Experienced human resource professionals may know the answer. But what if you run your own business and don’t have an experienced HR professional to rely on? What if you have not handled a workplace injury claim before or are uncertain about the claim process? This article will provide a summary of the process. Keep in mind that this summary applies to the California workers’ compensation system. Each state has its own system with its own claim process.
Does it matter how the injury is reported?
No. For the initial handling of a claim, it does not matter how an employer learns that an employee has been injured on the job. The California Labor Code, which controls the workers’ compensation system, requires an employee who has been injured on the job to serve his or her employer with a written claim form at some point. But section 5402(a) clarifies that, “Knowledge of an injury, obtained from any source…or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service…”
As soon as an employer has knowledge of a work place injury, the employer must address the potential workers’ compensation claim. What is the first step an employer should take?
Provide a claim form to the employee.
After learning of an injury, whether reported by the employee or from some other source, an employer must provide the employee with a claim form. Section 5401 requires, “Within one working day of receiving notice or knowledge of injury…the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits…”
Your insurance carrier or claim administrator should be able to provide claim forms which include the notice of benefits. The form, “Workers’ Compensation Claim Form (DWC1) & Notice of Potential Eligibility” is also available on the Division of Workers’ Compensation website.
Provide the form and attached notice of benefits to the employee. The employee will complete the employee section of the form and then return it. What is the next step?
Report the claim to your workers’ compensation insurance carrier.
Once an employee completes the form and returns it to the employer, an employer has one working day to complete the employer portion of the form, sign it, and date it. Section 5401(c) requires that an employer provide a copy of the completed claim form to its insurance carrier and to the employee.
Promptly reporting the claim to the insurance carrier is vital because an employer is required to authorize medical treatment almost immediately. Section 5402(c) requires, “Within one working day after an employee files a claim form…the employer shall authorize the provision of all treatment…” Medical treatment must be provided, up to $10,000 until the claim is either accepted or rejected. If the employee misses work, the employer has only 14 days to either start payment of temporary disability payments or an explanation for the delay.
Your insurance carrier will take over handling of the claim including providing the medical treatment, providing disability payments and conducting an investigation. So it is important to immediately report the claim to your insurance carrier. In addition to the workers compensation reporting requirements, there are also requirements that workplace injuries be reported to the Division of Occupational Safety and Health (commonly referred to as Cal OSHA). Consult with your insurance carrier or an attorney for more information about these reporting requirements.
You do have insurance, right?
Workers’ compensation insurance is not just a convenience, it is required by law. California requires that every private employer either have workers compensation insurance or be certified as self-insured. Failure to comply with the insurance requirement is a misdemeanor.
What if the claim is questionable or even false?
An investigation period is built into the claim process. An employer has 90 days from the date an employee files a claim to either accept or reject the claim. After that time, if the claim is not rejected, it is deemed to be accepted. Section 5402(d) explicitly provides that the provision of medical treatment does not waive the right to reject the claim.
Generally, the investigation and administration of the claim will be conducted by your insurance carrier. Every claim is unique and this is only a summary of the claim process. Questions about specific details, or handling the claim after the initial processing may arise, so it is important that you consult with your insurance carrier or an attorney once a claim is made. If you have any questions you may contact Christopher D. Holt at 714-542-1800 or firstname.lastname@example.org.
The opinions expressed in this employment update are general in nature, and are not meant to provide specific legal advice. For more information, please contact a Klinedinst attorney. No attorney/client privilege is created or assumed by reading this newsletter.