California Workers' Compensation Claims Handling
Core framework
California claims handling is driven by the Labor Code and the WCAB's rules of practice. A candidate must know the claims administrator's duty to investigate promptly, the one-day rule for reporting a serious injury or death to the DWC, and the claim form obligation to furnish a DWC-1 within one working day of knowledge of an injury. Understand presumption concepts for public safety personnel, the 90-day decision window to accept or deny (with the 14-day option when a claim is accepted), and the role of utilization review and independent medical review in treatment disputes.
Traps
Questions often confuse injury reporting deadlines (employee's 30-day notice) with the employer's obligation to file the DWC-1 and the claim administrator's decision deadline. Another trap is mixing medical-only claims with indemnity claims when calculating reserves or when determining whether a QME or P&S report is required. Watch for questions on penalties for unreasonable delay (Labor Code section 5814) versus interest on unpaid benefits.
Rule of thumb
When a claim is accepted, the administrator generally has 90 days from the date the claim form is filed to decide, but may take up to 14 days if accepting. If denied, the denial must be timely and specific. A useful worked example: an employee reports an injury Monday; the employer must provide the DWC-1 within one working day, and the administrator's 90-day clock starts from the filing date, not the injury date.
Key concepts
Know the DWC-1, claim status letters, reserves, subrogation, lien procedures, and WCAB petition timelines.