Denial based on ER level of investigation (California) (Cali

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Re: Denial based on ER level of investigation (California) (Cali

Postby jpod on Thu Nov 15, 2018 11:03 am

And there is the issue of whether what issued was actually a denial vs. a Reynolds notice. I agree with Vampire that is is unusual for a denial to issue when a claim has not been made. I don't know what effect a denial would have if the applicant never filed a claim form (not referring to the one filed after attorney became involved). What is being denied if applicant never made a claim?

Claims offices have a duty to investigate even when the employee has not returned the claim form. The wording you quoted does not say "injury (or claim) is denied" it says "investigation could not substantiate your injury". Part of that investigation may have been trying to obtain a claim form. The audit unit takes a dim view of denying a claim b/c an employee has not returned a claim form for the practical reason that ee's don't have to file a claim right away, they have one year. The best practice is to include a blank claim form along with Reynolds notice but it could have been provided by other means.
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Re: Denial based on ER level of investigation (California) (Cali

Postby carmen@npnlaw on Sun Nov 18, 2018 12:05 pm

I'm confused about the denial too. It's captioned "Notice Regarding Denial of Workers' Compensation Benefits". IW was sent to the doctor one week after she injured herself. Doctor stated in his report that IW gave a history of "lifting heavy box of strawberries and felt pain in low back". She was sent back to work with restrictions. No DWC-1 just a denial of injury 30 days later.
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Re: Denial based on ER level of investigation (California) (Cali

Postby jpod on Mon Nov 19, 2018 8:20 am

Denial of benefits is not denial of injury...; but its a defective Reynolds notice unless a claim form has been provided. What treatment was provided? The requirement to provide a claim form arises only if medical treatment beyond first aid was provided.
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Re: Denial based on ER level of investigation (California) (Cali

Postby carmen@npnlaw on Mon Nov 19, 2018 9:13 am

Doctor's first report "this is not a first aid claim". Confirmed no claim form was provided by ER. Carrier does not have a completed claim form except that which was provided by our office. DA still moving forward with the denial and SOL because app was not filed within one year from the denial.
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Re: Denial based on ER level of investigation (California) (Cali

Postby jpod on Mon Nov 19, 2018 9:27 am

Well unless there is some evidence a Reynolds noticed issued the Reynolds case says no SOL argument can prevail if employee was not advised of their rights. Beware of company forms that duplicate the notice of rights that is found on the back of the claim form though.

The statement this is not a "first aid claim" doesn't convert first aid treatment to medical treatment beyond first aid. FA is statutorily defined.
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