California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › 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 › Section 9812 - Benefit Payment and Notice

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.
(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 after 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 employee, the claims administrator shall send a subsequent delay
					 notice to the employee, not later than the determination date specified in the
					 previous delay notice, notifying the employee of the revised date by which the
					 claims administrator now expects the determination to be made. A subsequent
					 delay notice shall comply with all requirements for the contents of an original
					 delay notice.
(A) Where the delay is related
					 to a medical issue, and the claims administrator is requesting a comprehensive
					 medical evaluation, and the employee is not represented by an attorney, the
					 notice shall advise the employee of one of the following:
1. If the employee has already received a
					 comprehensive medical evaluation, the employee may be asked to return to that
					 physician for a new evaluation.
2.
					 If no comprehensive medical evaluation has taken place, the notice shall advise
					 the employee that if he or she disagrees with the results of the evaluation,
					 the employee must either:
a. contact the
					 claims administrator within the applicable time limit prescribed in Labor Code
					 section
					 4062(a)
					 to obtain the form prescribed by the DWC Medical Unit to request assignment of
					 a panel of Qualified Medical Evaluators, or
b. within the applicable time limit
					 prescribed in Labor Code section
					 4062(a),
					 download the form to request assignment of a panel of Qualified Medical
					 Evaluators from the DWC website. (Note: the notice shall provide the employee
					 with the url to enable the employee to download the applicable form.)
However, if the employee has already received a
						comprehensive medical evaluation, the notice may instead advise the employee to
						contact the claims administrator to arrange for the employee to return to that
						same medical evaluator for a new evaluation if
						possible.
(B) If the employee is represented by an
					 attorney, the notice shall instruct the employee to contact the attorney with
					 any questions.
(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. If the claims administrator's
					 determination is based on a medical report, a copy of the medical report(s)
					 shall be provided with the notice, except for psychiatric reports that the
					 psychiatrist has recommended not be provided to the employee.
(A) Where the denial is related to a medical
					 issue and the employee is not represented by an attorney, the notice shall
					 advise the employee of one of the following:
1. If the denial is based on a comprehensive
					 medical evaluation, and the employee disputes the results of the evaluation,
					 the employee may file an Application for Adjudication of Claim with the
					 WCAB.
2. If the denial is based on
					 the treating physician's evaluation of the employee's temporary disability
					 status and the claims administrator agrees with those findings, the notice
					 shall advise the employee that if he or she disagrees with the results of the
					 evaluation, the employee must either:
a.
					 contact the claims administrator within the applicable time limit prescribed in
					 Labor Code section
					 4062(a)
					 to obtain the form prescribed by the DWC Medical Unit to request assignment of
					 a panel of Qualified Medical Evaluators, or
b. within the applicable time limit
					 prescribed in Labor Code section
					 4062(a),
					 download the form to request assignment of a panel of Qualified Medical
					 Evaluators from the DWC website. (Note: the notice shall provide the employee
					 with the url to enable the employee to download the applicable form.)
However, if the employee has already received a
						comprehensive medical evaluation, the notice may instead advise the employee to
						contact the claims administrator to arrange for the employee to return to that
						same medical evaluator for a new evaluation if
						possible.
3. If
					 the denial is based on the treating physician's evaluation of the employee's
					 temporary disability status and the claims administrator disagrees with those
					 findings, the notice shall advise the employee that the claims administrator
					 disputes the result of the evaluation. If the claims administrator's
					 determination is based on a medical report, the notice shall be provided within
					 the applicable time limit prescribed in Labor Code section
					 4062(a),
					 notwithstanding the 14 days required by this subdivision. The notice shall
					 advise the employee that the claims administrator disputes the results of the
					 evaluation, and advise the employee that if he or she disagrees with the
					 results of the evaluation, the employee must either:
a. contact the claims administrator within
					 the applicable time limit prescribed in Labor Code section
					 4062(a)
					 to obtain the form prescribed by the DWC Medical Unit to request assignment of
					 a panel of Qualified Medical Evaluators, or
b. within the applicable time limit
					 prescribed in Labor Code section
					 4062(a),
					 download the form to request assignment of a panel of Qualified Medical
					 Evaluators from the DWC website. (Note: the notice shall provide the employee
					 with the url to enable the employee to download the applicable form.)
However, if the employee has already received a
						comprehensive medical evaluation, the notice may instead advise the employee to
						contact the claims administrator to arrange for the employee to return to that
						same medical evaluator for a new evaluation if
						possible.
(B) If the employee is represented by an
					 attorney, the notice shall instruct the employee to contact the attorney with
					 any questions or need for clarification.