"When will I get my policy?"

When all the information needed to produce the policy has been provided to CompWest, the policy can be printed and mailed within a few days.  Barring a special circumstance, you should receive your policy from your broker within two weeks of the effective date.

If you have not received a copy of your policy, need your policy number, or a certificate of insurance you should contact your broker.
 

How do I know if a complaint or illness is considered "work related?" If an employee simply "doesn't feel well", am I supposed to provide them with a Claim Form and send them to the clinic?

This depends - if the employee is merely engaging in good natured grousing, and DOES NOT request to see a physician, there would be no point in reporting it. If, however, the employee indicates he/she will need ongoing medical treatment it is likely a good thing to send the employee to the clinic for an evaluation and determination as to whether the physical injury could be related to their work.

"With all the new changes in the Workers' Compensation laws, have they changed the requirements for an injury to be work related?"

No. To be work related, an injury or illness must occur while the employee is in the scope of his/her job, and the injury or illness must arise from the performance of the job. Previous changes in the Labor Code imposed stricter requirements for psychiatric injuries to be compensable, and for injuries which are reported for the first time after an employee has been terminated.

Employers should be aware that they (and their insurance company) have 90 days from receipt of the claim form to obtain an investigation and make a decision regarding compensability. Recent court decisions have narrowed the potential circumstances under which a workers' comp claim can be considered as being formally reported to an employer and when the clock starts running on the 90 days. Essentially, the Court held that an actual return of the DWC-1 by an employee to his/her employer is necessary before the 90 days begins to run. If the employer neglects to provide a claim form on a timely basis, the Workers Compensation Appeals Board must determine if that delay was willful and designed to delay or prevent the provision of workers' compensation benefits to the employee. Barring such a finding the Courts have held the employer cannot be required to provide a claim form simply because a potential claim might exist. Though this decision was a relief to employers, it should be noted that a failure to provide a claim form to an employee will still likely be held to extend the statutory time period in which the injured worker has to file a formal claim with the Workers Compensation Appeals Board.

One change that does affect an employer's liability for non-work related injuries is the provision that an employer must begin providing medical treatment within one day of receipt of a claim form, and continue to provide treatment up to a maximum of $10,000 until such time as the compensability of the claimed injury is determined. Even if the claim is eventually denied as non-work related, the employer's liability remains for payment of medical treatment costs during the period between receipt of the DWC-1 and the issuance of a denial.

"What if an employee has a prior pre-designation or wants to pre-designate a doctor in the event they are injured at work?"

Other than providing the information contained in the pamphlet "Facts About Workers' Compensation" (the blue pamphlet in your Claims reporting kit), and the information you will be required to provide to employees in the formal Medical Provider Network (MPN) employee notification process, there is nothing you need to do about your employees' pre-designating their personal physicians to be their industrial doctor.

Once the Medical Provider Network is approved by the Division of Workers Compensation those employees who have not pre-designated will be required to obtain treatment for their industrial injuries from a physician in that MPN. In order for any pre-designation to be filed correctly, we recommend that the employer require the employee to provide the name and address of the physician being pre-designated, his/her specialty, and an affidavit from the physician that he/she is the employee's personal physician with access to the employee's medical records and is willing to provide medical treatment for any industrial injury for which the employee requires medical care.

We used to report all of our "First Aid's" - is that necessary?  How do I know if an injury/illness is actually considered a First Aid incident or injury?

You are not required to report First Aid's to your insurance carrier, but sometimes it's a good idea to let us know just in case we receive a bill from the occupational provider.

First Aid is defined in the Division of Workers' Compensation (DWC) Regulations, Section 9780(f). That section states, "First aid is any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, etc which do not ordinarily require medical care. Such one-time treatment, and follow-up visit for the purpose of observation, is considered first aid, even though provided by a physician or registered professional personnel."

The purpose for allowing first aid reimbursement directly by employers to clinics is so that employers who do not have nurses on staff, who might otherwise address these minor injuries, are not at a disadvantage with those companies that do have nursing staff in the computation of the frequency of their experience modification.

When determining if a specific situation meets the criteria for first aid it is best to look to the phrase in the definition which states that the injury/illness "does not normally require medical care." Examining the type of treatment provided by the physician in the context of whether that treatment required a physician to provide it should answer most questions as to whether an injury qualifies as "first aid" or not. For example, if the physician merely bandaged a wound and saw the employee back in a week to insure it was not infected, that could qualify as "first aid." If the physician ordered x-rays or prescribed medication, either of which requires a licensed physician to order, then the injury likely exceeds the "first aid" definition and should be reported.

Keep in mind that any case which involves disability beyond the date of injury is also beyond the limits of first aid and needs to be reported to CompWest.

Can we fire, lay off or reprimand an employee who has filed a work related injury?

As long as the personnel action is not taken in retaliation for, or because of, the employee's filing of a work related injury you may treat an injured worker the same as any other employee you have. However, you should keep in mind that what we do is not always viewed from the same perspective by those who are affected by our actions. This is probably more true when the affect is adverse. An employee who is disciplined or terminated after reporting an industrial injury might believe there is an association, and could file a Discrimination claim against you at the Workers' Compensation Appeals Board. Called a 132(a) claim, if the employee prevails it awards back pay, benefits, and a fine of 50% of the value of the employee's Workers' Compensation benefits up to a $10,000 cap on this 50% increase.

If you are involved in a personnel situation with an employee who also has a pending Workers' Compensation claim, it is probably best to consult your labor attorney for a recommendation on how best to proceed.

What if we think a claim is fraudulent?

Immediately call, or fax or e-mail one of the Claims contacts listed on this website. If you have specific information which supports your belief, that is all the better.

CompWest Insurance Company will look into any contention that a particular claim is fraudulent and, if it seems suspicious to us as well, we will report it to the Fraud Unit of the Department of Insurance, as well as to the local District Attorney.

The impact of such a report of fraud on the cost of a claim will depend on a number of factors, not the least of which is whether the authorities believe the case has sufficient merit to warrant an arrest and prosecution.

Do we have to pay an employee for time off to attend medical evaluations?  Do we have to allow an employee to attend medical appointments during work hours?

Though we do not have empirical data to support this statement, it is our belief that the majority of California employers do pay for employees to take a reasonable amount of time off to attend medical and physical therapy appointments. There is nothing wrong with encouraging employees to schedule these appointments before or after working hours, when feasible.

If you are absolutely opposed to the concept of paying for this time, there is nothing which mandates that you do continue salary for time taken off for medical appointments. However, many of your employees would then be entitled to temporary partial disability provided they did not earn more than the threshold of earnings for the maximum temporary disability rate. If they are above the maximum they might well be entitled to no temporary disability unless they missed all, or most, of a day's work.

It has been found to be discrimination to require an injured worker to exhaust his sick, vacation or personal days in order to maintain his salary for those trips to the doctor or therapist. However, an injured employee may choose to use personal or sick time if it's available to them. Time away to attend medical visits should be treated the same for work related injuries and personal injuries/illnesses.

In the best of all worlds, the employee would schedule his/her visits so that they caused the least possible disruption to the work day. Sometimes this can be as simple as finding a medical provider close to the employer who could administer treatment when the employee left work, or at lunch. CompWest has a statewide network of occupational medical providers, and provides each employer a list of local medical facilities.

If one of my employees seeks representation from an attorney and asks questions about their work related claim what should I do?

You can discuss any work related issues with your injured employee.  For instance you may discuss work modifications and should feel free to check on them to see how they are feeling.  You should refrain from asking them questions about the status of their litigation, specific benefit issues or any treatment that may be rendered for the work related injury.  If the employee has specific questions you need to direct them to contact their attorney.

When in doubt please contact any of our highly trained claims staff.  They will be happy to answer any questions you may have.  If you would like to email your  question to our general claims email please do so at claims@compwestinsurance.com  You will receive a response within 1 working day.