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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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§9812. Benefit Payment and Notice.

(a) Temporary Disability Notices. When an injury causes or is claimed to cause temporary disability:

(1) Notice of First Temporary Disability Indemnity Payment. The first time the claims administrator pays temporary disability indemnity, the claims administrator shall advise the employee of the amount of temporary disability indemnity due, how it was calculated, and the duration and schedule of indemnity payments. The notice shall be sent no later than the 14th day after the employer's date of knowledge of injury and disability. A copy of the most recent version of the DWC informative pamphlet "Temporary Disability Fact Sheet' shall be provided with the notice.

(2) Notice of Delay in Any Temporary Disability Indemnity Payment. If the employee's entitlement to any period of temporary disability indemnity cannot be determined within 14 days of the date of knowledge of injury and disability, the claims administrator shall advise the employee within the 14-day period of the delay, the reasons for it, the need, if any, for additional information required to make a determination, and when a determination is likely to be made. If the claims administrator cannot make a determination by the date specified in a notice to the injured worker, the claims administrator shall send a subsequent delay notice to the injured worker, not later than the determination date specified in the previous delay notice, notifying the injured worker of the revised date by which the claims administrator now expects the determination to be made.

(A) Where the delay is related to a medical issue, the notice shall advise an unrepresented employee of one of the following options:

1. If the injured worker has already received a comprehensive medical evaluation and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

2. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's temporary disability status and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(B) Where the delay is related to a medical issue, the notice shall advise a represented employee of one of the following options:

1. For dates of injury from January 1, 1994 through December 31, 2004, if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

2. For dates of injury on or after January 1, 2005, if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.2 and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

A copy of the most recent version of the DWC informative pamphlet "QME/AME Fact Sheet" shall be provided with the notice.

The additional delay notices shall comply with all requirements for an original delay notice, except that no copy of the DWC informative pamphlet "QME/AME Fact Sheet" need be provided with the notice unless it has been revised since it was last provided.

(3) Notice of Denial of Any Temporary Disability Indemnity Payment. If the claims administrator denies liability for the payment of any period for which an employee claims temporary disability indemnity, the notice shall advise the employee of the denial and the reasons for it. The notice shall be sent within 14 days after the determination to deny was made.

(A) Where the denial is related to a medical issue, the notice shall advise an unrepresented employee of one of the following options:

1. If the denial is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

3. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's temporary disability status and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(B) Where the denial is related to a medical issue, the notice shall advise a represented employee of one of the following options:

1. If the denial is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. For dates of injury from January 1, 1994 through December 31, 2004, if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

3. For dates of injury on or after January 1, 2005 if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.2 and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

A copy of the relevant DWC informative pamphlet(s) "TD Fact Sheet," "QME/AME Fact Sheet" and/or "Permanent Disability Fact Sheet" shall be provided at this time.

(b) Notice of Resumed Benefit Payments (TD, SC, PD, VRTD/VRMA). If the payment of temporary disability indemnity, salary continuation, permanent disability indemnity, or vocational rehabilitation temporary disability indemnity or maintenance allowance is resumed after terminating any of these benefits, the claims administrator shall advise the employee of the amount of indemnity due and the duration and schedule of payments. Notice shall be sent within 14 days after the employer's date of knowledge of the entitlement to additional benefits.

(c) Notice of Changed Benefit Rate, Payment Amount or Schedule (TD, SC, PD, VRTD/VRMA). When the claims administrator changes the benefit rate, payment amount or benefit payment schedule for temporary disability indemnity, salary continuation, permanent disability indemnity, or vocational rehabilitation temporary disability indemnity or maintenance allowance, the claims administrator shall advise the employee, as applicable, of the amount of the new benefit rate and the reason the rate is being changed, or of the new benefit payment schedule. Notice shall be given before or with the new payment.

(d) Notice that Benefits Are Ending (TD, SC, PD, VRTD/VRMA). With the last payment of temporary disability indemnity, permanent disability indemnity, salary continuation, or vocational rehabilitation temporary disability indemnity or maintenance allowance, the claims administrator shall advise the employee of the ending of indemnity payments and the reason, and shall make an accounting of all compensation paid to or on behalf of the employee in the species of benefit to which the notice refers, including the dates and amounts paid and any related penalties. If the decision to end payment of indemnity was made after the last payment, the claims administrator shall send the notice and accounting within 14 days of the last payment.

(1) The notice, except a notice that VRMA is ending, shall advise an unrepresented employee one of the following options:

(A) If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

(B) If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's temporary disability status or permanent impairment and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(2) The notice, except a notice that VRMA is ending, shall advise a represented employee:

(A) If the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation.

(B) If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.2 and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

A copy of the relevant DWC informative fact sheet pamphlet(s) "TD Fact Sheet," "QME/AME Fact Sheet" and/or "Permanent Disability Fact Sheet" shall be provided at this time.

(e) Permanent Disability Notices For Injuries That Occurred Prior To 1991:

(1) Existence and Extent of Permanent Disability is Known. Within 14 days after the claims administrator knows that the injury has caused permanent disability and knows the extent of that disability, the claims administrator shall advise the employee of the amount of the weekly permanent disability indemnity payment, how it was calculated, the duration and frequency of payments, the date payments can be expected to begin and the total amount to be paid.

(2) Existence of Permanent Disability is Known, Extent is Uncertain. If the claims administrator knows that the injury has caused permanent disability but cannot determine its extent within the 14 days after the last payment of temporary disability indemnity, or within 14 days after knowledge that the employee's injury has resulted in permanent disability if there was no compensable temporary disability, the claims administrator nevertheless shall make timely payment of permanent disability indemnity and shall advise the employee of the amount of the weekly permanent disability indemnity payment, how it was calculated, the duration and schedule of payments, and the claims administrator's reasonable estimate of the amount of permanent disability indemnity to be paid.

The claims administrator shall notify the employee that his or her medical condition will be monitored until the extent of permanent disability can be determined and that the disability payments will be revised at that time if appropriate. Within 14 days after the claims administrator determines the extent of permanent disability indemnity benefits, the claims administrator shall notify the employee as provided by paragraph (1).

(3) Existence of Permanent Disability is Uncertain. If the existence of permanent disability is uncertain, the claims administrator shall advise the employee within 14 days after the last payment of temporary disability indemnity, or within 14 days of receiving a claim or medical report alleging the existence of permanent disability if the claims administrator paid no temporary disability, that the claims administrator cannot yet determine whether the injury will cause permanent disability. The notice shall specify the reasons for the delay in determination, the need, if any, for additional information required to make a determination, and when the determination is likely to be made. If the claims administrator cannot make a determination by the date it specified in a notice to the injured worker, the claims administrator shall send a subsequent notice to the injured worker, not later than the determination date specified in the previous notice, notifying the injured worker of the date by which the claims administrator now expects the determination to be made. The additional delay notices shall comply with all requirements for an original delay notice. If the reason for the delay is that the employee's medical condition is not permanent and stationary, the claims administrator shall advise the employee that his or her medical condition will be monitored until it is permanent and stationary, at which time an evaluation will be performed to determine the amount of permanent disability indemnity, if any, due the employee. Within 14 days after the claims administrator determines that permanent disability exists, the claims administrator shall notify the employee of the commencement of permanent disability indemnity payments as provided by paragraph (1) or (2).

(4) Notice That No Permanent Disability Exists. If the claims administrator alleges that the injury has caused no permanent disability, the claims administrator shall advise the employee within 14 days after the claims administrator determines that the injury has caused no permanent disability.

(f) Permanent Disability Notices for Injuries Occurring in 1991, 1992, 1993.

(1) Condition Not Permanent and Stationary (P & S), May Cause Permanent Disability -Notice of Monitoring Until P&S Date. If the injury has resulted or may result in permanent disability but the employee's medical condition is not permanent and stationary, the claims administrator shall advise the employee, together with the last payment of temporary disability indemnity, that permanent disability indemnity is or may be payable but that the amount cannot be determined because the employee's medical condition has not yet reached a stationary status. The notice shall advise the employee that his or her medical condition will be monitored until it is permanent and stationary, at which time a medical evaluation will be performed to determine the existence and extent of permanent impairment or limitations and the need for continuing medical care. The notice shall advise the employee of the estimated date when a determination is likely to be made, and the claimant's remedies. If the claims administrator cannot make a determination of A) permanent and stationary status, B) the existence and extent of permanent impairment or limitations, and C) the need for continuing medical care by the date it specified in a monitoring notice to the injured worker, the claims administrator shall send a subsequent notice to the injured worker, not later than the determination date specified in the previous notice, notifying the injured worker of the date by which the claims administrator now expects the determination to be made. The additional notice shall comply with all requirements of the original delay notice.

(2) Condition Becomes Permanent and Stationary, May Cause Permanent Disability -Notice of Qualified Medical Evaluator (QME) Procedures. Within 5 working days after receiving information indicating that the employee's condition is permanent and stationary and has caused or may have caused permanent disability, the claims administrator shall advise the employee that his or her medical condition is permanent and stationary and of the procedures for evaluating permanent disability and need for continuing medical care.

(A) The notice shall advise an unrepresented employee of one of the following options:

1. If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

2. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's permanent and stationary status and/or need for future medical care and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(B) The notice shall advise a represented employee:

If the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

A copy of the most recent version of the DWC informative pamphlet "QME/AME Fact Sheet" shall be provided with the notice.

(3) Notice of Permanent Disability Indemnity Payment When Injury Causes Permanent Disability. If the claims administrator knows that the employee has sustained permanent disability, whether or not its extent is known and whether or not the employee's medical condition is permanent and stationary, the claims administrator shall advise the employee of the weekly permanent disability indemnity payment, how it was calculated, the duration and schedule of payments, and the claims administrator's reasonable estimate of permanent disability indemnity to be paid, within 14 days after knowledge that the employee's injury has resulted in permanent disability, whichever is later.

(A) The notice shall advise an unrepresented employee of one of the following options:

1. If the estimate is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

3. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's permanent impairment and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(B) The notice shall advise a represented employee of one of the following options:

1. If the determination is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. If the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation.

3. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

(4) Notice That No Permanent Disability Exists. If the claims administrator alleges that the injury has caused no permanent disability, the claims administrator shall advise the employee that no permanent disability indemnity is payable. This notice shall be sent within 14 days after the claims administrator determines that the injury has caused no permanent disability. The notice shall advise the employee of the process to obtain a formal medical evaluation to contest the determination that the employee has no permanent disability. If the basis for the claims administrator's determination is a medical report, a copy of the most recent version of the DWC informative pamphlet "QME/AME Fact Sheet," shall be provided with the notice.

(A) The notice shall advise an unrepresented employee of one of the following options:

1. If the determination is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

3. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's permanent impairment and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(B) The notice shall advise a represented employee of one of the following options:

1. If the determination is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. If the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

(g) Permanent Disability Notices For Injuries Occurring on or after 1/1/94. For injuries occurring on or after January 1, 1994:

(1) Condition Not Permanent and Stationary, May Cause Permanent Disability - Notice of Monitoring Until P&S Date. If the injury has resulted or may result in permanent disability but the employee's medical condition is not permanent and stationary, the claims administrator shall advise the employee together with the last payment of temporary disability indemnity, that permanent disability indemnity is or may be payable but that the amount cannot be determined because the employee's medical condition has not yet reached a stationary status. The notice shall advise the employee that his or her medical condition will be monitored until it is permanent and stationary, at which time a medical evaluation will be performed to determine the existence and extent of permanent impairment or limitations and the need for continuing medical care. The notice shall advise the employee of the estimated date when a determination is likely to be made. If the claims administrator cannot make a determination of A) permanent and stationary status, B) the existence and extent of permanent impairment or limitations, and C) the need for continuing medical care by the date it specified in a monitoring notice to the injured worker, the claims administrator shall send a subsequent notice to the injured worker, not later than the determination date specified in the previous notice, notifying the injured worker of the date by which the claims administrator now expects the determination to be made. The additional notice shall comply with all requirements of the original notice.

(2) Condition Becomes Permanent and Stationary, Causes Permanent Disability - Notice of QME/AME Procedures. Together with the last payment of temporary disability or within 14 days of knowledge that the injury is permanent and stationary or has caused permanent disability, the claims administrator shall provide notice of the procedures available to obtain a QME or AME evaluation. The claims administrator shall advise the employee of the claims administrator's estimate of the amount of permanent disability indemnity payable, the basis for the estimate, and whether there is need for continuing medical care. A copy of the medical report on which the estimate of permanent disability was based, and a copy of the most recent version of the DWC informative pamphlets, QME/AME Fact Sheet and/or Permanent Disability Fact Sheet, shall be provided with the notice.

(A) The notice shall advise an unrepresented employee of one of the following options:

1. If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

2. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1.

The notice shall include the claims administrator's decision on whether the claims administrator accepts or refutes the treating physician's evaluation of the employee's permanent impairment and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font at the top of the first page: 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.

(B) If the claims administrator is not requesting a rating from the Disability Evaluation Unit, the notice shall also advise the worker that he or she may contact an Information and Assistance Officer to have the treating physician's evaluation reviewed and rated by the Disability Evaluation Unit.

(C) If the claims administrator has or will be requesting a rating from the Disability Evaluation Unit on the treating physician's evaluation, the notice shall advise the employee that he or she will be receiving a rating based on the treating physician's evaluation from the Disability Evaluation Unit.

(D) The notice shall advise a represented employee of one of the following options:

1. For dates of injury from January 1, 1994 through December 31, 2004, if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

2. For dates of injury on or after January 1, 2005 if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.2 and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

(3) Notice That No Permanent Disability Exists. If the claims administrator alleges that the injury has caused no permanent disability, the claims administrator shall advise the employee that no permanent disability indemnity is payable. This notice shall be sent together with the last payment of temporary disability indemnity or within 14 days after the claims administrator determines that the injury has caused no permanent disability. A copy of the medical report on which the determination of no permanent disability was based, and a copy of the most recent version of the DWC informative pamphlets, QME/AME Fact Sheet and Permanent Disability Fact Sheet shall be provided with the notice. A copy of the DWC form prescribed by the Administrative Director for requesting assignment of a panel of Qualified Medical Evaluators shall be provided with the notice unless the employee is represented by an attorney.

(A) The notice shall advise an unrepresented employee of one of the following options:

1. If the determination is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. If the injured worker has already received a comprehensive medical evaluation, and either party disputes the results of that evaluation, the injured worker may be asked to return to that physician for a new evaluation.

3. If no comprehensive medical evaluation has taken place, the injured worker may obtain an evaluation by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.1. The notice shall also advise of the procedure for requesting the panel and shall be accompanied by the form prescribed by the DWC Medical Unit with which to request assignment of a panel of Qualified Medical Evaluators. The notice shall advise the injured worker of the 10 day time limit in which a panel may be requested and in which an appointment must be made following receipt of the panel.

The notice shall contain the following warning in not less than 12 point font: 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.

(B) If the denial is based upon the treating physician's report, the notice shall also advise the worker that he or she may contact an Information and Assistance office to have the treating physician's evaluation review and rated by the Disability Evaluation Unit.

(C) If the claims administrator requests a rating from the Disability Evaluation Unit on the treating physician's report, the notice shall advise the employee that he or she will be receiving a rating based on the treating physician's evaluation from the Disability Evaluation Unit.

(D) The notice shall advise a represented employee of one of the following options:

1. If the determination is based on a comprehensive medical evaluation, the injured worker may file an Application for Adjudication of Claim with the WCAB.

2. For dates of injury from January 1, 1994 through December 31, 2004, if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

3. For dates of injury on or after January 1, 2005 if the injured worker has already received a comprehensive medical evaluation, he or she may be asked to return to that physician for a new evaluation. If no comprehensive medical evaluation has taken place, an evaluation may be obtained from an Agreed Medical Evaluator if the parties agree or, if no agreement on an Agreed Medical Evaluator can be reached, the injured worker may be evaluated by a Qualified Medical Evaluator obtained from a panel issued by the DWC Medical Unit pursuant to Labor Code section 4062.2 and that arrangements for obtaining this evaluation should be discussed with the injured worker's attorney.

(4) Notice of Permanent Disability Indemnity Payment When Injury Causes Permanent Disability. If the claims administrator knows that the employee has sustained permanent disability, whether or not its extent is known and whether or not the employee's medical condition is permanent and stationary, the claims administrator shall advise the employee of the weekly permanent disability indemnity payment, how it was calculated, the duration and schedule of payments, and the claims administrator's reasonable estimate of permanent disability indemnity to be paid, within 14 days after the last payment of temporary disability indemnity, or within 14 days after knowledge that the employee's injury has resulted in permanent disability, whichever is later. A copy of the most recent version of the DWC informative pamphlet "Permanent Disability Fact Sheet," shall be provided with the notice.

For injuries occurring on or after January 1, 2005, the claims administrator shall, concurrently with any increased or decreased payment, notify the injured worker of any increase or decrease in the amount of the injured worker's permanent disability payments, pursuant to Labor Code section 4658, subdivision (d) resulting from the employer's offer of regular, modified or alternative work or resulting from the employer's failure to offer, or the employer's early termination of, regular, modified or alternative work. The information required by this subdivision shall be given in the appropriate PD payment start notice, PD payment resumption notice or notice of change in rate, payment amount or payment schedule.

(h) Notices to Dependents in Death Cases. In a case of fatal injury which is or is claimed to be compensable under the workers' compensation laws of this state, or involving accrued compensation which was not paid to an injured employee before the employee's death, the claims administrator shall advise the dependent(s) of the status of any benefits to which they may be entitled or which they have claimed as a result of the employee's death. As used in this subsection, "dependent" includes any person who may be or has claimed to be entitled to workers' compensation benefits as the result of an employee's death (including compensation which was accrued and unpaid to an injured worker before his or her death), and also includes the parent or legal guardian of minor dependent children. The claims administrator shall send each dependent a copy of all notices concerning benefits claimed by, or which may be payable to, that dependent, including notices sent to a different dependent if the benefits paid to the different dependent affect the amount payable to the other claimant. If the claims administrator discovers a new dependent after having sent a notice, the claims administrator shall send copies of each prior notice which concerned benefits to which the newly-discovered dependent might be entitled, to that dependent.

(1) Benefit Payment Schedule. If the claims administrator pays death benefits (including compensation which was accrued and unpaid to an injured worker before his or her death), the claims administrator shall advise each affected dependent of the amount of the death benefit payable to the dependent, how it was calculated, the duration and schedule of payments and other pertinent information. Notice is required within 14 days after the claims administrator's date of knowledge both of the death and of the identity and address of the dependent.

(2) Notice of Changed Benefit Rate, Amount or Schedule or that Benefits are Ending. If the claims administrator changes the benefit rate, amount or payment schedule, or ends payment, of a death benefit to a dependent, the claims administrator shall advise the affected dependent of the change and the reason for it, or of the new payment schedule. A notice that benefits are ending shall include an accounting of all compensation paid to the claimant. A notice that payment is ending shall be sent with the last payment unless the decision to end payment was made after that payment; in that case it shall be sent within 14 days of the last payment. Other notices concerning changed payments shall be sent before or with the changed payment, but not later than 14 days after the last payment which was made before the change.

(3) Delay in Determining Benefits. If the claims administrator cannot determine entitlement to some or all death benefits, the claims administrator shall advise each affected dependent of the delay, the reasons for it, the need, if any, for additional information required to make a determination, and when a determination is likely to be made. Notice is required within 14 days after the claims administrator's date of knowledge of the death, the identity and address of the affected dependent, and the nature of the benefit claimed or which might be due. If the claims administrator cannot make a determination by the date it specified in a notice to the affected dependent(s), the claims administrator shall send a subsequent notice to the affected dependent(s), not later than the determination date specified in the previous notice, notifying the affected dependent(s) of the date by which the claims administrator now expects the determination to be made. The additional delay notices shall include the employee's remedies and shall comply with all requirements for an original delay notice.

(4) Notices Denying Death Benefits. If the claims administrator denies liability for the payment of any or all death benefits, the claims administrator shall advise the affected dependent(s) of the denial and the reasons for it. The notice shall be sent within 14 days after the determination to deny was made.

(i) Notice Denying Liability for All Compensation Benefits. If the claims administrator denies liability for the payment of all workers' compensation benefits for any claim except a claim for death benefits, including medical-only claims, the claims administrator shall advise the employee of the denial and the reasons for it. The notice shall be sent no later than 14 days after the determination to deny was made. A copy of the most recent version of the DWC informative pamphlet "QME/AME Fact Sheet" shall be provided with the notice.

For claims reported on or after April 19, 2004, if an injured worker has filed a completed claim form with the employer, the claims administrator shall advise the injured worker to send for consideration of payment, all bills for medical services provided between the date the completed claim form was given to the employer and the date that liability for the claim is rejected, unless he or she has done so already. The claims administrator shall also advise the employee that the maximum payment for medical services that were provided consistent with the applicable treatment guidelines is $10,000.

A copy of the Notice Denying Liability for All Compensation Benefits shall be served on all lien claimants or all persons or entities who can reasonably be identified by the claims administrator from information in the claims file to be potential lien claimants on account of their having furnished benefits, goods or services for which a lien may be filed under Labor Code sections 4903 through 4906, inclusive.

(j) Notice of Delay in Determining All Liability. If the claims administrator cannot determine whether the employer has any liability for an injury, other than an injury causing death, within 14 days of the date of knowledge of injury, the claims administrator shall advise the employee within the 14-day period of the delay, the reasons for it, the need, if any, for additional information required to make a determination, and when a determination is likely to be made. If the claims administrator cannot make a determination by the date it specified in a notice to the injured worker, the claims administrator shall send a subsequent notice to the injured worker, not later than the determination date specified in the previous notice, notifying the injured worker of the date by which the claims administrator now expects the determination to be made. The additional delay notices shall comply with all requirements for an original delay notice. Where the delay is related to a medical issue, a copy of the most recent version of the DWC informative pamphlet "QME/AME Fact Sheet" shall be provided with the notice.

(1) For injuries on or after January 1, 1990, if the claims administrator sends a notice of a delay in its decision whether to accept or deny liability for the claim, the notice shall include an explanation that the claim is presumed to be compensable if not denied within 90 days from the filing of the claim form, and that this presumption can be rebutted only with evidence discovered after the 90-day period.

(2) For claims reported on or after April 19, 2004, regardless of the date of injury, if the claims administrator sends a notice of delay in its decision whether to accept or deny liability for the claim, the notice shall include an explanation that Labor Code section 5402(c), provides that within one working day after an employee files a claim form, the employer shall authorize the provision of all treatment, consistent with the applicable treatment guidelines, for the alleged injury and shall continue to provide treatment until the date that liability is rejected. The notice shall advise the injured worker that the employer's liability for medical treatment under this Labor Code section is limited to ten thousand dollars ($10,000).


Note: Authority cited: Sections 59, 133, 138.3, 138.4, 139.5(a)(2), 4636(d), 4637 and 5307.3, Labor Code. Reference: Sections 138.4, 139.5, 4061(a), (b), 4061(d), 4061(e), 4061(f), 4062.1, 4650(a)-(d), 4658(d), 4661.5, 4700, 4701, 4702, 4703, 4703.5, 4903-4906 and 5402, Labor Code.

 HISTORY 
   
1. Repealer and new section filed 7-11-89; operative 10-1-89 (Register 89 No. 28).

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

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

4. Change without regulatory effect amending subsection (g)(2) filed 12-9-2009 pursuant to section 100, title 1, California Code of Regulations (Register 2009, No. 50).


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