If you have tried to resolve an issue regarding an action or failure to act on an informal basis and would like to pursue the issue as a formal dispute, the avenue for doing so is either through your insurer's internal dispute process or the WCIRB's internal dispute process.
Disputing Your Insurer's Decision
To dispute a decision made by your insurer, the dispute must be in writing and sent to your insurer's designated office. Contact information for your insurer's dispute process is found in a policyholder notice attached to your policy titled "Your Right to Rating and Dividend Information," under the paragraph "Our Dispute Resolution Process." Issues disputed with your insurer may include classification assignments or premium issues. Claims-handling issues are not addressed in this procedure and should be directed to your claims adjuster.
Disputing the WCIRB's Decision
To dispute a decision made by the WCIRB, such as the classification of the operations assigned on a WCIRB inspection report or the calculation of your experience modification, follow the process explained in the California Workers' Compensation Uniform Statistical Reporting Plan - 1995, the California Workers' Compensation Experience Rating Plan - 1995 or the Miscellaneous Regulations for the Recording and Reporting of Data – 1995 under a section titled "Inquiries, Complaints and Requests for Action, Reconsideration, and Appeals."
Appealing to the Insurance Commissioner
If you have exhausted either your insurer's dispute process or the WCIRB's dispute process, and you are still not satisfied with the outcome, you have the right to appeal the issue to the Administrative Hearing Bureau at the California Department of Insurance. When responding to your dispute, your insurer or the WCIRB should provide you with contact information for filing your appeal with the Department of Insurance. The information is also found in the "Your Right to Rating and Dividend Information" policyholder notice attached to your workers' compensation policy; Part 1, Section V of the California Workers' Compensation Uniform Statistical Reporting Plan - 1995; and Section VIII of the California Workers' Compensation Experience Rating Plan - 1995. The appeals process is also found in the California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Article 9.7.
When filing an appeal, you should be as specific as possible concerning your issue and include any supporting documentation. You should also clearly explain why you believe your insurer or the WCIRB acted (or failed to act) in error.
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