Upon receipt of a completed claim form (DWC-1), claims administrators have 14 calendar days (plus 5 calendar days for mailing) to notify you if your claim is being accepted or if additional information may be needed.
If additional information is needed you should receive an Explanation of Benefits Notice letter indicating that your claim is delayed, the reason for the delay, what additional information is needed and the date a decision must be made.
While your employer is deciding whether to accept or reject your claim, you may receive up to $10,000 in approved medical treatment.
You should receive confirmation of whether your claim is accepted or denied within 90 calendar days (plus 5 days for mailing) from the date the claim form is given to your employer. If you do not, your injury may be presumed to be covered.
Claim Status
Types of Benefits
Workers' compensation insurance provides five basic benefits:
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Medical care: Paid for by your employer to help you recover from an injury or illness caused by work
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Temporary disability (TD) benefits (view chart): Payments if you lose wages because your injury prevents you from working while recovering. If you work for a school district or in a public safety occupation, you may be entitled to additional benefits
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Permanent disability (PD) benefits (view chart): Potential Payments if you don't recover completely
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Supplemental job displacement benefits (SJDB): (if your date of injury is in 2004 or later): Vouchers are used to help pay for retraining or skill enhancement if you don't recover completely and don't return to work for your employer. Learn more from the Department of Industrial Relations guidebook, Chapter 8: Supplemental Job Displacement Benefits
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Return to Work Supplement: If you were injured on or after January 1, 2013 and you received a voucher, you may be eligible for a Return-to-Work Supplement. Applications must be filed electronically with the Division of Workers’ Compensation at www.dir.ca.gov or by calling 510-286-0787. The deadline to file an application is one year from the date on the voucher. Learn more from the Department of Industrial Relations, Chapter 9: Return-to-Work Supplement Program
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Death benefits (view chart): Payments to the spouse, children or other dependents if a worker dies from a job injury or illness
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Learn more from the Department of Industrial Relations, Chapter 5: Temporary Disability Benefits and Chapter 7: Permanent Disability Benefits
Designed to address important safety related topics common in a K-12 environment.
Medical Disagreements
At some point during your claim, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. If there is a disagreement about whether your claim is covered by workers’ compensation, you may be evaluated by a qualified medical evaluator (QME). To qualify as a QME, a physician must meet additional educational and licensing requirements. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process. If you have an attorney, your attorney and your claims administrator might agree on a doctor to resolve medical disputes. This doctor is called an agreed medical evaluator (AME).
As of July 1, 2013, for all dates of injury, disagreements about a specific course of medical treatment recommended by the treating physician can only be resolved through a process called Independent Medical Review (IMR).
The Independent Medical Review (IMR) Process: If your physician requests medical treatment that is denied by utilization review, you have the right to ask for a review of that decision through an IMR. The costs of the IMR are paid by your employer. IMR physicians are independent and contracted by the Division of Workers’ Compensation. If a request for medical treatment is delayed, denied or modified by your claims administrator, you should receive an IMR application form which will include additional instructions. If you have questions about this process you should contact your claims examiner.
If Keenan is your employers’ claims administrator, you are encouraged to contact your Claims Examiner to discuss any concern you may have as that is often the quickest way to resolve any disagreement.
Claim Denial Disagreements
If your claim was denied and you want to object to the denial of your claim, you will need to file a case at one the Department of Workers’ Compensation (DWC) 24 offices located around the state. Each DWC office is a trial court where disputes that arise from workers’ compensation claims are decided by a judge without a jury.
In order to have your case heard by a judge, you must first file an Application for Adjudication of Claim. The application must be filed at the DWC office in the county where you live or in the county where you were injured. You must serve the application on all other parties, which is generally the claims administrator.
The DWC office where you filed the application will send you a notice confirming that it has been filed. The notice will include your assigned case number, which will begin with the letters “ADJ” followed by a sequence of numbers. Keep the notice and use the assigned case number on all documents and correspondence relating to your case.
If Keenan is your employers’ claims administrator, you are encouraged to contact your Claims Examiner to discuss any concern you may have as that is often the quickest way to resolve any disagreement.
Get a Hearing
You must file a Declaration of Readiness to Proceed to request a hearing. Your case will be scheduled for a hearing called a mandatory settlement conference (MSC).
You and your claims administrator or their attorney will appear before a judge. The judge will discuss the case with both of you and try to assist in reaching a settlement. If your case is not settled at the MSC, you will need to prepare documents that outline the dispute, identify the items each party will present at trial and the names of the witnesses that each party will ask to testify. The judge will then schedule a date for trial.
The trial will be held before another judge. You must attend the trial. The judge will issue a written decision following the trial and will send it to you by mail, which usually occurs between 30 and 90 days after the trial. If either you or the claims administrator disagrees with the judge’s decision, you can file a Petition for Reconsideration.
If Keenan is your employers’ claims administrator, you are encouraged to contact your Claims Examiner to discuss any concern you may have as that is often the quickest way to resolve any disagreement.