Generally, employers have 90 days from the date of an employee’s workers’ comp claim to investigate and then accept or deny the claim. And it’s critical not to miss the deadline because if you do, there will be a presumption that the injury is covered by workers’ comp. But suppose a worker who hasn’t filed a workers’ comp claim has mentioned on several occasions that he has medical problems stemming from workplace stress. Does the 90-day window begin running as soon as you hear about this, or only when the worker files a claim? A California appellate court recently considered that question. We’ll explain what the court said and provide practical tips for handling claims.
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Employer Denies Workers’Comp Claim
William Wagner was a sheet-metal worker for Honeywell. He requested a medical leave for psychiatric reasons and indicated on the leave form that his injury was work-related. The next day, Honeywell faxed Wagner a workers’ comp claim form and a pamphlet explaining workers’ compensation.
Wagner promptly completed and returned the form to Honeywell. Two months later, Honeywell denied the claim on the grounds that Wagner’s psychiatric injury wasn’t compensable because it stemmed from nonindustrial factors.
Employee Disputes Timeliness of Denial
Wagner balked. He argued that Honeywell missed the 90-day deadline for denying a claim. Specifically, he said Honeywell had been put on notice that his injury was work-related twice before. Six months earlier when Wagner was admitted to a psychiatric hospital, his wife told human resources that his problem was caused by work issues. And Wagner had sought medical attention for stress at Honeywell’s on-site medical clinic at least a year before. Honeywell countered that its denial was timely because the 90-day period didn’t commence until Wagner actually submitted the workers’ comp claim form.
When Does Clock Begin to Run?
The Workers’ Compensation Appeals Board ruled that Honeywell missed the 90-day deadline to reject Wagner’s claim. That’s because, said the WCAB, the 90 days begin when an employer is “reasonably certain” of an industrial injury or claim and doesn’t give the employee a claim form at that time.
But a California Court of Appeal disagreed with the WCAB. According to the court, the 90-day law clearly provides that the employer must reject liability within 90 days after the claim form is filed. The clock can only start earlier, the court said, if there is evidence of egregious employer misconduct, which is determined by either of two factors: 1) that the employer deliberately or intentionally refused to provide the required claim form to the employee or 2) that the employer made false statements to the employee to prevent or delay the employee’s completion and filing of the claim form.The case will now return to the WCAB to determine whether Honeywell acted egregiously in not providing the claim form to Wagner months earlier.
3 Practical Tips for Handling Claims
This case highlights the importance of having a consistent process for handling workers’ comp claims. Here’s what you can do:
- Promptly provide claim forms. Within one working day of finding out about an on-the-job injury, you must provide the injured worker with a claim form (DWC Form 1), and you have up to five days to provide the person with an injured worker pamphlet, either in person or by first-class mail. The forms and pamphlets are available from your workers’ comp insurer. You must provide claim forms only when the injury results in lost time beyond the date it occurred, or when the employee requires treatment beyond first aid.
- Notify your insurer. You have five working days from learning about an injury to report it to your workers’ comp carrier. Use DLSR Form 5020, Employer’s Report of Occupational Injury or Illness, available from your insurer.
- Keep detailed records. Your records should reflect the date the claim form and pamphlet were provided to the employee and the method of delivery, as well as the date your insurer was notified.