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The Workers' Compensation Dispute Process

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The Workers' Compensation Dispute Process

March 25, 2015

Every insurer that is licensed to underwrite workers’ compensation insurance in California is required to have a dispute process to facilitate the resolution of policyholders’ issues. Similarly, the WCIRB has a dispute resolution process. This requirement is found in the Insurance Code, and the applicable regulations, including Title 10 of the California Code of Regulations (Article 9.7 Section 2509.40, et seq.), Section VIII of the California Workers’ Compensation Experience Rating Plan—1995 (ERP), and Part 1, Section V, of the California Workers’ Compensation Uniform Statistical Reporting Plan—1995 (USRP).

Disputing a WCIRB Action

A policyholder can file a dispute with the WCIRB regarding classifications assigned on their WCIRB Inspection Report, the calculation of their experience modification, or the combinability of entities for experience rating purposes. Premium disputes, employment status and claims handling issues are not within the WCIRB’s jurisdiction and should not be raised in a dispute filed with the WCIRB. These issues should be directed to the insurer. There are three steps in the WCIRB’s dispute process: the initial Inquiry, which could be followed by a Complaint and Request for Action, and, if necessary, a Request for Reconsideration.

Disputing an Insurer’s Action

Disputes filed with insurers may address issues such as the classifications applied to a policy, the application of an experience modification, claims handling, premium disputes, and employment status. The insurer’s dispute process has only two steps: the initial Complaint and Request for Action and, if necessary, a Request for Reconsideration.

A dispute, regardless of whether it pertains to an action of the WCIRB or an insurer, must be submitted in writing and should include the name of the employer, the name of the insurer, the policy period in question, all related policy numbers and a detailed description of the dispute and why you believe the insurer’s or the WCIRB’s decision, action or failure to act is incorrect. The dispute letter should be signed and dated, and printed on company letterhead (if possible), and it should indicate whether it is in regard to an Inquiry, a Complaint and Request for Action, or a Request for Reconsideration.

If a policyholder has a dispute with an insurer, contact information can be found in the Policyholder Notice “Your Right to Rating and Dividend Information” under the paragraph “Disputing Our Actions.” If the dispute is with the WCIRB, contact information can be found in the ERP and the USRP under the section entitled “Inquiries, Complaints and Requests for Action, Reconsideration, and Appeals."

After a policyholder has exhausted the dispute process with the WCIRB or an insurer, the policyholder can appeal to the Insurance Commissioner by filing an appeal with the Administrative Hearing Bureau at the California Department of Insurance (CDI). See the CDI website for additional information.

Where to Find Additional Information

A brief but comprehensive educational online module regarding the dispute process can be found in the Education on Demand section in the Learning Center on the WCIRB Website (www.wcirb.com). This learning module provides detailed information including the steps for filing a dispute with the insurer or the WCIRB and the prescribed time limits for filing the dispute, receiving a response, and filling an appeal with the Administrative Hearing Bureau at the CDI.

The WCIRB Policyholder Ombudsman is available to provide assistance to employers and answer questions regarding the dispute process. Employers can contact the Ombudsman by phone at 415.778.7159 or via email at [email protected], or by filling out Request for Assistance Form on the WCIRB Website. Agents and brokers may contact WCIRB’s Customer Service at 888.229.2472 or by email at [email protected].

Related Information

Policyholder Ombudsman
Online Guide to Workers Compensation: Dispute Process and Further Assistance

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