Let Workers’ Compensation Insurer Check on Claim Validity

One of my employees came to me today and said his back was sore and that he hurt it while moving some equipment, so we sent him to the doctor to get treatment. Shortly after this employee left for the doctor’s office, another employee came to me and told me the first employee actually hurt his back at home the night before, and was lying about getting hurt at work. Knowing what the second employee told me, do I still have to process the employee’s workers’ compensation claim?

The short answer is “yes.” California Labor Code Section 5401 requires an employer to provide its employees with the workers’ compensation claim form (DWC-1) within one working day from the time the employer receives notice or knowledge of an injury that results in lost time from work, or requires more medical treatment than first aid.

As a result, if an employee tells you that he or she was injured at work, you must provide the employee with the claim form.

Investigation of Claims

You can, however, pass on the information you received to your insurance carrier and the insurance company has up to 90 days to investigate the claim to determine whether it arose out of employment and occurred in the course of employment.

If your insurance carrier determines that the employee was not hurt at work or while working, it can deny the claim. The obligation to investigate the validity of a workers’ compensation claim rests with your insurance carrier.

Employer Obligation

As the employer, your obligation is to process the claim to the insurance company and to provide it with whatever relevant information you believe will assist it in evaluating the claim properly.

There is no direct penalty for failing to provide the claim form to the employee, but failing to provide the claim form can extend the employee’s statute of limitations for filing the claim and could jeopardize the insurance company’s ability to actually deny the claim if the insurance company believes the injury did not occur in the course of employment.

Column based on questions asked by callers on the Labor Law Helpline, a service to California Chamber of Commerce preferred and executive members. For expert explanations of labor laws and Cal/OSHA regulations, not legal counsel for specific situations, call (800) 348-2262 or submit your question at www.hrcalifornia.com.

Staff Contact: David Leporiere