This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at http://www.dir.ca.gov/od_pub/disclaimer.html.

Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 8. Benefit Notices; Claims Administrator’s Duties and Responsibilities; Claim Form and Notice of Potential Eligibility for Benefits; Regulatory Authority of the Administrative Director.

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§9811. Definitions.

As used in this Article:

(a) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, a self-administered joint powers authority, a self-administered legally uninsured, a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority, or an administrator for an alternative dispute resolution (ADR) program established under Labor Code section 3201.5 or 3201.7.

(b) "Date of knowledge of injury" means the date the employer had knowledge of a worker's injury or claim of injury.

(c) "Date of knowledge of injury and disability" means the date the employer had knowledge of (1) a worker's injury or claim of injury, and (2) the worker's inability or claimed inability to work because of the injury.

(d) "Duration" means any known period of time for which benefits are to be paid, or, where benefits will continue for an unknown period of time the event that will occur which will determine when benefits will terminate.

(e) "Employee" includes dependent(s) in the event of any injury which results in death.

(f) "Employee's (or claimant's) remedies", means a statement of the employee's rights of which an employee or claimant shall be informed in benefit notices when specified in these regulations.

Every benefit notice, excepting those mandatory notices set forth in statute or where a specific notice form has been adopted as a regulation, shall include a mandatory statement of employee's (or claimant's) remedies:

For claims not falling under an alternative dispute resolution program (ADR) program under Labor Code sections 3201.5 or 3201.7, the following language shall be used:

You have a right to disagree with decisions affecting your claim. If you have any questions regarding the information provided to you in this notice, please call: (insert adjuster's name and telephone number). However, if you are represented by an attorney, you should call your attorney, not the claims adjuster. If you want further information on your rights to benefits or disagree with our decision, you may contact your local state Information & Assistance Office of the Division of Workers' Compensation by calling (insert local I&A number).

For recorded information and a list of offices, call (800)736-7401. You may also visit the DWC website at:

http://www.dir.ca.gov/DWC/dwc_home_page.htm

You also have a right to consult with an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits.

To resolve a dispute, you may apply to [choose appropriate option(s)] the Workers' Compensation Appeals Board, the Vocational Rehabilitation Unit, or the Administrative Director.

For employees subject to an ADR program under Labor Code sections 3201.5 or 3201.7, the claims administrator may substitute the following language where appropriate:

You have a right to disagree with decisions affecting your claim. If you have any questions regarding the information provided to you in this notice, please call: (insert adjuster's name and telephone number) or, (insert name of ombudsperson or mediator if employee is subject to an ADR agreement). However, if you are represented by an attorney, you should call your attorney, not the claims adjuster, ombudsperson or mediator. If you want further information on your rights to benefits or disagree with our decision, you may also contact your local state Information & Assistance Office of the Division of Workers' Compensation by calling (insert local I&A number). Please be sure to inform the Information and Assistance Officer that you are subject to an alternative dispute resolution program.

For recorded information and a list of offices, call (800)736-7401. You may also visit the DWC website at:

http://www.dir.ca.gov/DWC/dwc_home_page.htm

NOTE: For employees subject to an ADR program under Labor Code section 3201.5, the claims administrator may include the following language if appropriate under the provisions of the ADR program:

In accordance with the (insert union name) agreement, active participation by an attorney is not allowed in the Ombudsman and Mediation stages of the ADR workers' compensation process. Your right to obtain legal advice is not limited and you may obtain such at your own expense at anytime. If the Ombudsman and Mediation stages of dispute resolution are unsuccessful and a written request for Arbitration has been timely filed, attorney participation is allowed.

(g) "Employer" means any person or entity defined as an employer by Labor Code Section 3300.

(h) "Injury" means any injury as defined in Labor Code Section 3208 which results in medical treatment beyond first aid, lost time beyond the date of injury, or death.

(i) "Permanent and stationary status," means the point when the employee has reached maximal medical improvement his or her condition is well stabilized and unlikely to change substantially in the next year with or without medical treatment.


     Note: Authority cited: Sections 59, 133, 138.3, 138.4 and 5307.3, Labor Code. Reference: Sections 138.4, 139.5(c), (d), 3201.5, 3201.7, 3208, 3300, 3351, 3351.5, 3700, 3753, 4635(a), 4650(a)-(d), 4653, 4654, 4700 and 4701, Labor Code; Sections 11651 and 11652, Insurance Code; Sections 2330 and 2332, Civil Code.  


 HISTORY 
   
1. Amendment of section and Notefiled 1-7-94; operative 1-7-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 94, No. 1).

2. Amendment of section andNote filed 12-11-2007; operative 4-9-2008 (Register 2007, No. 50).

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