Newsline No. 56-08 printer image Printer friendly

September 9, 2008

 

Division of Workers’ Compensation posts revised benefit notices manual

The Division of Workers' Compensation (DWC) has updated three benefit notices and posted a revised benefit notice manual and sample benefit notices to its Web site. The benefit notice manual offers guidance for claims administrators in providing injured workers with notices that comply with the benefit notice regulations.

California’s regulations (Title 8, California Code of Regulations, sections 9810, 9811, 9812, 9813, 9813.1 and 9813.2) provide that benefit notices, except those notices whose language or format is set forth in statute, or those specific notice forms adopted by regulation, may be produced in any format developed by the claims administrator. The regulations require that each benefit notice contain all relevant elements required by either statute or regulation. They also require the DWC administrative director to make sample notices that comply with these requirements available on the DWC Web site.

The following statement has been added to the sample “Notice of Denial and Delay of all Workers’ Compensation Benefits” (section 9812(i)) and the “Notice of Delay in Determining Liability” (section 9812(j)):

Note: For unrepresented workers, Labor Code §4060(e)(1) requires that each notice shall describe the administrative procedures available to the injured employee with respect to a comprehensive medical-legal evaluation. Unrepresented workers need to be advised when the compensability of the claim is based upon a medical decision. Should they choose to dispute the medical decision, the procedure is through Labor Code §4062.1. Place the following warning in not less than 12 point font at the top of the first page of the notice: “You may lose important rights if you do not take certain actions within 10 days. Read this letter and any enclosed fact sheets very carefully.” Attach a copy of the Request for QME Panel (IMC form 106) to the notice.

The “QME Panel Request Form” should also be included as an enclosure to the “Notice of Denial and Delay of all Workers’ Compensation Benefits” (section 9812(i)), the “Notice of Delay in Determining Liability” (section 9812(j)),and the “Notice Regarding Denial of Workers’ Compensation Benefits.”

The division has received questions concerning whether an AME/QME fact sheet should be provided to an injured worker who sustains permanent disability, but who has lost no time from work as a result of his or her injury. Although the benefit notice regulations do not address this issue, the division believes that a prudent claims administrator should provide the AME/QME fact sheet once an injured worker in a medical only case achieves P&S status and has permanent disability and/or a need for future medical care.

The sample notices are not intended to be used verbatim in lieu of individual notices tailored to the specific facts of each claim. The revised benefit notice manual and sample benefit notices can be found on the DWC Web site at http://www.dir.ca.gov/dwc/audit.html.

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