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  1. #1
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    Question Who is In Charge of the Defense of a Worker's Comp Claim

    CA WC relative: Who has the last word regarding my case, or should I say who has the ultimate power to control my WC case, ER legal, or ER IC? What if ER is its own IC?
    Last edited by jo51; 10-11-2008 at 10:10 AM. Reason: Too many words

  2. #2
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    Default Re: Who Rules?

    the comp court has the power to over rule either party.
    as far as defense decisions the carrier/adjuster as the client makes the call.
    In self-insured situations the employer has much more say then the adjusting agent.

  3. #3
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    Default Re: Who Rules?

    Virtually any decision by a WCAB judge is subject to appeal by the side that feels the decision was not favorable to them...there are cases that proceed all the way to the State Supreme Court...since SB227/899 threre are more and more of these appeals all the time.

  4. #4
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    Question Re: Who Rules?

    Quote Quoting .SH View Post
    the comp court has the power to over rule either party.
    as far as defense decisions the carrier/adjuster as the client makes the call.
    In self-insured situations the employer has much more say then the adjusting agent.
    Thank you for explaining ULTIMATE FINAL say in a wc case, I understand that the UR (court) has that position.
    So, youre saying, it's the ATTORNEY (as a 'representative' of the er) that has final say over the IC if self insured?

  5. #5
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    Default Re: Who Rules?

    I understand that the UR (court) has that position
    "UR" is Utilization Review... that is a process as allowed by law, for the ER/IC to control the medical costs in a claim... this is not a ''court'', and the decisions of a UR doctor can be challenged... the purpose of UR is to determine, per the guidelines... ACOEM/MUTS/EBM... the 'medical necessity' and 'reasonableness' of a requested treatment... that's IT...

    So, youre saying, it's the ATTORNEY (as a 'representative' of the er) that has final say over the IC if self insured?
    The DA/Defense Atty, is not a 'end all' or anyway near a 'final say' to any claim...
    The DA is there to mitigate the costs of a claim to the ER/IC... whether self-insured, or purchasing the coverage for WC benefits through a IC/policy...

    The 'final' say is through the courts...to the supremes if necessary....

    Where the ER purchases a policy to provide the benefits due to an EE where there is a work related injury, the IC becomes the "ER" for all intent/purpose in providing the benefits... until the IW is determined P&S/MMI, the ER has virtually no input in the administration of the benefits to the claim...

    Where the ER is 'self-insured'... there is usually a TPA/Third Party Administrator providing the benefits and costs involved in the claim...and the decisions as necessary. The ER usually doesn't get involved... IF on the onter hand, the ER is large enough to maintain a 'in-house' claims dept... all of the decisions will be made 'in-house' by a CA/Claims Administrator...

    As a receipient of WC benefits, it really doesn't, or shouldn't, matter whether the ER is covered by an IC/policy, or is self-insured... the benefits you are entitled to are the same, as determined by statute/law/code/rules...

  6. #6
    Join Date
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    california
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    Default Re: Who Rules?

    Quote Quoting BvIA View Post
    "UR" is Utilization Review... that is a process as allowed by law, for the ER/IC to control the medical costs in a claim... this is not a ''court'', and the decisions of a UR doctor can be challenged... the purpose of UR is to determine, per the guidelines... ACOEM/MUTS/EBM... the 'medical necessity' and 'reasonableness' of a requested treatment... that's IT...


    The DA/Defense Atty, is not a 'end all' or anyway near a 'final say' to any claim...
    The DA is there to mitigate the costs of a claim to the ER/IC... whether self-insured, or purchasing the coverage for WC benefits through a IC/policy...

    The 'final' say is through the courts...to the supremes if necessary....

    Where the ER purchases a policy to provide the benefits due to an EE where there is a work related injury, the IC becomes the "ER" for all intent/purpose in providing the benefits... until the IW is determined P&S/MMI, the ER has virtually no input in the administration of the benefits to the claim...

    Where the ER is 'self-insured'... there is usually a TPA/Third Party Administrator providing the benefits and costs involved in the claim...and the decisions as necessary. The ER usually doesn't get involved... IF on the onter hand, the ER is large enough to maintain a 'in-house' claims dept... all of the decisions will be made 'in-house' by a CA/Claims Administrator...

    As a receipient of WC benefits, it really doesn't, or shouldn't, matter whether the ER is covered by an IC/policy, or is self-insured... the benefits you are entitled to are the same, as determined by statute/law/code/rules...
    Thank you for thoroughly explaining.

  7. #7
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    Default Re: Who Rules?

    no. the self-insured employers atty does NOT have decision making authority over the employers claims handling. If the atty wants to stay employed they will give their client appropriate legal advice but in the end it is the client eg the self-insured employer who makes the business decision.
    The consequence of the claim will fall on the employer not the atty i.e. liability for penalties, sanctions, costs, etc.

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