Bulletin 94-9

November 4, 1994

DWC ENCOURAGES WCAB SETTLEMENTS

IF SUMMARY RATING NOT TIMELY ISSUED

The Division of Workers' Compensation is taking another step towards resolving the delays associated with the backlog of requests for summary rating determinations. Claims administrators are being encouraged to attempt to reach proposed settlements with unrepresented injured workers if the parties have not received a summary rating within the statutorily required 20 days, and then submit the settlements to the local WCAB office for review and approval.

Since 1991, the law has provided a mechanism for injured workers who are not represented by an attorney to obtain a permanent disability rating based on a medical evaluation by a Qualified Medical Evaluator (QME) selected by the worker from a three-member panel randomly assigned by the state Industrial Medical Council. This summary rating process is intended to provide unrepresented workers an expeditious, fair permanent disability rating without the need for litigation. DWC is required to provide a rating of medical evaluations it receives within 20 days.

For a variety of reasons, DWC has been unable to issue ratings within the statutory 20 day period. A large backlog of summary rating requests has developed at many of the offices around the state. Statewide, approximately 20,000 cases await ratings from DWC's Disability Evaluation Unit. In some offices it now takes up to a year to obtain a rating. In addition, approximately 2,500 cases are awaiting a decision on a request for reconsideration of a summary rating.

The additional resources DWC has devoted to these functions has improved the situation, but it remains intolerable for both injured workers who are waiting for their benefits and claims administrators who are trying to promptly resolve cases.

The law requires unrepresented workers injured after January 1, 1991 to obtain an evaluation from a QME in accordance with the statutory requirements, and prohibits the filing of an application for adjudication (or a declaration of readiness for post January 1, 1994 injuries) until the appropriate medical evaluation has been

performed. Additionally, settlements cannot be approved unless the appeals board determines the settlement is in the best interest of the employee and that proper procedures have been followed in determining the permanent disability rating.

In the normal course of events, a settlement involving an unrepresented worker should not be approved unless a summary rating has been obtained. However, once the statutory deadline for DWC to issue a rating has passed, there is no way that "proper procedures" can ever be considered to have been followed. Therefore, where a summary rating has not been issued within the 20 day statutory deadline, DWC is encouraging the parties to attempt to negotiate a settlement and submit it to the local office of the appeals board for approval.

To assure prompt processing, the following documents should be included when submitting these settlements:

* WCAB Data Entry Form;

* All medical reports;

* Completed "Employee's Permanent Disability Questionnaire" (DEU Form

100);

* Claims administrator's rating which led to the proposed agreement;

* Job description or job analysis, if available;

* Wage statement for employees with less than maximum earnings;

* Signed Stipulated Findings and Award or Compromise and Release

Agreement;

* DEU Summary Rating, if completed during or after the settlement discussions.

Upon receipt, the Disability Evaluation Unit will be internally advised that a settlement has been received so they know a rating is no longer required. However, DEU will be consulted as necessary to review proposed ratings that are complex or appear to be inaccurate.

If the settlement proposal appears to be inadequate, the claims administrator will be advised that the settlement will be set for hearing on adequacy unless it is increased to an amount determined appropriate by the assigned appeals board personnel. Cases not resolved in this manner will be set for hearing.

Parties who have requested reconsideration of a summary rating should also feel free to send a letter withdrawing their request at any time and instead resolve the

case by submitting a proposed settlement to the local office of the appeals board.

DWC will concurrently monitor the success of the pilot project recently initiated in San Bernadino to expedite the resolution of cases through informal conferences with Information and Assistance Officers.