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Thread: Penalties

  1. #1
    Join Date
    Apr 2007
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    63

    Default Penalties

    My workers compensation claim was made in the State of: hi ineed help in finding out how to calculate the amount of penalty from the insurance cop.for not approving dr request on time.thank you

  2. #2
    Join Date
    Oct 1971
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    5,172

    Default Re: Penalties

    Quote Quoting mark14 View Post
    My workers compensation claim was made in the State of: hi ineed help in finding out how to calculate the amount of penalty from the insurance cop.for not approving dr request on time.thank you
    There are no penalties, just remedies - If there where, you wouldn't stand a chance of pursuing them without a lawyer.
    Was this request approved through the UR process?
    If so, file for an expedited hearing.

    Q. What is utilization review?
    A. UR is the program claims administrators use to make sure the treatment you receive is medically necessary. All claims administrators are required by law to have a utilization review program. This program will be used to decide whether or not to approve medical treatment recommended by your doctor.
    https://www.dir.ca.gov/dwc/WCFaqIW.html#MedicalCare

    Q. What if more than 14 days have gone by since my doctor requested treatment and we haven’t heard or received anything from the claims administrator?
    A. If your doctor has not been able to get a response from the claims administrator, you should file a declaration of readiness to proceed to expedited hearing. A claims administrator who fails to meet the appropriate deadline for a utilization review cannot object to the doctor providing the requested treatment.
    Q. If my doctor's request for treatment is not approved, what can I do?
    A. If you agree with the treatment requested by your doctor and the treatment is denied after being reviewed through the UR process, the dispute will be resolved through IMR, for all dates of injury.
    https://www.dir.ca.gov/dwc/Utilizati...uredWorker.htm

    In the future, post the state, I see you're in California from past postings.
    You need to lawyer up to avoid these types of issues, your ignorance of how the system works may be why you're having problems.

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  3. #3
    Join Date
    Apr 2007
    Posts
    63

    Default Re: Penalties

    Tony i did file for hearing and the judge who told me to file for penalties this why i asked for help i am in ca .every dr request was approved from U.R.never was in timly manner .

  4. #4
    Join Date
    Oct 1971
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    5,172

    Default Re: Penalties

    Quote Quoting mark14 View Post
    Tony i did file for hearing and the judge who told me to file for penalties this why i asked for help i am in ca .every dr request was approved from U.R.never was in timly manner .
    There may not be much in it for you but there may be for the return-to-work fund if they can show this is a "general business practice" of the employer or carrier.
    That may be why he said that, he's trying to establish a pattern of behavior so they can impose administrative penalties

    Have to admit, this is the first I've heard of this in California over medical but I found it.
    You must first prove the medical was unreasonably delayed or refused.
    The law gives the percentage relevant to payment, if the issue is medical the penalty is at the discretion of the judge.

    There is a two year statute of limitations, meaning you can only file penalties for offenses two years prior.
    Unless the delay or refusal was intentional and grievous I don't see them applying penalties, the courts favor the carrier - I still say you'll need a lawyer, especially if you don't know what you're doing.
    If you win the claim for penalties, the court will also award your attorney fees so you have nothing to lose.

    LABOR CODE - LAB
    DIVISION 4. WORKERS' COMPENSATION AND INSURANCE [3200 - 6002] ( Heading of Division 4 amended by Stats. 1979, Ch. 373. )
    PART 4. COMPENSATION PROCEEDINGS [5300 - 6002] ( Part 4 enacted by Stats. 1937, Ch. 90. )
    CHAPTER 6. Findings and Awards [5800 - 5816] ( Chapter 6 enacted by Stats. 1937, Ch. 90. )
    5814.
    (a) When payment of compensation has been unreasonably delayed or refused, either prior to or subsequent to the issuance of an award, the amount of the payment unreasonably delayed or refused shall be increased up to 25 percent or up to ten thousand dollars ($10,000), whichever is less. In any proceeding under this section, the appeals board shall use its discretion to accomplish a fair balance and substantial justice between the parties.
    (e) No unreasonable delay in the provision of medical treatment shall be found when the treatment has been authorized by the employer in a timely manner and the only dispute concerns payment of a billing submitted by a physician or medical provider as provided in Section 4603.2.
    (g) Notwithstanding any other provision of law, no action may be brought to recover penalties that may be awarded under this section more than two years from the date the payment of compensation was due.

    https://leginfo.legislature.ca.gov/f...ectionNum=5814.

    II. Audit penalty: Any employer or insurer that knowingly violates section 5814
    with a frequency that indicates a general business practice is liable for administrative
    penalties
    of not to exceed four hundred thousand dollars ($400,000). Penalty
    payments shall be imposed by the administrative direction and deposited into the
    return-to-work fund established pursuant to section 139.48.
    The administrative
    director may impose a penalty under either this section or subdivision (e) of section
    129.5.
    https://www.dir.ca.gov/dwc/educonf12/5814/Penalty.pdf

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

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