What Is A Claims Administrator?

A Claims Administrator for Workers’ Compensation is a company working under the guidelines of the California Division of Workers’ Compensation (DWC) and is charged with expediting the delivery of workers’ compensation benefits and services to injured workers’ without unnecessary litigation or delays. Typical examples of claims administrators are:

  • Insurance Carrier – internal claims department

  • Third-Party Administrator (TPA) – that is where we fit in, Elite Claims Management

  • Self-Insured Employer – employer’s internal claims department

Here are a few important details to keep in mind about a workers’ compensation claim:

  • Within 14-days of knowledge of the claim a notice will be mailed to the injured employee and all parties of either acceptance, delay, or denial of the claim

  • The date of knowledge begins with the employer’s date of knowledge not the claim analyst’s date

  • If claim is delayed a decision must be made within 90-days of receipt of the DWC 1 claim form

  • If claim is delayed and later accepted lost time benefits must be mailed within 14-days of the claim being accepted

Examples of Work-Related Injuries or Illnesses

The injury or illness must arise out of employment (AOE) and occur during the course of employment (COE). Examples of on-the-job injuries or illnesses are:

  • Cumulative trauma injury caused by repetitive keyboarding (RSI/musculoskeletal)

  • A broken arm from falling off a ladder

  • Lower back strain from lifting a box or prolonged seating

  • Hearing loss due to ongoing exposure to excessive noise levels

Not a work injury? Here are examples of injuries or illnesses that are not considered work related:

  • Post termination or after notice of lay-off

  • Ordinary commute to or from work (going and coming rule)

  • Off-duty recreational activity

  • Injuries caused by intoxication or drugs (medical evidence)

  • Psychiatric injuries – employee must be employed by employer for at least 6-months and 51% caused by employment (except: violent act, loss of limb, paralysis, severe burn or head injury)

Types Of Workers’ Compensation Claims

If a work-related injury or illness occurs at your company, there are several scenarios that the particular incident may fall into, including:

Incident or Report Only

  • No medical care was necessary – your option of reporting to TPA

First Aid

  • Requires one-time medical visit and one follow up visit

  • No lost time beyond the date of injury (DWC-1 is not required)

Medical Only

  • Medical care needed (DWC-1 is required)

  • Injury is not disputed

  • Injury is not litigated

  • No lost time

  • Full recovery and discharge is anticipated

Indemnity

May include one or more of the following:

  • Lost time (DWC-1 required)

  • Entitled to temporary disability, LC4850, or salary continuation benefits

  • Injury results in permanent disability

  • Potential for 3rd party subrogation

  • Delayed claim

  • Litigated claim

Future Medical

  • Claim has been settled and a need for future medical treatment was included within the settlement

Types Of Settlements For Permanent Disability Claims

If you have a Permanent Disability (PD) caused by a work-related injury or illness, the State of California has two types of settlements that you may receive, known as “Stipulations with Request for Award” and “Compromise and Release”.

Stipulations with Request for Award

If a workers’ compensation case goes to a hearing, the judge may rule for a Stipulation with Request for Award. This type of settlement will usually require payment of a specified weekly benefit for a specified number of weeks. This agreement settles the extent and level of Permanent Disability, but leaves open future medical care provisions.

Compromise and Release

The second type of settlement is known as a Compromise and Release. Under this settlement, the employee agrees to accept a lump sum of money to resolve the workers’ compensation claim. That payment settles the entire aspect of the claim – Permanent Disability, Temporary Disability, and all future medical care costs. In other words, there will be no future payment of benefits and the insurance company will have no obligation to pay for future medical care costs.

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