why the 90-Day Rule Matters for Injured Workers in California
The 90-day rule protects injured employees by creating a legal deadline for employers and insurers, highlighting the importance of timely reporting of workplace injuries. This is important because:
- Delays in medical treatment can worsen injuries.
- Financial instability can occur while waiting for benefit approval, especially if financial compensation is delayed.
- Unfair claim denials can be contested using the 90-day rule.
Knowing about this rule empowers injured workers to assert their rights when employers or insurers delay or avoid responding after a workplace injury, ensuring they can receive workers compensation benefits.
Step-by-Step: How the 90-Day Rule Applies to Your Case
The 90-day rule outlines the claim processing timeline for workers compensation claims, detailing each step from reporting a work injury to final claim resolution.
- Report the Injury Immediately
Notify your supervisor or employer immediately after a work injury. Prompt reporting ensures timely investigation, medical care, and claim processing, and delays can negatively impact your benefits. - File a DWC-1 Claim Form
Complete and submit the official workers’ compensation claim form. Your employer must provide this form within one working day of your report. After a work injury, seek medical treatment as soon as possible to ensure proper documentation and support for your claim. - Employer Acknowledges and Files the Claim
Once submitted, the employer must forward the form to their insurance company. The 90-day window for claim processing begins on the date you submitted the DWC-1. - Claim Investigation Period Begins
The claims administrator is responsible for claim processing and investigation. Claims administrators oversee workers compensation claims, including reviewing documentation, authorizing medical treatment, and resolving any disputes. - Access Medical Treatment During Investigation
You are entitled to up to $10,000 in medical care during the 90-day evaluation period, regardless of whether the claim is ultimately accepted. - Claim Not Denied Within 90 Days?
If the claim is not denied within 90 days, it is presumed accepted by law.
Workers’ Compensation Insurance: Who Pays and How It Works
In California, the responsibility for workers compensation insurance falls squarely on employers. By law, every employer must carry workers compensation insurance to cover the costs associated with work related injuries and illnesses. The cost of this insurance is typically determined by the employer’s payroll size and the level of risk associated with the type of work performed.
When an employee files a workers compensation claim, the insurance company steps in to pay for necessary medical treatment, lost wages, and other benefits owed to the injured worker. Employers are also required to post information about their workers compensation insurance in a visible location at the workplace, so employees know where to turn if they’re hurt on the job.
The 90 day rule is a critical part of this process: once a claim is filed, the employer and their insurance company have 90 days to accept or deny it. If they fail to respond within this timeframe, they may face penalties and increased liability, ensuring that injured workers are not left waiting for the support they need.
Medical Provider Network: Your Options for Treatment
When you’re injured at work in California, getting the right medical treatment is crucial for your recovery and your workers compensation claim. Most employers’ insurance companies use a medical provider network (MPN)—a group of approved doctors and specialists who are familiar with workers compensation law and treatment guidelines.
As an injured worker, you generally need to seek medical care within this network, but you do have the right to choose your provider from the list.
If you wish to see a doctor outside the MPN, you must first get approval from the insurance company. The treating physician’s medical report will play a key role in determining the extent of your injury or illness, the medical treatments you’ll receive, and whether you qualify for permanent disability benefits or supplemental job displacement benefits if you can’t return to your previous job.
Because these decisions can have a lasting impact on your health and financial future, it’s wise to consult an experienced workers compensation attorney to help you understand your options and ensure you receive the care and benefits you deserve.
What Happens After the 90-Day Period?
If no denial is issued, the claim becomes presumptively valid. Afterward:
- Medical treatment continues as prescribed. Settlements may also include provisions for future medical care and future medical treatment related to your work injury.
- Temporary or permanent disability payments may begin. You may receive a permanent disability award or permanent partial disability benefits, which are calculated based on your average weekly wages and wage loss.
- Settlements may include a lump sum payment and consideration of your future earning capacity.
- You may be eligible for a settlement or additional vocational benefits if you cannot return to work. If your injury results in long-term impairment, you may be eligible to receive permanent disability benefits.
What Happens After 104 Weeks of Workers’ Comp in California?
California law limits temporary disability payment to 104 weeks within a five-year period from the date of injury. Temporary disability payments generally begin on the fourth day after an injury if the worker misses more than three days of work due to the injury. Employees are entitled to temporary disability benefits for up to 104 weeks, except in cases of serious conditions such as chronic lung disease, which may extend this duration. After this:
- You may be evaluated for permanent disability benefits.
- You could pursue vocational retraining under SJDB.
- If your injury is severe, you might qualify for a life pension or additional support.
How Long Does an Employer Have to Hold a Job While You’re on Workers’ Compensation?
California law does not mandate that employers hold your job indefinitely. However:
- Employers cannot retaliate or fire you solely for filing a claim.
- You may have protections under the Fair Employment and Housing Act (FEHA) or Family and Medical Leave Act (FMLA).
- If you’re able to return with restrictions, your employer must attempt to reasonably accommodate you. Employer responsibilities under California law include providing reasonable accommodations, informing you of your rights, and ensuring compliance with workers’ compensation requirements.
- If your employer refuses to accept your medical restrictions or does not accommodate your return, you may have grounds for legal action or eligibility for additional disability benefits.
What Is the New Workers’ Comp Law in California?
As of 2024, updates to California workers compensation laws include:
- Expansion of presumptive coverage for first responders.
- Tighter enforcement of timely medical authorizations, with reference to updated medical treatment guidelines such as the Medical Treatment Utilization Schedule (MTUS).
- Digital filing and streamlined documentation requirements for employers and providers.
These changes aim to reduce delays and improve outcomes for injured workers.
Exceptions and Challenges to the 90-Day Rule
While the 90-day rule offers strong protections, there are exceptions:
- Fraud or misrepresentation by the employee may invalidate the presumption.
- Claims involving cumulative trauma or delayed symptoms may face scrutiny. For injuries that develop gradually, such as repetitive strain injuries, the 90-day reporting period starts when the employee is aware of the work-related connection.
- Employers may still contest aspects of the claim after acceptance, such as the extent of disability or treatment. In these disputes, medical evidence and medical records play a crucial role in supporting or challenging the claim.
- If an employer fails to respond within the 90-day period, the workers compensation case may be reviewed by a workers compensation judge or the workers compensation appeals board, which oversee the resolution of such disputes.
Legal representation is critical to protect your full entitlement.
Regional Relevance: California’s Strict Timelines and Legal Protections
California has some of the strongest employee protections in the country for workers’ comp claims, with California’s workers compensation laws providing strong protections for work injuries. Courts enforce the 90-day rule strictly, penalizing insurers who delay without just cause. Employers who miss the 90-day deadline cannot simply deny your claim later without clear, substantiated legal grounds.
Consult a Workers’ Compensation Attorney If Your Claim Is Denied
If your claim was denied after 90 days or you were denied early treatment, it’s time to seek legal support. Consulting a workers compensation lawyer, workers comp lawyer, or workers comp attorney can help you understand your rights and improve your chances of overturning a denial or securing the benefits you deserve. At Scher, Bassett & Hames, we:
- Investigate claim denials and insurer delays
- Enforce the full scope of your legal rights
- Secure retroactive and future compensation
Call 408-739-5300 for a free case review. There’s no fee unless we win.
Further Reading:
- What is the Statute of Limitations on Work Comp Claims in California?
- How Much Are California Workers’ Compensation Settlements?
- When Can You Sue for a Work-Related Injury in California?
- How Long Does It Take for a Workers Comp Settlement in California?
Resources:
- California Department of Industrial Relations – Workers’ Compensation Overview
- California Labor Code Section 5402
- DWC Claims Filing Guidelines
- State of California – Division of Workers’ Compensation Forms
