Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1.5. INJURIES ON OR AFTER JANUARY 1, 1990
ARTICLE 9. CLAIM FORM: AVAILABILITY, FILING, ACKNOWLEDGEMENT OF RECEIPT, DISMISSAL

§ 10141. Dismissal of Inactive Claim by Operation of Law After Notice.

(a) Where a claim form has been filed for an injury that occurred prior to January 1, 1994, the claim has been denied, and there has been no activity for 180 days, the claims administrator may issue a notice of dismissal of the claim as follows:

(1) The notice shall include the following:

NOTICE REGARDING WORKERS' COMPENSATION CLAIM

You applied for workers' compensation benefits. A copy of your claim form is attached. We have not heard from you since we sent you a letter denying your claim on ________ [Date]. Your case has been inactive for at least 180 days. If you are still claiming benefits, you must file an Application for Adjudication of Claim with the Workers' Compensation Appeal Board within 180 days of the date this notice is served on you. The date of service is listed at the bottom of this form. IF YOU DO NOT FILE THE APPLICATION BY THE DEADLINE, THE CLAIM WILL AUTOMATICALLY BE DISMISSED "BY OPERATION OF LAW". This means you will not be able to claim benefits for the injury or illness listed on the claim form unless you file the Application for Adjudication of Claim by the deadline. Please call me at ________ [phone number] if you want more information or help figuring out the deadline for filing an Application.

You can get the Application form, help figuring out the deadline for filing an Application, and information about your claim by calling the State of California Division of Workers' Compensation Information and Assistance Office. [Enter telephone number of district Information and Assistance Office closest to injured workers' residence.] You may hear recorded information by calling 1-800-736-7401. You may also consult an attorney.

_____________________________________

[Claims Administrator Representative]

Date Notice Is Served:______________

(2) The blank(s) in the prescribed notice language shall be completed by the claims administrator to specify the information described in brackets. The date of service of the Notice shall be inserted on the Notice by the claims administrator or process server to accurately reflect the date service is effected in accordance with the Code of Civil Procedure as specified in subsection (d).

(b) Where a claim form has been filed for an injury that occurred prior to January 1, 1994, benefits have been furnished, and there has been no activity for 180 days, the claims administrator may issue a notice of dismissal of the claim as follows:

(1) The notice shall include the following:

NOTICE REGARDING WORKERS' COMPENSATION CLAIM

You applied for workers' compensation benefits. A copy of your claim form is attached. Your case has been inactive for at least 180 days.

Your right to workers' compensation benefits will end on _______ [Insert date - either five years from the date of injury or one year from the last furnishing of benefits, whichever is later], unless you file an Application for Adjudication of Claim by that date. That date is ________ [insert either "five years from the date of your injury", or "one year from the date of the last benefit provided to you."]

IF YOU DO NOT FILE THE APPLICATION BY THE DEADLINE, THE CLAIM WILL AUTOMATICALLY BE DISMISSED "BY OPERATION OF LAW". This means you will not be able to claim further benefits for the injury or illness listed on the claim form unless you file the Application for Adjudication of Claim by the deadline. Please call me at _______ [phone number] if you want more information.

You can get the application form and information about your claim by calling the State of California Division of Workers' Compensation Information and Assistance Office at _______ [Enter telephone number of district Information and Assistance Office closest to injured worker's residence.] You may hear recorded information by calling 1-800-736-7401. You may also consult an attorney.

_____________________________________

[Claims Administrator Representative]

(2) The date of last furnishing of benefits shall be the latter of: the latest date of receipt by the employee of medical or rehabilitation services, or the latest date that payment of any compensation benefit was mailed or personally delivered to the employee or any service provider.

(3) The blanks in the prescribed notice language shall be completed by the claims administrator to specify the information described in brackets.

(c) The Notice under (a)(2) and (b)(2) shall further contain the date(s) of injury, name of the employee, the name of the employer, identification of the claims administrator, including address and telephone number, and claim number, if any. A copy of the claim form(s) shall be attached to the notice prior to service.

(d) The claims administrator shall serve notice on the employee in the manner prescribed for a summons in a civil action in accordance with Article 3 (commencing with Section 415.10) of Chapter 4 of Title 5 of the Code of Civil Procedure.

If the employee is represented by an attorney, the claims administrator shall in addition serve a copy of the notice on the attorney by personal delivery or first class mail. Where no Application for Adjudication of Claim has been filed, but the Workers' Compensation Appeals Board has assigned a case number to the matter because of a pre-Application filing, the claims administrator shall also serve a copy of the notice on the appeals board. Proof of service shall be made in accordance with Title 8, CCR section 10975.

(e) The occurrence of any of the following during the 180 days prior to service of the notice is evidence that the claim is not inactive and there can be no dismissal under (a)(1) or (a)(2): the employee has made demand for payment or provision of benefits (whether indemnity, medical, or other), the claims administrator has knowledge that there are benefits due and unpaid, there has been treatment rendered for the industrial injury, there has been a medical-legal evaluation of the employee, there has been a deposition in regard to the claim, the claims administrator has other knowledge that the employee is actively pursuing his or her claim.

Note: Authority cited: Sections 133, 5307.3 and 5404.5, Labor Code. Reference: Sections 5401, 5402 and 5404.5, Labor Code.

HISTORY

1. Change without regulatory effect renumbering former section 10120 to section 10141 filed 4-7-2008 pursuant to section 100, title 1, California Code of Regulations (Register 2008, No. 15).