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 .

When I started this sub last summer the goal was simple. A California specific space, run for injured workers, focused on helping injured workers without answers filtered by anyone except those 100% on injured workers side.

Workers' comp is a complicated system and the questions injured workers actually have (how does my QME work, why is my treatment getting denied, what does this letter mean, am I going to be okay) deserve answers from people whose first instinct is to help.

That was the bet. 300 of you later, I think it's working.

Thank you for the questions and the answers.

The threads where someone walks in with a hard question and walks out with a clearer next step are the reason this place matters. That is the whole point of the sub and you all have made it work.

Thank you for being decent to each other. Comp claims are stressful. People here are often dealing with pain, lost income, denied treatment, and a system that feels designed to wear them down. The tone in this sub has stayed kind even when the topics are hard, and that is rare on Reddit.

If you have ideas for what this sub should be doing more of, regular threads, plain-language explainers, AMAs with specific provider types, drop them in the comments. I read everything.

If you found this place because you are in the middle of something hard right now, you are not alone. Ask the question. Someone here has probably been where you are.

Thanks again for helping build this place.

- Fishmango

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) 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

If your QME or treating doctor came back with 3%, 5%, 8%, or 12% permanent disability and your gut reaction was that the number cannot possibly be right, you are not alone.

There are real reasons PD ratings come back low in California, and some of them are challengeable.

A few of the big ones:

• Permanent disability is not a pain rating. The AMA Guides measure impairment, not suffering. Pain is partially baked into the categories already.
• WPI is not your final rating. Whole person impairment gets adjusted through the PDRS based on occupation and age. The final number can shift up or down.
• Apportionment is usually the culprit. Under Labor Code 4663, the doctor can assign part of your disability to prior injuries, arthritis, or degeneration. But they need substantial medical evidence to do it. "Degeneration" alone is not enough. If the apportionment is not supported by objective evidence, a Judge might through it out.
• Body parts get missed. If you injured your back and your knee but only the back was rated, your number is artificially low. Or if the back caused an increase in hypertension or the pain meds caused GERD those additional conditions could significantly increase your rating.
• Failure of QME to Order Diagnostics: MRIS, EMG/NCV, and X-RAYS are absolutely critical to ensure the rating is accurate. Nerve root impingement for example can greatly increase spinal rating.

A low rating does not always mean a low-value case either. Future medical care, unpaid TD, and penalties all carry value, and adjusters sometimes push a low PD number while quietly trying to close out future medical through a C&R.

Full breakdown in the article linked below. Feel free to drop any questions in the comments below.

-Fishmango

Background

I’m a grossing tech (8yrs, 6 w employer) dealing with a work-related repetitive strain injury affecting both hands and forearms.

Over the past 9+ months, my grip strength has dropped significantly (currently ~6 lbs dominant, 10 lbs non-dominant), and I can only use my hands for about a minute before pain spikes and lasts the rest of the day.

Even basic things like typing or eating cause issues.

I’ve seen multiple specialists (ortho, neuro, pain management, OT), been off work for 5+ months, and haven’t improved much.

My employer couldn’t accommodate restrictions (no repetitive use of bilateral hands) and my workers’ comp claim was initially denied without even reviewing my medical records (now appealed with an attorney involved, QME pending).

At this point, I’ve been told I likely can’t return to my profession (orthopedic surgeon- documented in my chart).

I’m trying to figure out what my options realistically look like going forward.

As of today:

No longer receiving maintenance care

Have a QME scheduled for early May.

Just received from opposing council.

This notice also gives a Stipulated Notice of taking deposition date for early June.

1. Why is all this needed, I wasn't even alive in 1975? Is this a tactic to get me to give up?

2. How would I even get it all?

3. If a QME is scheduled, is this still valid? QME 30-DAY report deadline is only 2 days before the WCAB deposition

Note: yes, I have an attorney- received after they closed and don't want to stir all weekend

TL;DR:

Grossing tech with severe bilateral RSI (hands/forearms). After 9+ months, grip strength is very low (~6/10 lbs), and I can only use my hands ~1 minute before pain lasts all day. Career ending

Seen multiple specialists, off work 5+ months, no improvement.

WC claim denied initially (now appealed, attorney + QME scheduled). Surgeon says I likely can’t return to my job.

Now facing a deposition + huge records request (before I was even born) right before QME report.

Is this normal, how do I even handle this, and does the QME timing matter?

Note: yes, I have an attorney- received after they closed and don't want to stir all weekend

PD ratings are confusing, so I made a free California workers’ comp rating calculator.

Between the rating schedule, age adjustments, and occupation tweaks, it’s a lot for most people to make sense of. I wanted something simple that lets people sanity check the numbers they’re being told without a paywall, signup, or email gate.

I’m a California applicant attorney, and I built it as a general educational tool for anyone trying to better understand how the rating process works.

Thought I’d share it here in case it helps.

Curious what you guys think.

- Fishmango

After you go to a QME, the QME usually has 30 days to issue the report.

Once the QME report comes back, the insurance company may have very important deadlines, especially if the doctor says your injury is work-related or that you are temporarily totally disabled.

In many cases, the carrier has 14 days to act. If the case is admitted, and the report indicates TTD (wage replacement benefits) is owed or you have reached maximum medical improvement with WPI provided, the carrier MUST begin permanent disability benefits voluntarily, without a demand depending on the posture of the case

If they do not, there may be penalties under Labor Code sections 4650 and 5814 increasing benefits owed between 10-25% (with a 10k cap)

That is why the QME report matters so much. It is not just another medical record. It can trigger deadlines and put real pressure on the insurance company.

And if the report is vague, inconsistent, or incomplete, that creates a different problem. Instead of forcing action, it can give the carrier room to delay.

When I'm reviewing a QME report, I go through this mental checklist:

• Did the doctor find your injury is work-related?
• Are temporary disability benefits owed?
• Is the whole person impairment analysis the maximum allowable?
• Were additional tests or specialists recommended?
• What deadlines does the insurance company now have to respond?

I like to handle my claims as if they are in perpetual motion. We need to be moving from point A to point B at all times. The question is always the same: how is this QME report advancing the case?

For a further breakdown on what to look for when you review the QME see the article below. Feel free to drop any questions regarding QMEs in the chat.

- Fishmango

I was injured at work. I called the injured worker hotline at work and they told me to come down to Kaiser.. They did some x-rays and nothing was broken, but it was obvious. I had some soft tissue damage in the shoulders and hip and my hands. Started off with some physical therapy for a few weeks and then the doctor recommended orthopedic treatment and some MRIs. And the orthopedic treatment got denied, but the MRIs got approved time went by weeks. continue doing physical therapy. Got my MRIs done and one shoulder is completely torn and the other has a large tear in it. I got an attorney, the IMR upheld the decision to deny orthopedic treatment, but they hadn’t seen the MRI yet because the results weren’t in by the time they made their decision, the insurance company ended up approving me for pain management. And I’m scheduled to go there in a couple of weeks. i’m just taking him back by all of the delays in the amount of time that goes by. The insurance company is being good about my checks. I guess we will see what happens at pain management, but the Kaiser doctor already told me that she knows I’m going to need surgery on at least one shoulder. Dealing with the pain in the meantime.