How to Help Policyholders Resolve Disputes

9/9/2019

Agents and brokers are often asked to assist their policyholder customers during disputes with the WCIRB or insurance companies. The WCIRB and insurers licensed to underwrite workers’ compensation insurance in California are required to have a policyholder dispute resolution process. Following are steps that agents and brokers should know so they can assist policyholders with their disputes.

WCIRB Dispute Process

If a policyholder has a dispute with the WCIRB, the first step is to submit an Inquiry letter. The Inquiry letter to the WCIRB can dispute the following:

  • A classification on a WCIRB Inspection Report
  • The calculation of an experience modification
  • The combinability of entities for experience rating purposes

The WCIRB can only accept Inquiries regarding issues within its legislative authority such as issues involving classification or experience rating. For example, it cannot advise on the determination of employment status, the amount of premium due on a policy or claims handling issues, such as the insurance company’s determination of the value or the status of a claim, i.e., whether a claim is fraudulent or non-compensable.

If the WCIRB’s response to the Inquiry does not fully answer the questions or if the policyholder has additional information that might have a bearing on the decision reached by the WCIRB, the policyholder can proceed to the next step in the dispute process by submitting a Complaint and Request for Action to the WCIRB. If the WCIRB’s letter does not resolve the matter, the policyholder may either submit a Request for Reconsideration to the WCIRB or file an appeal with the California Department of Insurance (CDI).

If the policyholder doesn’t agree with the WCIRB’s decision on the Complaint or the Request for Reconsideration, the policyholder can appeal it to the CDI by completing the Workers’ Compensation Insurance Policy Appeal form available on the CDI website and filing it with the Administrative Hearing Bureau at the CDI.

The regulations explaining the WCIRB dispute process are in the California Workers' Compensation Uniform Statistical Reporting Plan—1995, the California Workers' Compensation Experience Rating Plan—1995 and the Miscellaneous Regulations for the Recording and Reporting of Data—1995 under the “Inquiries, Complaints and Requests for Action, Reconsideration and Appeals” section.

Insurance Company Dispute Process

Unlike disputing an issue with the WCIRB, it’s not necessary for the policyholder to submit an Inquiry letter to an insurance company. In this instance, the first step is to submit a Complaint and Request for Action letter directly to the insurance company. The contact information for the insurance company’s dispute process is in a notice attached to the policy titled “Your Right to Rating and Dividend Information” under the “Our Dispute Resolution Process” section. The insurance company contact information is also on the CDI website.

  • Disputes submitted to insurance companies can address issues such as the following:
  • Classifications assigned to employees by the insurance company
  • Application of an experience modification
  • Employment status
  • Premium disputes

If the insurance company’s letter in response to the Complaint does not resolve the dispute, the policyholder can submit a Request for Reconsideration letter to the insurance company or proceed directly to file an appeal with the Administrative Hearing Bureau at the CDI.

WCIRB Policyholder Ombudsman

Policyholders and their representatives are welcome to contact the WCIRB Policyholder Ombudsman for assistance with questions regarding disputes with the insurance company or the WCIRB. The Ombudsman performs the following functions:

  • Assists with questions regarding workers’ compensation insurance
  • Explains California insurance regulations
  • Helps policyholders navigate and understand the dispute resolution process with their insurance company or the WCIRB
  • Acts as an intermediary and works to facilitate a resolution to issues or disputes

Contact the Ombudsman by phone at 415.778.7159, via email at [email protected] or by filling out the Request for Assistance Form on the WCIRB website.