When assigning permanent impairment for a spinal injury under the AMA Guides, 5th Edition, two primary pathways emerge: the Diagnosis-Related Estimates (DRE) method and the Range of Motion (ROM) method. The stakes are high for claims adjusters, as choosing the proper approach—and scrutinizing the results—can drastically impact claim reserves and settlement strategies. Below is a […]
California Labor Code §3600(a)(10) provides employers and insurers a valuable defense when workers’ compensation claims are filed after an employee has received notice of termination or layoff. However, this post-termination defense is not absolute. Cumulative trauma (CT) claims, particularly those hinging on the “date of injury” under Labor Code §5412, can pose unique challenges. Below […]
(A Humorous Look at the Intersection of Brackets and Claims Adjusting) I might not walk in your well-heeled shoes (or well-worn loafers) as a claims adjuster, but I see you. You are out there balancing a mountain of case files while your co-workers argue over which 13-seed is destined to wreck everyone’s bracket. So, from […]
Death benefits under California’s workers’ compensation laws can be a complex area for employers and claims adjusters to navigate. Understanding how the Labor Code treats “total” and “partial” dependency is vital for accurate benefit calculation, appropriate benefit distribution, and overall claims resolution. Below is an overview tailored to those who regularly handle claims—focusing on the […]
Introduction When a California law enforcement officer sustains two separate workplace injuries—especially if those injuries overlap in time—how should Labor Code § 4850 “leave of absence” benefits be applied? That is the question at the heart of Agaiby v. City of Culver City (2024 Cal. Wrk. Comp. P.D. LEXIS 382), a recent Workers’ Compensation Appeals […]
Introduction A recent panel decision out of the California Workers’ Compensation Appeals Board—Robasciotti v. Maxim Healthcare (2024 Cal. Wrk. Comp. P.D. LEXIS 365)—provides important lessons on how multiple impairments may be combined or “added” when rating an injured worker’s permanent disability. In particular, it underscores the continued importance of the “Kite doctrine,” which allows for […]
1. Apportionment Pitfalls and Documentation Key TrendMany recent WCAB decisions have emphasized the need for clear, well-supported medical opinions on apportionment. Panels repeatedly admonished parties where physicians simply assigned percentages with inadequate rationales or failed to distinguish non-industrial from industrial factors. Adjusters often faced delays and higher litigation costs when an inadequate physician report triggered […]
In a recent panel decision, the Workers’ Compensation Appeals Board (WCAB) offered a cautionary tale for claims administrators and insurance carriers on how a seemingly straightforward denial can inadvertently fail to trigger the one-year statute of limitations (SOL). Although Bracy v. State of California is not binding precedent, it provides valuable insights into best practices […]
In a significant decision for California public employers and claims professionals, the California Supreme Court in Department of Corrections and Rehabilitation v. Workers’ Compensation Appeals Board (Ayala) has clarified that Industrial Disability Leave (IDL) benefits paid under the Government Code do not qualify as “compensation” under the Workers’ Compensation Act. This means that when an […]
Introduction In California’s workers’ compensation system, utilization review (UR) is the primary “gatekeeper” to determine whether requested medical treatment is medically necessary. If UR is performed timely and in compliance with statutory and regulatory requirements, a Workers’ Compensation Judge (WCJ) generally cannot second-guess or overturn the treatment determination. Instead, disputes go to Independent Medical Review […]
