California Workers Compensation insurance companies send injured workers form notifications of important events in a claim that affect benefits. Notices relate to:
- Injured worker rights
- Acceptance of claim
- Medical appointment and treatment
- Medical record requests
- Available permanent work
- Job Vouchers
In this article, our California personal injury attorneys will explain in detail the notices an injured worker will receive and the effect each notice will have on the collection of workers compensation benefits.
Common notices an injured worker will receive include:
- 1. Claim Form and Notice of Potential Eligibility
- 2. Letter to accept or deny injury
- 3. Approval or denial of medical treatment
- 4. Payment of disability benefits
- 5. Notice of request for medical records
- 6. Notice of medical appointments
- 7. Notice of available work
- 8. Supplemental Job Displacement Benefits
- 9. Notices of Hearing
- 10. Minutes of Hearing
- 11. Notices provide important information about an injured worker's benefits
When an employee reports an injury, the employer is required to give him or her a claim form & notice of potential eligibility within one working day.1
The injured worker uses the Claim Form to file a California workers' compensation claim with his or her employer.
The form contains information about:
- release of prior medical records
- Action when an injured worker disagrees with a doctor's recommendations
- Payment of lost wages
- Ability to continue working
- Payments if the injured worker does not completely recover from his or her injury
- Retraining vouchers
- Death benefits
- Getting fired for filing a claim
- State disability benefits for denied claims
- Contacting an Information and Assistance Officer for questions
- The right to consult with an attorney
In the form, the injured worker will need to describe the injury and state which parts of body are injured. The form is returned to the employer by mail or in person.
The employer is required to sign and date the claim form and give a copy to the injured worker and the insurance company.2
Once this form is turned in the injured worker can select a treating doctor and obtain medical treatment.
The insurance company must provide up to $10,000 in medical care until it decides to accept or deny the claim for injury.3
After an injured worker turns in a claim form, the insurance company must decide within 90 days if they believe there was an injury at work.
But if the insurance company can't decide within the first 14 days, they are required to send the injured worker a notice that there will be a delay in making a decision.4
If the insurance company disputes that there was a work injury, it has to send a notice within 14 days of making that decision. It is required to include any medical reports that factored into the decision with the notice.5
If workers' compensation benefits for the injury are delayed or denied the injured worker will also get a form to request an independent doctor review his or her case to determine if there is a work injury.6
If the injured worker's claim is not denied within 90 days of the claim form, it is considered accepted.
All medical treatment for a work injury is reviewed by an independent process called “Utilization Review” to determine if it is appropriate.7
The injured worker's doctor will send the request to the insurance company, who will send the request to Utilization Review. The insurance company has five days to decide to approve the treatment.8
A notice of the medical treatment decision will be sent to the doctor and the injured worker. The notice will state:
- the date of the request
- description of the treatment
- the decision to approve or deny and an explanation
- how to resolve any dispute
If the treatment is approved, there is a date it must be completed by.9
If the treatment is denied the notice will also state:
"You have a right to disagree with decisions affecting your claim. If you have questions about the information in this notice, please call me (insert claims adjuster's name in parentheses) at (insert telephone number). However, if you are represented by an attorney, please contact your attorney instead of me.
"For information about the workers' compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an Information and Assistance (I&A) officer of the state Division of Workers' Compensation. For recorded information and a list of offices, call toll-free 1-800-736-7401."10
An injured worker will receive a notice the first time benefits are paid for lost wages.11 It will state:
- the amount due
- how it was calculated
- how long it will last
The notice is sent within 14 days of the start of the lost wages.
The insurance company must provide a notice if:
- there is a delay in its ability to determine if lost wages are due12 or
- there is a denial of those benefits.13
the insurance company must state the reason for any delay or denial of temporary disability,. If the denial is based on a medical report, that report must be included with the notice.14
When an injured worker stops getting payments for lost wages he or she must be told that:
- his or her medical condition has stabilized and will likely not improve and the amount of permanent damage; or
- his or her medical condition has not stabilized, and it is too soon to tell if there will be permanent damage15
Permanent damage is considered permanent disability in a workers comp case. In this case the injured worker will receive a notice that will come at the same time as the last notice of lost wages or within 14 days of finding out there is permanent disability.16
If the injured worker does not have an attorney, the notice will have instructions on:
- How to file an Application for Adjudication of Claim if the injured worker disagrees with the level of disability
- How to get the medical report reviewed for the level of permanent disability
- How to request a second opinion for the disability from a different doctor
If there is permanent damage and payment of permanent disability, the notice will state:
- the weekly payment amount
- how it was calculated
- how long payments will last
- estimate of total payments
An employee will also receive notices when:
- disability benefits are stopped17
- disability benefits are restarted18
- the rate of disability benefits changes19
An insurance company requests an injured worker's medical or personnel records using a subpoena. This is a court document sent by the person who wants the records to the person who has the records.
The insurance company can request records from any of the injured worker's:
- prior medical doctors
- visits to an emergency room
- hospital stays
- psychiatric treatment
- current employer
- prior employers
- prior insurance claims
The insurance company can request any records that may be in some way related to the work injury.
However, the injured worker will be notified and have a chance to stop the records from being given out.20
The injured worker can notify the party obtaining the records and the party that has the records that there is an objection to turning over the records. The should be done five days before the records are turned over. If that deadline can't be met it should be done before the date they are to be turned over.
The issue is either worked out by the two parties or resolved by a judge.
If the injured worker does not object the records are collected, company will come and copy the records, or the facility will mail the records out.
Example: Jim receives a notice on April 20th that records from his family doctor and prior employer have been requested by the insurance company in his workers' compensation claim. The notice also states that the records will be turned over on May 12th.
Jim objects on May 7th to the records being turned over to the insurance company.
A doctor examining an injured worker must send out a notice of the appointment within five days of making the appointment.21
The notice goes to the injured worker and the claims administrator for the insurance company.
The doctor cannot cancel the appointment less than six calendar days before the appointment without a good reason.
The claims administrator for the insurance company has to send all of the injured workers medical records and reports to the doctor before the exam date.
Even if the doctor does not get the medical records before the exam date, that is not a valid reason to cancel the exam.22
A Notice of Regular, Modified, or Alternate Work tells an injured worker if an employer has a job for him or her after his or her injury has stabilized.23
An injured worker may or may not completely recover from an injury. At some point his or her condition will stabilize. When that happens, the employer has to review the injured worker's current condition and decide if there is a job available.
If an injured worker has permanent damage from a work injury, he or she may not be able to do the same job in the same way as before the injury. Once this happens, the insurance company and employer have 60 days to make an offer to modify the injured worker's job or offer alternate work.24
The physical requirements of any work must be within the abilities of the injured worker. This is based on the injured worker's condition after the injury and physical restrictions given by his or her doctor.
The form will state:
- position offered
- job title
- job description
- physical requirements
The job must be expected to last at least 12 months.
Regular work means the injured worker can do the same job. Modified or alternate work has to be at least 85% of the injured worker's prior salary and within a reasonable commuting distance.25
The injured worker can object to the offer if the commute is too long compared to his or her prior location or if the shift is different.
If the injured worker does not accept the offer, the employer will not take them back.
The injured worker has 30 days to decide.26
The injured worker will not be able to receive any money to train for another type of work if he or she does not accept the offer.
If an employer does not make an offer of work within 60 days, it has to send a supplement job displacement voucher to the injured worker.27
The voucher is for $6,000. It can be used for:
- education-related training
- examination and licensing fees
- job search assistance
- educational training tools
- computer equipment up to $1,000
- up to $500 for miscellaneous expenses
The voucher will include forms for the injured worker to fil to out request each of these.
The voucher will state the date it expires.
The workers' compensation court, known as the Workers' Compensation Appeals Board, will notify the injured worker of any hearing dates related to his or her case.28
The notice has to be given at least ten days before the hearing.29
A Minutes of Hearing shows who attended a hearing on a specific date and the result of the hearing.30
Each person who attends the hearing puts their name on the form. It is specifically noted whether the injured worker is present or not present.
The judge will write on the form what happened at the hearing and what the next step will be. This could be another hearing or instructions as to what one party must do as a result of the hearing.
If there is another hearing, the date, time, and location will be listed on the Minutes of Hearing.
All of the parties involved in the case will receive a copy of the Minutes of Hearing in the mail.
An Insurance company is required to provide notices to injured workers about the actions it takes in a claim.
By understanding the information received from an insurance company, the injured worker can make sure he or she is getting the all the benefits available in the workers' compensation settlement.
Cal. Lab. Code § 5401(a) Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, which injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits under this division to the injured employee, or in the case of death, to his or her dependents.
Cal. Lab. Code § 5401(c) A dated copy of the completed form shall be provided by the employer to the employer's insurer and to the employee, dependent, or agent who filed the claim form.
Cal. Lab. Code § 5402(c) Within one working day after an employee files a claim form under Section 5401, the employer shall authorize the provision of all treatment, consistent with Section 5307.27, for the alleged injury and shall continue to provide the treatment until the date that liability for the claim is accepted or rejected. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000)
Cal. Code Regs., tit. 8, § 9812(g)
Cal. Code Regs., tit. 8, § 9812(i)
Cal. Code Regs., tit. 8, § 9812
Cal. Lab. Code § 4610
Cal. Code Regs., tit. 8, § 9792.9.1
Cal. Code Regs., tit. 8, § 9792.9.1(d)(1)
Cal. Code Regs., tit. 8, § 9792.9.1(b)(1)(E)
Cal. Code Regs., tit. 8, § 9812(a)(1)
Cal. Code Regs., tit. 8, § 9812(a)(2)
Cal. Code Regs., tit. 8, § 9812(a)(3)
Cal. Code Regs., tit. 8, § 9812(a)(2)&(3)
Cal. Lab. Code § 4061(a)
Cal. Code Regs., tit. 8, § 9812(e)
Cal. Code Regs., tit. 8, § 9812(d)
Cal. Code Regs., tit. 8, § 9812(b)
Cal. Code Regs., tit. 8, § 9812(c)
Cal Code Civ Proc § 1985.3(g)
Cal. Code Regs., tit. 8, 110
Cal. Code Regs., tit. 8, 35
8 CCR 10133.34
Cal. Lab. Code § 4658.7
Cal. Lab. Code § 4658.1
Cal. Lab. Code § 4658.6
Cal. Lab. Code § 4658.7(c)
Cal. Lab. Code § 5504
Cal. Code Regs., tit. 8, § 10544
Cal. Code Regs., tit 8 § 10566