WCIRB Monitors Immediate Medical Care Treatment Claims

On April 19, 2004, Senate Bill No. 899 (SB 899) was signed by the Governor into law. One of the key provisions of SB 899 amended Labor Code §5402 to provide that within one day of receiving an employee claim form, the employer will authorize and provide medical treatment until such time as the claim is denied. The employer’s liability for medical treatment prior to the time the claim is accepted or denied is limited to $10,000.

The WCIRB and its committees considered whether the California Workers’ Compensation Experience Rating Plan—1995 should be revised to specifically reference immediate medical care treatment claims. A decision was made that because the change in law is recent and there is limited data available to assess the frequency and cost of immediate medical care treatment claims or their potential impact on experience modifications, such claims will be treated the same as other claims for unit statistical reporting purposes. Specifically, once a claim is submitted to an insurer, the value of the claim must be reported to the WCIRB in accordance with the requirements set forth in the California Workers’ Compensation Uniform Statistical Reporting Plan—1995 (USRP). If a claim is ultimately determined to be non-compensable, the claim should be reported to the WCIRB as a non-compensable claim in accordance with the USRP. The USRP provides several bases for determining when a claim is non-compensable. One such basis, which is likely to apply to more claims as a result of the enactment of §5402, arises when an insurer rejects a claim for benefits and no application for adjudication of the claim is filed during the applicable statute of limitations.

WCIRB staff will continue to monitor immediate medical care treatment claims. Once more information is available regarding the magnitude and distribution of these claims, staff will reevaluate the appropriateness of continuing to treat immediate medical care treatment claims as non-compensable for unit statistical and experience rating purposes.

Topics Claims