WHY IS MY WORKERS’ COMPENSATION CLAIM DELAYED?  INJURED WORKERS, OUTSTANDING CLAIMS, AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

Many Injured Workers have their workers’ compensation claims delayed.

This article will discuss why claims are delayed and what Insurance Company activities occur during the delay period.

Why Are Claims Delayed?

Insurance Companies delay claims in order to verify that there is a legitimate claim.  Per the Labor Code, they are afforded this opportunity to investigate.

As part of their investigation, Insurance Companies will investigate the following matters.

Coverage: Insurance Companies need to verify that they actually insure the Employer for the date of the injury.

Employment Verification: Insurance Companies need to verify the Injured Worker actually worked for the Insured Employer.

Date of Injury:  Insurance Companies need to verify the date of injury.

Employer Injury Knowledge:  Insurance Companies need to know if the Employer knows about the work injury.  They need to know the details how the injury happened, whether there were witnesses,  and whether it was reported to management.

Medical Verification: Insurance Companies will seek to obtain the medical reporting from the Industrial Clinic or the Medical Provider who treated the worker.

Statements: Insurance Companies may seek the use of an investigator to take statements of the injured worker, other employees of the company, or witnesses,  to verify the injury.  Investigations can be done by Attorney who may take depositions.

Records:  Insurance Companies may seek records from prior employers, insurance companies or medical providers

Qualified Medical Evaluation: An Insurance Company may seek a Panel Evaluator from the State of California to obtain a medical opinion on causation. .

What is the Authority for Delaying a Workers’ Compensation Claim?

Labor Code Section 5402(b) provides for a 90 day period upon which Insurance Companies have to deny a claim.  Thus, there is a 90 day period to delay the claim and investigate.  This 90 days is from the knowledge of the claim.

The date of knowledge is per LC 5402(a) which provides that “ [k]nowledge of an injury, obtained from any source, on the part of an employer, his or her managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400.” Thus, employer knowledge can trigger the start of the insurance company’s delay period

What If I Need Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact us today for more information.

 

THE JOINT POWERS INSURANCE AUTHORITY: WORKERS’ COMPENSATION INSURANCE COVERAGE FOR GOVERNMENT AGENCIES: WHAT YOU NEED TO KNOW

The State of California provides for Private industry and Government Entities a variety of ways in which they can fulfill their commitment to maintain workers’ compensation coverage for their workers.  One of the entities that assists Government Entities provide workers’ compensation coverage is the Joint Powers insurance Authority (JPIA.)

While Injured Workers are entitled to benefits in accordance with workers’ compensation law, it is important to know who is providing the coverage.  This knowledge provides insight as to how the claim will be managed and how a settlement may occur.

This article with discuss what is the Joint Powers insurance Authority and how the JPIA is involved with workers’ compensation coverage.

What is the Joint Powers Insurance Authority?

The Joint Powers Insurance Authority is a Risk Management Entity.  The JPIA was formed to fill the needs for public agencies to handle their risk obligations.  For public agencies with employees, one of their risk obligations is workers’ compensation.

In addition to the Authority, the Joint Powers members have associations which may lobby on their behalf to impact workers’ compensation legislation.

How Does the Joint Powers insurance Authority Provide Workers’ Compensation Coverage?

Per the JPIA, “[t]he California JPIA provides workers’ compensation coverage that offers members two options: the primary workers’ compensation program and the excess workers’ compensation program.”

What Is a Primary Workers’ Compensation Program?

A primary workers’ compensation program would provide coverage and administration in the adjustment of workers’ compensation claims. JPIA members will generally use a third-party administrator to adjuster their claims.

What is An Excess Workers’ Compensation Program?

Excess Workers’ Compensation Insurance is coverage that covers costs that exceed a set point.   This set point of excess is to be determined by the insurance.  It can be for payments exceeding $500,000.00 or $1,000,000.00.   The coverage can be capped. The coverage can even be unlimited.  Excess coverage protects the employer in the event of a catastrophic case.  Additionally, an employer can purchase multiple policies to cover various levels of excess amounts.

Note: My personal experience is that excess carriers can be difficult and resist in contributing to settlements of cases.   There have been many times in which the employer is at odds with their excess carrier on the issues of settlement.

How Extensive is the JPIA?

JPIA is quite extensive. There are a number of agencies which employ their services.   JPIA indicates that they have more than 100 public agencies have partnered with them.  Also, the agencies employing JPIA include small, single-purpose entities to cities to special districts.

What Are The Core Values of JPIA?

Per their website, there core values are “Integrity: We hold ourselves to the highest ethical and professional standards. We pledge to fulfill our duties and deliver on our commitments; Excellence: We pursue distinction with a passion. We proactively assess our performance and strive to continuously improve programs, services, and work product;  Innovation: We foster creativity as we explore opportunities and meet challenges; Teamwork: We pursue productive relationships through communication, collaboration, understanding, and respect.”

Note:  The Core Values are all about risk management.  There is no mention of any values directly related to workers’ compensation and the treatment of injured workers.

How Do I Know My Claim Is Being Handled via JPIA?

If you work for a government agency, there is the possibility that JPIA may be involved in your case.   Further, JPIA may not be administering the claim.   It will most likely be a third-party administrator.   On your claim correspondence, however, there may be a reference to JPIA.

What if I Need Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact us today for more information.

 

 

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