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Chapter 8. Office of the Director
Subchapter 2. Administration of Self-Insurance Plans
Article 11. Hearing and Appeal Procedures

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§15431.2. Complaints.

(a) Any self-insured employer, administrator, the Self-Insurers' Security Fund, or injured employee of a self-insured employer may file a complaint to the manager in writing concerning the failure of any self-insured employer or administrator to provide timely payment of benefits due or to fund the payment of such benefits.

(b) The Manager shall review any complaints received and may investigate the complaint, determine what benefits may be due and order payment thereof, audit the claim records of the self-insurer or administrator, and take action to revoke the certificate or certificate to administer for cause.

(c) The Manager shall not seek to substitute his/her judgement for that of the Workers' Compensation Appeals Board on any adjudicated claim and may refuse to consider the complaint of any injured worker's entitlement to benefit or self-insurer where the matter involved in the complaint is waiting the decision of the Appeals Board.

(d) Any written complaint shall include the following information:

(1) The basis of jurisdiction of the Director;

(2) The relief or action requested;

(3) The grounds for the requested relief or action;

(4) The facts involved in the complaint;

(5) A statement of whether or not the specific claim or claims is being adjudicated before the Workers' Compensation Appeals Board and the Appeal number of the claim before the Appeals Board; and

(6) The name of the parties known to the complainant against which any relief is sought or who have an interest in the proceeding. The complaint shall be served on these other persons who may have interest in the proceedings by the person submitting the complaint.

NOTE: Authority cited: Sections 54, 55 and 3702.10, Labor Code. Reference: Sections 59, 3700, 3701, 3701.5, 3702, 3702.1, 3702.7, 3702.9, 3702.10 and 3740-3747, Labor Code; Sections 11181-11188 and 15378, Government Code.

HISTORY

1. New section filed 12-17-90; operative 1-16-91 (Register 91, No. 6).

2. Editorial correction of printing error of NOTE (Register 91, No. 46).

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