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 [...]
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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 [...]
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 [...]
Workers’ Compensation claims are limited to work related instances resulting in injury, illness, or death. The benefits available to the injured employee are determined by the state of California and work through a process known as “No Fault System / Exclusive Remedy”. This means that an employee relinquishes the right to sue the employer in exchange for a specified set of benefits. Medical Treatment Prompt and quality medical treatment subject to approval (Utilization Review process) Governed by the Medical Treatment Utilization Schedule (MTUS) Employer covers 100% of costs (limits to physical therapy and chiropractic treatment – 24 visits) Costs subject to [...]
Permanent Disability (PD) is defined by the State of California as any lasting disability from your work injury or illness that affects your ability to earn a living. If your injury or illness results in PD you are entitled to PD benefits, even if you are able to go back to work. Most employees injured on-the-job fully recover from job injuries but some continue to have medical problems. However, PD benefits are limited and you may not recover all of your lost income. Here is more information to understand: Determined at the time the injured worker is deemed Permanent & Stationary (P&S) [...]
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 [...]
Supplemental Job Displacement Benefits (SJDB) is a non-transferable voucher that can be used to pay for educational retraining or skill enhancement (or both), at a state-approved or state-accredited school. The employee must have had a permanent partial disability caused by an injury on or after January 1, 2004 to qualify for SJDB. Here are a few more details to consider: Vouchers to help pay for retraining or skill enhancement if employee doesn’t recover completely and does not return to work 10% of amount can be used for vocational and return to work counseling, if needed Amount of voucher – for DOIs [...]
Life Pension There are two types of Life Pension that you may be entitled to: Permanent Total Disability and Permanent Partial Disability. You must have a Permanent Disability (PD) rating of 70% or more to be entitled to a life pension. The amount is based upon a formula using variable determined by your PD rating and your weekly earnings. We understand this can be a confusing topic, so feel free to reach out to our experienced claims analysts to answer your questions. Here are a few more details to remember: Injuries resulting in PD ratings 70% through 99 ¾% Payments begin after [...]
If your workers' compensation claim is accepted, you are entitled to receive payments because you can't perform your usual and customary work. We have listed some important information regarding your Lost Time Benefits: Lost Time Benefit, or Temporary Disability (TD) is not paid for the first 3-days (waiting period) until the employee has lost 14-days or the employee is hospitalized Benefit calculated based on a 7-day workweek Benefit check must be mailed no later than 14-days from the 1st day of lost time and every 14-days thereafter If TD due is not paid timely, the amount of the late payment must [...]
When you suffer an injury or illness at work, it is important to receive the necessary medical treatment to help get you healthy and back to work. A doctor or a physician will be responsible for requesting your treatment. For a physician to obtain medical treatment authorization, the requesting physician must submit a compliant Request For Authorization (RFA) to the claims administrator. In response, if the claims administrator does not authorize the treatment request, the RFA is sent to an accredited Utilization Review (UR) company to approve, modify, or deny the requested treatment. Whatever the outcome, claims administrators or the utilization [...]