citation: LAB § 5102

text: The appeals board may order the lump sum paid directly to the injured employee or his dependents, or deposited with any savings bank or trust company authorized to transact business in this state, which agrees to accept the same as a deposit bearing interest; or the appeals board may order the lump sum deposited with the State Compensation Insurance Fund. Any lump sum so deposited, together with all interest derived therefrom, shall thereafter be held in trust for the injured employee, or in the event of his death, for his dependents. In the event of the employee’s death, his dependents shall have no further recourse against the employer under this chapter.


kind: section

code: LAB

citation: LAB § 5103

text: Payments from the lump sum so deposited shall be made by the trustee only in the amounts and at the time fixed by order of the appeals board and until the lump sum and interest thereon are exhausted.

history: (History: Amended by Stats. 1965, Ch. 1513.)

division: 4. WORKERS' COMPENSATION AND INSURANCE

chapter: 3. Lump Sum Payments

path: 4. WORKERS' COMPENSATION AND INSURANCE > 3. Lump Sum Payments


citation: LAB § 5104

text: In the appointment of the trustee, preference may be given to the choice of the injured employee or his dependents.

history: (History: Enacted by Stats. 1937, Ch. 90.)


citation: LAB § 5105

text: Upon the payment of a lump sum, the employer shall present to the appeals board a proper receipt evidencing the same, executed either by the injured employee or his dependents, or by the trustee. The appeals board shall thereupon issue its certificate in proper form evidencing such payment. Such certificate, upon filing with the clerk of the superior court in which any judgment upon an award has been entered, operates as a satisfaction of the award and fully discharges the employer from any further liability on account thereof.


citation: LAB § 5106

text: The appeals board shall, upon the request of the Director of Industrial Relations, where the employer is uninsured and the installments of compensation awarded are to be paid in the future, determine the present worth of the future payments, discounted at the rate of 3 percent per annum, and order the present worth paid into the Uninsured Employers Fund, which fund shall thereafter pay to the beneficiaries of the award the future payments as they become due.

history: (History: Amended by Stats. 1987, Ch. 202, Sec. 3.)


citation: LAB § 5270

text: This part shall not apply in cases where an injured employee or dependent is involved unless the employee or dependent is represented by an attorney.

history: (History: Amended by Stats. 1990, Ch. 1550, Sec. 49.)

part: 3.5. ARBITRATION

path: 4. WORKERS' COMPENSATION AND INSURANCE > 3. Lump Sum Payments > 3.5. ARBITRATION


text:
(a) The presiding workers’ compensation judge at each district office shall prepare a list of all eligible attorneys who apply to be placed on the list of eligible arbitrators. Attorneys are eligible to become arbitrators if they are active members of the California State Bar Association and are one of the following:

(1) A certified specialist in workers’ compensation, or eligible to become certified.

(2) A retired workers’ compensation judge.

(3) A retired appeals board member.

(4) An attorney who has been certified to serve as a judge pro tempore.

(b) No attorney shall be included in a panel of arbitrators, if he or she has served as a judge in any proceeding involving the same case, or has represented, or whose firm has represented, any party in the same case.

history: (History: Added by Stats. 1989, Ch. 892, Sec. 44.)


citation: LAB § 5271

text:
(a) The parties to a dispute submitted for arbitration may select any eligible attorney from the list prepared by the presiding workers’ compensation judge to serve as arbitrator. However, when the disputed issue involves insurance coverage, the parties may select any attorney as arbitrator upon agreement of the parties.

(b) If the parties cannot select an arbitrator by agreement, either party may request the presiding workers’ compensation judge to assign a panel of five arbitrators selected at random from the list of eligible attorneys. No more than three arbitrators on a five-member panel may be defense attorneys, no more than three may be applicant’s attorneys, and no more than two may be retired workers’ compensation judges or appeals board commissioners.

(c) For each party in excess of one party in the capacity of employer and one party in the capacity of injured employee or lien claimant, the presiding judge shall randomly select two additional arbitrators to add to the panel. For each additional party in the capacity of employer, the presiding judge shall assign a retired workers’ compensation judge or retired appeals board commissioner and an applicant’s attorney. For each additional party in the capacity of injured employee or lien claimant, the presiding judge shall assign a retired workers’ compensation judge or retired appeals board commissioner and a defense attorney. For each additional other party, the presiding judge shall assign two arbitrators to the panel, in order of rotation from case to case, as follows: a retired workers’ compensation judge or retired appeals board commissioner, an applicant’s attorney, a defense attorney.

(d) A party may petition the presiding workers’ compensation judge to remove a member from the panel pursuant to Section 170.1 of the Code of Civil Procedure. The presiding workers’ compensation judge shall assign another eligible attorney to replace any member removed under this subdivision.

(e) Each party or lien claimant shall strike two members from the panel, and the remaining attorney shall serve as arbitrator.

history: (History: Amended by Stats. 1990, Ch. 1550, Sec. 50.)


citation: LAB § 5272

text:
Arbitrators shall have all of the statutory and regulatory duties and responsibilities of a workers’ compensation judge, as set forth in Chapter 1 (commencing with Section 5300) of Part 4, except for the following:

(a) Arbitrators shall have no power to order the injured worker to be examined by a qualified medical evaluator pursuant to Sections 5701 and 5703.5.

(b) Arbitrators shall not have power of contempt.

history: (History: Amended by Stats. 1990, Ch. 1550, Sec. 51.)


citation: LAB § 5273

text:
(a) In disputes between an employee and an employer, the employer shall pay all costs related to the arbitration proceeding, including use of facilities, hearing reporter per diems and transcript costs.

(b) In all other disputes, the costs of the arbitration proceedings, including the arbitrator’s compensation, shall be paid as follows:

(1) By the parties equally in any dispute between an employer and an insurer, or an employer and a lien claimant.

(2) By the parties equally in proceedings subject to Section 5500.5.

(3) By the dependents in accordance with their proportionate share of death benefits, where there is no dispute as to the injury causing death.

(c) Disputes regarding the costs or fees for arbitration shall be within the exclusive jurisdiction of the appeals board, and shall be determined initially by the presiding judge of the district office.

history: (History: Amended by Stats. 1990, Ch. 1550, Sec. 52.)


citation: LAB § 5275

text:
(a) Disputes involving the following issues shall be submitted for arbitration:

(1) Insurance coverage.

(2) Right of contribution in accordance with Section 5500.5.

(b) By agreement of the parties, any issue arising under Division 1 (commencing with Section 50) or Division 4 (commencing with Section 3200) may be submitted for arbitration, regardless of the date of injury.

history: (History: Amended by Stats. 2002, Ch. 6, Sec. 70.5. Effective January 1, 2003.)


citation: LAB § 5276

text:
(a) Arbitration proceedings may commence at any place and time agreed upon by all parties.

(b) If the parties cannot agree on a time or place to commence arbitration proceedings, the arbitrator shall order the date, time and place for commencement of the proceeding. Unless all parties agree otherwise, arbitration proceedings shall commence not less than 30 days nor more than 60 days from the date an arbitrator is selected.

(c) Ten days before the arbitration, each party shall submit to the arbitrator and serve on the opposing party reports, records and other documentary evidence on which that party intends to rely. If a party intends to rely upon excerpts of records or depositions, only copies of the excerpts shall be submitted to the arbitrator.


citation: LAB § 5277

text:
(a) The arbitrator’s findings and award shall be served on all parties within 30 days of submission of the case for decision.

(b) The arbitrator’s award shall comply with Section 5313 and shall be filed with the appeals board office pursuant to venue rules published by the appeals board.

(c) The findings of fact, award, order, or decision of the arbitrator shall have the same force and effect as an award, order, or decision of a workers’ compensation judge.

(d) Use of an arbitrator for any part of a proceeding or any issue shall not bind the parties to the use of the same arbitrator for any subsequent issues or proceedings.

(e) Unless all parties agree to a longer period of time, the failure of the arbitrator to submit the decision within 30 days shall result in forfeiture of the arbitrator’s fee and shall vacate the submission order and all stipulations.

(f) The presiding workers’ compensation judge may submit supplemental proceedings to arbitration pursuant to this part.

history: (History: Amended by Stats. 2006, Ch. 538, Sec. 490. Effective January 1, 2007.)


citation: LAB § 5278

text:
(a) No disclosure of any offers of settlement made by any party shall be made to the arbitrator prior to the filing of the award.

(b) Article 7 (commencing with Section 11430.10) of Chapter 4.5 of Part 1 of Division 3 of Title 2 of the Government Code applies to a communication to the arbitrator or a potential arbitrator.

history: (History: Amended by Stats. 1995, Ch. 938, Sec. 75. Effective January 1, 1996. Operative July 1, 1997, by Sec. 98 of Ch. 938.)


citation: LAB § 5300

text:
All the following proceedings shall be instituted before the appeals board and not elsewhere, except as otherwise provided in Division 4:

(a) For the recovery of compensation, or concerning any right or liability arising out of or incidental thereto.

(b) For the enforcement against the employer or an insurer of any liability for compensation imposed upon the employer by this division in favor of the injured employee, his or her dependents, or any third person.

(c) For the determination of any question as to the distribution of compensation among dependents or other persons.

(d) For the determination of any question as to who are dependents of any deceased employee, or what persons are entitled to any benefit under the compensation provisions of this division.

(e) For obtaining any order which by Division 4 the appeals board is authorized to make.

(f) For the determination of any other matter, jurisdiction over which is vested by Division 4 in the Division of Workers’ Compensation, including the administrative director and the appeals board.

history: (History: Amended by Stats. 1994, Ch. 146, Sec. 152. Effective January 1, 1995.)

chapter: 1. Jurisdiction

path: 4. WORKERS' COMPENSATION AND INSURANCE > 1. Jurisdiction


citation: LAB § 5301

text: The appeals board is vested with full power, authority and jurisdiction to try and determine finally all the matters specified in Section 5300 subject only to the review by the courts as specified in this division.


citation: LAB § 5302

text: All orders, rules, findings, decisions, and awards of the appeals board shall be prima facie lawful and conclusively presumed to be reasonable and lawful, until and unless they are modified or set aside by the appeals board or upon a review by the courts within the time and in the manner specified in this division.


citation: LAB § 5303

text: There is but one cause of action for each injury coming within the provisions of this division. All claims brought for medical expense, disability payments, death benefits, burial expense, liens, or any other matter arising out of such injury may, in the discretion of the appeals board, be joined in the same proceeding at any time; provided, however, that no injury, whether specific or cumulative, shall, for any purpose whatsoever, merge into or form a part of another injury; nor shall any award based on a cumulative injury include disability caused by any specific injury or by any other cumulative injury causing or contributing to the existing disability, need for medical treatment or death.

history: (History: Amended by Stats. 1968, 1st Ex. Sess., Ch. 4.)


citation: LAB § 5304

text: The appeals board has jurisdiction over any controversy relating to or arising out of Sections 4600 to 4605 inclusive, unless an express agreement fixing the amounts to be paid for medical, surgical or hospital treatment as such treatment is described in those sections has been made between the persons or institutions rendering such treatment and the employer or insurer.


citation: LAB § 5305

text: The Division of Workers’ Compensation, including the administrative director, and the appeals board have jurisdiction over all controversies arising out of injuries suffered outside the territorial limits of this state in those cases where the injured employee is a resident of this state at the time of the injury and the contract of hire was made in this state. Any employee described by this section, or his or her dependents, shall be entitled to the compensation or death benefits provided by this division.

history: (History: Amended by Stats. 2002, Ch. 6, Sec. 71. Effective January 1, 2003.)


citation: LAB § 5306

text: The death of an employer subsequent to the sustaining of an injury by an employee shall not impair the right of the employee to proceed before the appeals board against the estate of the employer, and the failure of the employee or his dependents to cause the claim to be presented to the executor or administrator of the estate shall not in any way bar or suspend such right.


citation: LAB § 5307

text:
(a) The appeals board may, by an order signed by four members, do all of the following:

(1) Adopt reasonable and proper rules of practice and procedure.

(2) Regulate and provide the manner in which, and by whom, minors and incompetent persons are to appear and be represented before it.

(3) Regulate and prescribe the kind and character of notices, where not specifically prescribed by this division, and the service thereof.

(4) Regulate and prescribe the nature and extent of the proofs and evidence.

(b) No rule or regulation of the appeals board pursuant to this section shall be adopted, amended, or rescinded without public hearings. Any written request filed with the appeals board seeking a change in its rules or regulations shall be deemed to be denied if not set by the appeals board for public hearing to be held within six months of the date on which the request is received by the appeals board.

history: (History: Amended by Stats. 2011, Ch. 559, Sec. 11. (AB 1426) Effective October 7, 2011.)


text:
(a) (1) The administrative director, after public hearings, shall adopt and revise periodically an official medical fee schedule that shall establish reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods described in Section 4600 and provided pursuant to this section. Except for physician services, all fees shall be in accordance with the fee-related structure and rules of the relevant Medicare and Medi-Cal payment systems, provided that employer liability for medical treatment, including issues of reasonableness, necessity, frequency, and duration, shall be determined in accordance with Section 4600. Commencing January 1, 2004, and continuing until the time the administrative director has adopted an official medical fee schedule in accordance with the fee-related structure and rules of the relevant Medicare payment systems, except for the components listed in subdivision (j), maximum reasonable fees shall be 120 percent of the estimated aggregate fees prescribed in the relevant Medicare payment system for the same class of services before application of the inflation factors provided in subdivision (g), except that for pharmacy services and drugs that are not otherwise covered by a Medicare fee schedule payment for facility services, the maximum reasonable fees shall be 100 percent of fees prescribed in the relevant Medi-Cal payment system. Upon adoption by the administrative director of an official medical fee schedule pursuant to this section, the maximum reasonable fees paid shall not exceed 120 percent of estimated aggregate fees prescribed in the Medicare payment system for the same class of services before application of the inflation factors provided in subdivision (g). Pharmacy services and drugs shall be subject to the requirements of this section, whether furnished through a pharmacy or dispensed directly by the practitioner pursuant to subdivision (b) of Section 4024 of the Business and Professions Code.

(2) (A) The administrative director, after public hearings, shall adopt and review periodically an official medical fee schedule based on the resource-based relative value scale for physician services and nonphysician practitioner services, as defined by the administrative director, provided that all of the following apply:

(i) Employer liability for medical treatment, including issues of reasonableness, necessity, frequency, and duration, shall be determined in accordance with Section 4600.

(ii) The fee schedule is updated annually to reflect changes in procedure codes, relative weights, and the adjustment factor provided in subdivision (g).

(iii) The maximum reasonable fees paid shall not exceed 120 percent of estimated annualized aggregate fees prescribed in the Medicare payment system for physician services as it appeared on July 1, 2012, before application of the adjustment factor provided in subdivision (g). For purposes of calculating maximum reasonable fees, any service provided to injured workers that is not covered under the federal Medicare program shall be included at its rate of payment established by the administrative director pursuant to subdivision (d).

(iv) There shall be a four-year transition between the estimated aggregate maximum allowable amount under the official medical fee schedule for physician services prior to January 1, 2014, and the maximum allowable amount based on the resource-based relative value scale at 120 percent of the Medicare conversion factors as adjusted pursuant to this section.

(B) The official medical fee schedule shall include payment ground rules that differ from Medicare payment ground rules, including, as appropriate, payment of consultation codes and payment evaluation and management services provided during a global period of surgery.

(C) Commencing January 1, 2014, and continuing until the time the administrative director has adopted an official medical fee schedule in accordance with the resource-based relative value scale, the maximum reasonable fees for physician services and nonphysician practitioner services, including, but not limited to, physician assistant, nurse practitioner, and physical therapist services, shall be in accordance with the fee-related structure and rules of the Medicare payment system for physician services and nonphysician practitioner services, except that an average statewide geographic adjustment factor of 1.078 shall apply in lieu of Medicare’s locality-specific geographic adjustment factors, and shall incorporate the following conversion factors:

(i) For dates of service in 2014, forty-nine dollars and five thousand three hundred thirteen ten thousandths cents ($49.5313) for surgery, fifty-six dollars and two thousand three hundred twenty-nine ten thousandths cents ($56.2329) for radiology, thirty dollars and six hundred forty-seven ten thousandths cents ($30.0647) for anesthesia, and thirty-seven dollars and one thousand seven hundred twelve ten thousandths cents ($37.1712) for all other before application of the adjustment factor provided in subdivision (g).

(ii) For dates of service in 2015, forty-six dollars and six thousand three hundred fifty-nine ten thousandths cents ($46.6359) for surgery, fifty-one dollars and one thousand thirty-six ten thousandths cents ($51.1036) for radiology, twenty-eight dollars and six thousand sixty-seven ten thousandths cents ($28.6067) for anesthesia, and thirty-eight dollars and three thousand nine hundred fifty-eight ten thousandths cents ($38.3958) for all other before application of the adjustment factor provided in subdivision (g).

(iii) For dates of service in 2016, forty-three dollars and seven thousand four hundred five ten thousandths cents ($43.7405) for surgery, forty-five dollars and nine thousand seven hundred forty-four ten thousandths cents ($45.9744) for radiology, twenty-seven dollars and one thousand four hundred eighty-seven thousandths cents ($27.1487) for anesthesia, and thirty-nine dollars and six thousand two hundred five ten thousandths cents ($39.6205) for all other before application of the adjustment factor provided in subdivision (g).

(iv) For dates of service on or after January 1, 2017, 120 percent of the 2012 Medicare conversion factor as updated pursuant to subdivision (g).

(b) In order to comply with the standards specified in subdivision (f), the administrative director may adopt different conversion factors, diagnostic-related group weights, and other factors affecting payment amounts from those used in the Medicare payment system, provided estimated aggregate fees do not exceed 120 percent of the estimated aggregate fees paid for the same class of services in the relevant Medicare payment system.

(c) (1) Notwithstanding subdivisions (a) and (d), the maximum facility fee for services performed in a hospital outpatient department, shall not exceed 120 percent of the fee paid by Medicare for the same services performed in a hospital outpatient department, and the maximum facility fee for services performed in an ambulatory surgical center shall not exceed 80 percent of the fee paid by Medicare for the same services performed in a hospital outpatient department.

(2) The department shall study the feasibility of establishing a facility fee for services that are performed in an ambulatory surgical center and are not subject to a fee paid by Medicare for services performed in an outpatient department, set at 85 percent of the diagnostic-related group (DRG) fee paid by Medicare for the same services performed in a hospital inpatient department. The department shall report the finding to the Senate Labor Committee and Assembly Insurance Committee no later than July 1, 2013.

(d) If the administrative director determines that a medical treatment, facility use, product, or service is not covered by a Medicare payment system, the administrative director shall establish maximum fees for that item, provided that the maximum fee paid shall not exceed 120 percent of the fees paid by Medicare for services that require comparable resources. If the administrative director determines that a pharmacy service or drug is not covered by a Medi-Cal payment system, the administrative director shall establish maximum fees for that item. However, the maximum fee paid shall not exceed 100 percent of the fees paid by Medi-Cal for pharmacy services or drugs that require comparable resources.

(e) (1) Prior to the adoption by the administrative director of a medical fee schedule pursuant to this section, for any treatment, facility use, product, or service not covered by a Medicare payment system, including acupuncture services, the maximum reasonable fee paid shall not exceed the fee specified in the official medical fee schedule in effect on December 31, 2003, except as otherwise provided in this subdivision.

(2) Any compounded drug product shall be billed by the compounding pharmacy or dispensing physician at the ingredient level, with each ingredient identified using the applicable National Drug Code (NDC) of the ingredient and the corresponding quantity, and in accordance with regulations adopted by the California State Board of Pharmacy. Ingredients with no NDC shall not be separately reimbursable. The ingredient-level reimbursement shall be equal to 100 percent of the reimbursement allowed by the Medi-Cal payment system and payment shall be based on the sum of the allowable fee for each ingredient plus a dispensing fee equal to the dispensing fee allowed by the Medi-Cal payment systems. If the compounded drug product is dispensed by a physician, the maximum reimbursement shall not exceed 300 percent of documented paid costs, but in no case more than twenty dollars ($20) above documented paid costs.

(3) For a dangerous drug dispensed by a physician that is a finished drug product approved by the federal Food and Drug Administration, the maximum reimbursement shall be according to the official medical fee schedule adopted by the administrative director.

(4) For a dangerous device dispensed by a physician, the reimbursement to the physician shall not exceed either of the following:

(A) The amount allowed for the device pursuant to the official medical fee schedule adopted by the administrative director.

(B) One hundred twenty percent of the documented paid cost, but not less than 100 percent of the documented paid cost plus the minimum dispensing fee allowed for dispensing prescription drugs pursuant to the official medical fee schedule adopted by the administrative director, and not more than 100 percent of the documented paid cost plus two hundred fifty dollars ($250).

(5) For any pharmacy goods dispensed by a physician not subject to paragraph (2), (3), or (4), the maximum reimbursement to a physician for pharmacy goods dispensed by the physician shall not exceed any of the following:

(A) The amount allowed for the pharmacy goods pursuant to the official medical fee schedule adopted by the administrative director or pursuant to paragraph (2), as applicable.

(B) One hundred twenty percent of the documented paid cost to the physician.

(C) One hundred percent of the documented paid cost to the physician plus two hundred fifty dollars ($250).

(6) For the purposes of this subdivision, the following definitions apply:

(A) “Administer” or “administered” has the meaning defined by Section 4016 of the Business and Professions Code.

(B) “Compounded drug product” means any drug product subject to Article 4.5 (commencing with Section 1735) of Division 17 of Title 16 of the California Code of Regulations or other regulation adopted by the State Board of Pharmacy to govern the practice of compounding.

(C) “Dispensed” means furnished to or for a patient as contemplated by Section 4024 of the Business and Professions Code and does not include “administered.”

(D) “Dangerous drug” and “dangerous device” have the meanings defined by Section 4022 of the Business and Professions Code.

(E) “Documented paid cost” means the unit price paid for the specific product or for each component used in the product as documented by invoices, proof of payment, and inventory records as applicable, or as documented in accordance with regulations that may be adopted by the administrative director, net of rebates, discounts, and any other immediate or anticipated cost adjustments.

(F) “Pharmacy goods” has the same meaning as set forth in Section 139.3.

(7) To the extent that any provision of paragraphs (2) to (6), inclusive, is inconsistent with any provision of the official medical fee schedule adopted by the administrative director on or after January 1, 2012, the provision adopted by the administrative director shall govern.

(8) Notwithstanding paragraph (7), the provisions of this subdivision concerning physician-dispensed pharmacy goods shall not be superseded by any provision of the official medical fee schedule adopted by the administrative director unless the relevant official medical fee schedule provision is expressly applicable to physician-dispensed pharmacy goods.

(f) Within the limits provided by this section, the rates or fees established shall be adequate to ensure a reasonable standard of services and care for injured employees.

(g) (1) (A) Notwithstanding any other law, the official medical fee schedule shall be adjusted to conform to any relevant changes in the Medicare and Medi-Cal payment systems no later than 60 days after the effective date of those changes, subject to the following provisions:

(i) The annual inflation adjustment for facility fees for inpatient hospital services provided by acute care hospitals and for hospital outpatient services shall be determined solely by the estimated increase in the hospital market basket for the 12 months beginning October 1 of the preceding calendar year.

(ii) The annual update in the operating standardized amount and capital standard rate for inpatient hospital services provided by hospitals excluded from the Medicare prospective payment system for acute care hospitals and the conversion factor for hospital outpatient services shall be determined solely by the estimated increase in the hospital market basket for excluded hospitals for the 12 months beginning October 1 of the preceding calendar year.

(iii) The annual adjustment factor for physician services shall be based on the product of one plus the percentage change in the Medicare Economic Index and any relative value scale adjustment factor.

(B) The update factors contained in clauses (i) and (ii) of subparagraph (A) shall be applied beginning with the first update in the Medicare fee schedule payment amounts after December 31, 2003, and the adjustment factor in clause (iii) of subparagraph (A) shall be applied beginning with the first update in the Medicare fee schedule payment amounts after December 31, 2012.

(C) The maximum reasonable fees paid for pharmacy services and drugs shall not include any reductions in the relevant Medi-Cal payment system implemented pursuant to Section 14105.192 of the Welfare and Institutions Code.

(2) The administrative director shall determine the effective date of the changes, and shall issue an order, exempt from Sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), informing the public of the changes and their effective date. All orders issued pursuant to this paragraph shall be published on the Internet Web site of the Division of Workers’ Compensation.

(3) For the purposes of this subdivision, the following definitions apply:

(A) “Medicare Economic Index” means the input price index used by the federal Centers for Medicare and Medicaid Services to measure changes in the costs of a providing physician and other services paid under the resource-based relative value scale.

(B) “Hospital market basket” means the input price index used by the federal Centers for Medicare and Medicaid Services to measure changes in the costs of providing inpatient hospital services provided by acute care hospitals that are included in the Medicare prospective payment system.

(C) “Hospital market basket for excluded hospitals” means the input price index used by the federal Centers for Medicare and Medicaid Services to measure changes in the costs of providing inpatient services by hospitals that are excluded from the Medicare prospective payment system.

(D) “Relative value scale adjustment factor” means the annual factor applied by the federal Centers for Medicare and Medicaid Services to the Medicare conversion factor to make changes in relative value units for the physician fee schedule budget neutral.

(h) This section does not prohibit an employer or insurer from contracting with a medical provider for reimbursement rates different from those prescribed in the official medical fee schedule.

(i) Except as provided in Section 4626, the official medical fee schedule shall not apply to medical-legal expenses, as that term is defined by Section 4620.

(j) The following Medicare payment system components shall not become part of the official medical fee schedule until January 1, 2005:

(1) Inpatient skilled nursing facility care.

(2) Home health agency services.

(3) Inpatient services furnished by hospitals that are exempt from the prospective payment system for general acute care hospitals.

(4) Outpatient renal dialysis services.

(k) Except as revised by the administrative director, the official medical fee schedule rates for physician services in effect on December 31, 2012, shall remain in effect until January 1, 2014.

(l) Notwithstanding subdivision (a), any explicit reductions in the Medi-Cal fee schedule for pharmacy services and drugs to meet the budgetary targets provided in Section 14105.192 of the Welfare and Institutions Code shall not be reflected in the official medical fee schedule.

(m) On or before July 1, 2013, the administrative director shall adopt a regulation specifying an additional reimbursement for MS-DRGs Medicare Severity Diagnostic Related Groups (MS-DRGs) 028, 029, 030, 453, 454, 455, and 456 to ensure that the aggregate reimbursement is sufficient to cover costs, including the implantable medical device, hardware, and instrumentation. This regulation shall be repealed as of January 1, 2014, unless extended by the administrative director.

history: (History: Amended by Stats. 2012, Ch. 363, Sec. 74. (SB 863) Effective January 1, 2013.)


text: The administrative director shall contract with an independent consulting firm, to the extent permitted by state law, to perform an annual study of access to medical treatment for injured workers. The study shall analyze whether there is adequate access to quality health care and products, including prescription drugs and pharmacy services, for injured workers and make recommendations to ensure continued access. If the administrative director determines, based on this study, that there is insufficient access to quality health care or products for injured workers, including access to prescription drugs and pharmacy services, the administrative director may make appropriate adjustments to medical, prescription drugs and pharmacy services, and facilities’ fees. When there has been a determination that substantial access problems exist, the administrative director may, in accordance with the notification and hearing requirements of Section 5307.1, adopt fees in excess of 120 percent of the applicable Medicare payment system fee, or in excess of 100 percent of the fees prescribed in the relevant Medi-Cal payment system, for the applicable services or products.

history: (History: Amended by Stats. 2008, Ch. 193, Sec. 1. Effective January 1, 2009.)


text:
The administrative director may adopt, amend, or repeal any rules and regulations that are reasonably necessary to enforce this division, except where this power is specifically reserved to the appeals board.

No rule or regulation of the administrative director pursuant to this section shall be adopted, amended, or rescinded without public hearings. Any written request filed with the administrative director seeking a change in its rules or regulations shall be deemed to be denied if not set by the administrative director for public hearing to be held within six months of the date on which the request is received by the administrative director.

history: (History: Amended by Stats. 2011, Ch. 559, Sec. 12. (AB 1426) Effective October 7, 2011.)


text:
(a) Public hearings required under Sections 5307 and 5307.3 shall be subject to the provisions of this section except to the extent that there is involved a matter relating to the management, or to personnel, or to public property, loans, grants, benefits, or to contracts, of the appeals board or the administrative director.

(b) Notice of the rule or regulation proposed to be adopted, amended, or rescinded, shall be given to such business and labor organizations and firms or individuals who have requested notice thereof. The notice shall include all of the following:

(1) A statement of the time, place, and nature of the public hearings.

(2) Reference to the legal authority under which the rule is proposed.

(3) Either the terms or substance of the proposed rule, or a description of the subjects and the issues involved.

(c) Except where the proposed rule or regulation has a significant impact on the public, this section shall not apply to interpretive rules, general statements of policy, or rules of agency organization.

(d) After notice required by this section, the appeals board or the administrative director shall give interested persons the opportunity to participate in the rulemaking through submission of written data, views, or arguments, with opportunity for oral presentation. If, after consideration of the relevant matter presented, the appeals board or the administrative director adopts a rule, it or he shall publish a concise, general statement of reasons for the adoption of the rule. The rule and statement of reasons shall be given to the same individuals and organizations who have requested notice of hearings.

(e) The notice required under this section shall be made not less than 30 days prior to the public hearing date.

history: (History: Added by Stats. 1977, Ch. 517.)


text:
The appeals board or a workers’ compensation judge may:

(a) Appoint a trustee or guardian ad litem to appear for and represent any minor or incompetent upon the terms and conditions which it deems proper. The guardian or trustee shall, if required by the appeals board, give a bond in the form and of the character required by law from a guardian appointed by a superior court and in the amount which the appeals board determines. The bond shall be approved by the appeals board, and the guardian or trustee shall not be discharged from liability until he or she files an account with the appeals board or with the superior court and the account is approved. The trustee or guardian shall receive the compensation for his or her services fixed and allowed by the appeals board or by the superior court.

(b) Provide for the joinder in the same proceeding of all persons interested therein, whether as employer, insurer, employee, dependent, creditor, or otherwise.

history: (History: Amended by Stats. 1985, Ch. 326, Sec. 13.)


text:
(a) The administrative director shall adopt and revise a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time he or she adopts and revises the medical fee schedule pursuant to Section 5307.1.

The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.

(b) A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of his or her usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.

(c) In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employer’s or carrier’s subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.

(d) (1) No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.

(2) This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.

history: (History: Amended by Stats. 1993, Ch. 1242, Sec. 38. Effective January 1, 1994.)


text:
(a) On or before January 1, 2013, the administrative director shall adopt, after public hearings, a fee schedule that shall establish reasonable fees paid for services provided by vocational experts, including, but not limited to, vocational evaluations and expert testimony determined to be reasonable, actual, and necessary by the appeals board.

(b) A vocational expert shall not be paid, and the appeals board shall not allow, vocational expert fees in excess of those that are reasonable, actual, and necessary, or that are not consistent with the fee schedule adopted by the administrative director.

history: (History: Amended by Stats. 2012, Ch. 363, Sec. 75. (SB 863) Effective January 1, 2013.)


text:
(a) Notwithstanding Section 5307.1, the administrative director shall adopt, after public hearings, a schedule for payment of home health care services provided in accordance with Section 4600 that are not covered by a Medicare fee schedule and are not otherwise covered by the official medical fee schedule adopted pursuant to Section 5307.1. The schedule shall set forth fees and requirements for service providers, and may be based upon, but is not limited to, being based upon, either of the following:

(1) The maximum service hours and fees as set forth in regulations adopted pursuant to Article 7 (commencing with Section 12300) of Chapter 3 of Part 3 of Division 9 of the Welfare and Institutions Code.

(2) A state or federal home health care services fee schedule other than the schedule described in paragraph (1), including a fee schedule authorized for purposes of the Medi-Cal program or a fee schedule administered by the federal Office of Workers’ Compensation Programs.

(b) Fees shall not be provided for any services, including any services provided by a member of the employee’s household, to the extent the services had been regularly performed in the same manner and to the same degree prior to the date of injury. If appropriate, attorney’s fees for recovery of home health care services fees under this section may be awarded in accordance with Section 4906 and any applicable rules or regulations.

history: (History: Amended by Stats. 2015, Ch. 542, Sec. 5. (SB 542) Effective January 1, 2016.)


text: On or before December 31, 2013, the administrative director, in consultation with the Commission on Health and Safety and Workers’ Compensation, shall adopt, after public hearings, a schedule of reasonable maximum fees payable for copy and related services, including, but not limited to, records or documents that have been reproduced or recorded in paper, electronic, film, digital, or other format. The schedule shall specify the services allowed and shall require specificity in billing for these services, and shall not allow for payment for services provided within 30 days of a request by an injured worker or his or her authorized representative to an employer, claims administrator, or workers’ compensation insurer for copies of records in the employer’s, claims administrator’s, or workers’ compensation insurer’s possession that are relevant to the employee’s claim. The schedule shall be applicable regardless of whether payments of copy service costs are claimed under the authority of Section 4600, 4620, or 5811, or any other authority except a contract between the employer and the copy service provider.

history: (History: Added by Stats. 2012, Ch. 363, Sec. 77. (SB 863) Effective January 1, 2013.)


text: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates. Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this section.

history: (History: Added by Stats. 2001, Ch. 252, Sec. 1. Effective January 1, 2002.)


text:
(a) If a health care provider or health facility, licensed pursuant to Section 1250 of the Health and Safety Code, and an entity that provides physician network services, as defined in subdivision (b) of Section 4616.5, or an entity that provides ancillary network services, as defined in subdivision (c) of Section 4616.5, contract for a reimbursement rate that is more than 20 percent below the official medical fee schedule, excluding goods and pharmaceuticals, the entity that provides physician or ancillary network services shall provide the payor with a written disclosure, on a form promulgated by the administrative director, of the reimbursement amount paid to the provider.

(b) Before providing the disclosure required pursuant to subdivision (a), the entity that provides physician or ancillary network services may require the payor to sign a nondisclosure agreement with the entity that provides physician or ancillary network services agreeing to maintain the confidentiality of the disclosed information.

(c) A nondisclosure agreement signed pursuant to subdivision (b) shall not prohibit the division from obtaining the information disclosed pursuant to subdivision (a). This subdivision is declaratory of existing law.

(d) This section does not apply to an entity that provides physician or ancillary network services that discloses, or arranges for the disclosure of, the same pricing and payment information to both the health care provider or health facility and the person or entity paying for the services.

(e) This section shall become operative on July 1, 2021.

history: (History: Added by Stats. 2019, Ch. 647, Sec. 9. (SB 537) Effective January 1, 2020. Operative July 1, 2021, by its own provisions.)


text:
(a) The administrative director, in consultation with the Commission on Health and Safety and Workers’ Compensation, shall adopt, after public hearings, a medical treatment utilization schedule, that shall incorporate the evidence-based, peer-reviewed, nationally recognized standards of care recommended by the commission pursuant to Section 77.5, and that shall address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases. Evidence-based updates to the utilization schedule shall be made through an order exempt from Sections 5307.3 and 5307.4, and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), but the administrative director shall allow at least a 30-day period for public comment and a public hearing. The administrative director shall provide responses to submitted comments prior to the effective date of the updates. All orders issued pursuant to this subdivision shall be published on the Internet Web site of the Division of Workers’ Compensation.

(b) On or before July 1, 2017, the medical treatment utilization schedule adopted by the administrative director shall include a drug formulary using evidence-based medicine. Nothing in this section shall prohibit the authorization of medications that are not in the formulary when the variance is demonstrated, consistent with subdivision (a) of Section 4604.5.

(c) The drug formulary shall include a phased implementation for workers injured prior to July 1, 2017, in order to ensure injured workers safely transition to medications pursuant to the formulary.

(d) This section shall apply to all prescribers and dispensers of medications serving injured workers under the workers’ compensation system.

history: (History: Amended by Stats. 2016, Ch. 868, Sec. 10. (SB 1160) Effective January 1, 2017.)


text:
(a) Prior to the adoption of a drug formulary as required by Section 5307.27, the administrative director shall meet and consult regarding the establishment of a formulary with stakeholders, including, but not limited to, employers, insurers, private sector employee representatives, public sector employee representatives, treating physicians actively practicing medicine, pharmacists, pharmacy benefit managers, attorneys who represent applicants, and injured workers.

(b) Commencing July 1, 2016, and concluding with the implementation of the formulary, the administrative director shall publish at least two interim reports on the Internet Web site of the Division of Workers’ Compensation describing the status of the creation of the formulary.

history: (History: Added by Stats. 2015, Ch. 525, Sec. 5. (AB 1124) Effective January 1, 2016.)


text:
(a) The administrative director shall make provision for no less than quarterly updates to the drug formulary to allow for the provision of all appropriate medications, including those new to the market.

(b) Changes made to the list of drugs in the drug formulary described in Section 5307.27 shall be made through an order exempt from Sections 5307.3 and 5307.4, and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), informing the public of the changes and their effective date. All orders issued pursuant to this subdivision shall be published on the Internet Web site of the Division of Workers’ Compensation.

(c) The administrative director shall establish an independent pharmacy and therapeutics committee to review and consult with the administrative director on available evidence of the relative safety, efficacy, and effectiveness of drugs within a class of drugs in the updating of an evidence-based drug formulary, as required by Section 5307.27.

(1) The committee shall consist of six members and the Executive Medical Director of the Division of Workers’ Compensation. The committee shall consist of medical doctors or doctors of osteopathy holding a physician and surgeon license pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, and pharmacists licensed pursuant to Chapter 9 (commencing with Section 4000) of Division 2 of the Business and Professions Code. A committee member shall have knowledge or expertise in one or more of the following:

(A) Clinically appropriate prescribing of covered drugs.

(B) Clinically appropriate dispensing and monitoring of covered drugs.

(C) Drug use review.

(D) Evidence-based medicine.

(2) Committee members shall not be employed by a pharmaceutical manufacturer, a pharmacy benefits management company, or a company engaged in the development of a pharmaceutical formulary for commercial sale during his or her term, and shall not have been so employed for 12 months prior to his or her appointment.

(3) A committee member shall not have a substantial financial conflict of interest pursuant to standards established by the administrative director. The administrative director may, in his or her sole discretion, disqualify a potential or current member of the committee if the administrative director determines that a substantial conflict of interest exists.

(4) A committee member shall agree to keep all proprietary information confidential to the extent required by existing law.

history: (History: Added by Stats. 2015, Ch. 525, Sec. 6. (AB 1124) Effective January 1, 2016.)


citation: LAB § 5308

text:
The appeals board has jurisdiction to determine controversies arising out of insurance policies issued to self-employing persons, conferring benefits identical with those prescribed by this division.

The appeals board may try and determine matters referred to it by the parties under the provisions of Title 9 (commencing with Section 1280) of Part 3 of the Code of Civil Procedure, with respect to controversies arising out of insurance issued to self-employing persons under the provisions of this division. Such controversies may be submitted to it by the signed agreement of the parties, or by the application of one party and the submission of the other to its jurisdiction, with or without an express request for arbitration.

The State Compensation Insurance Fund, when the consent of the other party is obtained, shall submit to the appeals board all controversies susceptible of being arbitrated under this section.

In acting as arbitrator under this section, the appeals board has all the powers which it may lawfully exercise in compensation cases, and its findings and award upon such arbitration have the same conclusiveness and are subject to the same mode of reopening, review, and enforcement as in compensation cases. No fee or cost shall be charged by the appeals board for arbitrating the issues presented under this section.

history: (History: Amended by Stats. 1967, Ch. 125.)


citation: LAB § 5309

text:
The appeals board may, in accordance with rules of practice and procedure which it shall adopt and upon the agreement of the parties, on the application of either, or of its own motion, and with or without notice, direct and order a workers’ compensation judge:

(a) To try the issues in any proceeding before it, whether of fact or of law, and make and file a finding, order, decision, or award based thereon.

(b) To hold hearings and ascertain facts necessary to enable the appeals board to determine any proceeding or to make any order, decision, or award that the appeals board is authorized to make under Divisions 4 or 5, or necessary for the information of the appeals board.

(c) To issue writs or summons, warrants of attachment, warrants of commitment, and all necessary process in proceedings for direct and hybrid contempt in a like manner and to the same extent as courts of record. For the purposes of this section, “hybrid contempt” means a charge of contempt which arises from events occurring in the immediate presence of the workers’ compensation judge for reasons which occur outside the presence of the workers’ compensation judge.

history: (History: Amended by Stats. 1988, Ch. 222, Sec. 1.)


citation: LAB § 5310

text: The appeals board may appoint one or more workers’ compensation administrative law judges in any proceeding, as it may deem necessary or advisable, and may refer, remove to itself, or transfer to a workers’ compensation administrative law judge the proceedings on any claim. The administrative director may appoint workers’ compensation administrative law judges. Any workers’ compensation administrative law judge appointed by the administrative director has the powers, jurisdiction, and authority granted by law, by the order of appointment, and by the rules of the appeals board.

history: (History: Amended by Stats. 2011, Ch. 559, Sec. 13. (AB 1426) Effective October 7, 2011.)


citation: LAB § 5311

text: Any party to the proceeding may object to the reference of the proceeding to a particular workers’ compensation judge upon any one or more of the grounds specified in Section 641 of the Code of Civil Procedure and the objection shall be heard and disposed of by the appeals board. Affidavits may be read and witnesses examined as to the objections.

history: (History: Amended by Stats. 1985, Ch. 326, Sec. 16.)


text: The administrative director shall require all workers’ compensation administrative law judges to participate in continuing education to further their abilities as workers’ compensation administrative law judges, including courses in ethics and conflict of interest. The director may coordinate the requirements with those imposed upon attorneys by the State Bar in order that the requirements may be consistent.

history: (History: Amended by Stats. 2011, Ch. 559, Sec. 14. (AB 1426) Effective October 7, 2011.)


citation: LAB § 5312

text: Before entering upon his or her duties, the workers’ compensation judge shall be sworn, before an officer authorized to administer oaths, faithfully and fairly to hear and determine the matters and issues referred to him or her, to make just findings and to report according to his or her understanding.

history: (History: Amended by Stats. 1985, Ch. 326, Sec. 17.)


citation: LAB § 5313

text: The appeals board or the workers’ compensation judge shall, within 30 days after the case is submitted, make and file findings upon all facts involved in the controversy and an award, order, or decision stating the determination as to the rights of the parties. Together with the findings, decision, order or award there shall be served upon all the parties to the proceedings a summary of the evidence received and relied upon and the reasons or grounds upon which the determination was made.

history: (History: Amended by Stats. 1985, Ch. 326, Sec. 18.)


citation: LAB § 5315

text: Within 60 days after the filing of the findings, decision, order or award, the appeals board may confirm, adopt, modify or set aside the findings, order, decision, or award of a workers’ compensation judge and may, with or without further proceedings, and with or without notice, enter its order, findings, decision, or award based upon the record in the case.

history: (History: Amended by Stats. 1985, Ch. 326, Sec. 19.)


citation: LAB § 5316

text: Any notice, order, or decision required by this division to be served upon any person either before, during, or after the institution of any proceeding before the appeals board, may be served in the manner provided by Chapter 5, Title 14 of Part 2 of the Code of Civil Procedure, unless otherwise directed by the appeals board. In the latter event the document shall be served in accordance with the order or direction of the appeals board. The appeals board may, in the cases mentioned in the Code of Civil Procedure, order service to be made by publication of notice of time and place of hearing. Where service is ordered to be made by publication the date of the hearing may be fixed at more than 30 days from the date of filing the application.

history: (History: Amended by Stats. 1965, Ch. 1513.)


citation: LAB § 5317

text: Any such notice, order or decision affecting the State or any county, city, school district, or public corporation therein, shall be served upon the person upon whom the service of similar notices, orders, or decisions is authorized by law.

history: (History: Enacted by Stats. 1937, Ch. 90.)


citation: LAB § 5400

text: Except as provided by sections 5402 and 5403, no claim to recover compensation under this division shall be maintained unless within thirty days after the occurrence of the injury which is claimed to have caused the disability or death, there is served upon the employer notice in writing, signed by the person injured or someone in his behalf, or in case of the death of the person injured, by a dependent or someone in the dependent’s behalf.

chapter: 2. Limitations of Proceedings

path: 4. WORKERS' COMPENSATION AND INSURANCE > 2. Limitations of Proceedings


citation: LAB § 5401

text:
(a) Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, which injury results in lost time beyond the employee’s work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits under this division to the injured employee, or in the case of death, to his or her dependents. As used in this subdivision, “first aid” means any one-time treatment, and any followup visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and followup visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel. “Minor industrial injury” shall not include serious exposure to a hazardous substance as defined in subdivision (i) of Section 6302. The claim form shall request the injured employee’s name and address, social security number, the time and address where the injury occurred, and the nature of and part of the body affected by the injury. Claim forms shall be available at district offices of the Employment Development Department and the division. Claim forms may be made available to the employee from any other source.

(b) Insofar as practicable, the notice of potential eligibility for benefits required by this section and the claim form shall be a single document and shall instruct the injured employee to fully read the notice of potential eligibility. The form and content of the notice and claim form shall be prescribed by the administrative director after consultation with the Commission on Health and Safety and Workers’ Compensation. The notice shall be easily understandable and available in both English and Spanish. The content shall include, but not be limited to, the following:

(1) The procedure to be used to commence proceedings for the collection of compensation for the purposes of this chapter.

(2) A description of the different types of workers’ compensation benefits.

(3) What happens to the claim form after it is filed.

(4) From whom the employee can obtain medical care for the injury.

(5) The role and function of the primary treating physician.

(6) The rights of an employee to select and change the treating physician pursuant to subdivision (e) of Section 3550 and Section 4600.

(7) How to get medical care while the claim is pending.

(8) The protections against discrimination provided pursuant to Section 132a.

(9) The following written statements:

(A) You have a right to disagree with decisions affecting your claim.

(B) To obtain important information about the workers’ compensation claims process and your rights and obligations, go to [applicable Internet Web site(s)], or contact an information and assistance (I&A) officer of the state Division of Workers’ Compensation. You can also hear recorded information and a list of local I&A offices by calling [applicable information and assistance telephone number(s)].

(C) You can consult an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee will be taken out of some of your benefits. For names of workers’ compensation attorneys, call the State Bar of California at [telephone number of the State Bar of California’s legal specialization program, or its equivalent].

(c) The completed claim form shall be filed with the employer by the injured employee, or, in the case of death, by a dependent of the injured employee, or by an agent of the employee or dependent. Except as provided in subdivision (d), a claim form is deemed filed when it is personally delivered to the employer or received by the employer by first-class or certified mail. A dated copy of the completed form shall be provided by the employer to the employer’s insurer and to the employee, dependent, or agent who filed the claim form.

(d) The claim form shall be filed with the employer prior to the injured employee’s entitlement to late payment supplements under subdivision (d) of Section 4650, or prior to the injured employee’s request for a medical evaluation under Section 4060, 4061, or 4062. Filing of the claim form with the employer shall toll, for injuries occurring on or after January 1, 1994, the time limitations set forth in Sections 5405 and 5406 until the claim is denied by the employer or the injury becomes presumptively compensable pursuant to Section 5402. For purposes of this subdivision, a claim form is deemed filed when it is personally delivered to the employer or mailed to the employer by first-class or certified mail.

history: (History: Amended by Stats. 2011, Ch. 544, Sec. 6. (AB 335) Effective January 1, 2012.)


text:
The claim form shall contain, prominently stated, the following statement:

“Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.”

The statements required to be printed or displayed pursuant to Section 1871.2 of the Insurance Code may, but are not required to, appear on the claim form.

history: (History: Amended by Stats. 2022, Ch. 424, Sec. 30. (SB 1242) Effective January 1, 2023.)


citation: LAB § 5402

text:
(a) Knowledge of an injury, obtained from any source, on the part of an employer, the employer’s managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400.

(b) (1) If liability is not rejected within 90 days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division. The presumption of this subdivision is rebuttable only by evidence discovered subsequent to the 90-day period.

(2) Notwithstanding paragraph (1), for injuries or illnesses defined in Sections 3212 to 3212.85, inclusive, and Sections 3212.9 to 3213.2, inclusive, if the liability is not rejected within 75 days after the date the claim form is filed pursuant to Section 5401, the injury shall be presumed compensable under this division. The presumption of this subdivision is rebuttable only by evidence discovered subsequent to the 75-day period.

(c) Within one working day after an employee files a claim form under Section 5401, the employer shall authorize the provision of all treatment, consistent with Section 5307.27, for the alleged injury and shall continue to provide the treatment until the date that liability for the claim is accepted or rejected. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000).

(d) Treatment provided under subdivision (c) does not give rise to a presumption of liability on the part of the employer.

(e) Upon appropriation by the Legislature, the Division of Workers’ Compensation shall identify and amend its existing data collection processes to include collection of the date on which the claimant is notified of acceptance, denial, or conditional denial of liability for a claim, consistent with this section.

history: (History: Amended by Stats. 2022, Ch. 835, Sec. 3. (SB 1127) Effective January 1, 2023.)


citation: LAB § 5403

text: The failure to give notice under section 5400, or any defect or inaccuracy in a notice is not a bar to recovery under this division if it is found as a fact in the proceedings for the collection of the claim that the employer was not in fact misled or prejudiced by such failure.


citation: LAB § 5404

text: Unless compensation is paid within the time limited in this chapter for the institution of proceedings for its collection, the right to institute such proceedings is barred. The timely filing of an application with the appeals board by any party in interest for any part of the compensation defined by Section 3207 renders this chapter inoperative as to all further claims by such party against the defendants therein named for compensation arising from that injury, and the right to present such further claims is governed by Sections 5803 to 5805, inclusive.


text:
(a) Where a claim form has been filed prior to January 1, 1994, and where the claim is denied by the employer, the claim may be dismissed if there has been no activity for the previous 180 days and if the claims adjuster has served notice pursuant to Article 3 (commencing with Section 415.10) of Chapter 4 of Title 5 of the Code of Civil Procedure. The notice shall specify that the claim will be dismissed by operation of law unless an application for adjudication of the claim is filed within 180 days of service of the notice.

(b) Where a claim form has been filed prior to January 1, 1994, and where benefits have been furnished by the employer, the claim may be dismissed if there has been no activity for the previous 180 days and if the claims adjuster has served notice pursuant to Article 3 (commencing with Section 415.10) of Chapter 4 of Title 5 of the Code of Civil Procedure. The notice shall specify that the claim will be dismissed by operation of law unless an application for adjudication of the claim is filed within five years of the date of injury or within one year of the last furnishing of benefits, whichever is later.

(c) The administrative director may adopt rules of practice and procedure consistent with this section.

(d) The provisions of subdivisions (a) and (b) do not limit the jurisdiction of the appeals board.

(e) This section is applicable to injuries occurring before January 1, 1994.

history: (History: Amended by Stats. 1993, Ch. 1242, Sec. 40. Effective January 1, 1994.)


citation: LAB § 5405

text:
The period within which proceedings may be commenced for the collection of the benefits provided by Article 2 (commencing with Section 4600) or Article 3 (commencing with Section 4650), or both, of Chapter 2 of Part 2 is one year from any of the following:

(a) The date of injury.

(b) The expiration of any period covered by payment under Article 3 (commencing with Section 4650) of Chapter 2 of Part 2.

(c) The last date on which any benefits provided for in Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 were furnished.

history: (History: Amended by Stats. 2002, Ch. 6, Sec. 78. Effective January 1, 2003.)


citation: LAB § 5406

text:
(a) Except as provided in Section 5406.5, 5406.6, or 5406.7, the period within which may be commenced proceedings for the collection of the benefits provided by Article 4 (commencing with Section 4700) of Chapter 2 of Part 2 is one year from:

(1) The date of death if death occurs within one year from date of injury.

(2) The date of last furnishing of any benefits under Chapter 2 (commencing with Section 4550) of Part 2, if death occurs more than one year from the date of injury.

(3) The date of death, if death occurs more than one year after the date of injury and compensation benefits have been furnished.

(b) Proceedings shall not be commenced more than one year after the date of death, nor more than 240 weeks from the date of injury.

history: (History: Amended by Stats. 2015, Ch. 303, Sec. 378. (AB 731) Effective January 1, 2016.)


text: In the case of the death of an asbestos worker or firefighter from asbestosis, the period within which proceedings may be commenced for the collection of the benefits provided by Article 4 (commencing with Section 4700) of Chapter 2 of Part 2 is one year from the date of death.

history: (History: Amended by Stats. 2003, Ch. 831, Sec. 1. Effective January 1, 2004.)


text:
(a) In the case of the death of a health care worker, a worker described in Section 3212, or a worker described in Section 830.5 of the Penal Code from an HIV-related disease, the period within which proceedings may be commenced for the collection of benefits provided by Article 4 (commencing with Section 4700) of Chapter 2 of Part 2 is one year from the date of death, providing that one or more of the following events has occurred:

(1) A report of the injury or exposure was made to the employer or to a governmental agency authorized to administer industrial injury claims, within one year of the date of the injury.

(2) The worker has complied with the notice provisions of this chapter and the claim has not been finally determined to be noncompensable.

(3) The employer provided, or was ordered to provide, workers’ compensation benefits for the injury prior to the date of death.

(b) For the purposes of this section, “health care worker” means an employee who has direct contact, in the course of his or her employment, with blood or other bodily fluids contaminated with blood, or with other bodily fluids identified by the Division of Occupational Safety and Health as capable of transmitting HIV, who is either (1) any person who is an employee of a provider of health care, as defined in Section 56.05 of the Civil Code, including, but not limited to, a registered nurse, licensed vocational nurse, certified nurse aide, clinical laboratory technologist, dental hygienist, physician, janitor, or housekeeping worker, or (2) an employee who provides direct patient care.

history: (History: Amended by Stats. 2013, Ch. 444, Sec. 21. (SB 138) Effective January 1, 2014.)


text:
(a) In addition to the timelines established pursuant to Section 5406, proceedings for the collection of the benefits provided by Article 4 (commencing with Section 4700) of Chapter 2 of Part 2 may be commenced after 240 weeks from the date of injury and no later than 420 weeks from the date of injury, but in no event more than one year after the date of death, if all of the following criteria are met:

(1) The proceedings are brought for the collection of benefits by, or on behalf of, a person who was a dependent on the date of death. The extent of dependency shall be determined in accordance with the facts as they existed at the time of death of the employee.

(2) The injury causing death is one of the following:

(A) An injury as defined in Section 3212.1 to a person described in Section 3212.1.

(B) An injury as defined in Section 3212.6 to a person described in Section 3212.6.

(C) An injury as defined in Section 3212.8 to a person described in Section 3212.8.

(3) The date of injury is during the person’s active service in applicable capacities described in Section 3212.1, 3212.6, or 3212.8.

(b) This section does not apply to claims for the collection of benefits pursuant to Article 4 (commencing with Section 4700) of Chapter 2 of Part 2 that have already been adjudicated, or otherwise finalized, or for which the commencement period lapsed on or before December 31, 2014.

(c) No dependency death benefit shall be payable pursuant to proceedings commenced more than 240 weeks from the date of injury unless either no proceedings were commenced within 240 weeks from the date of injury, or, if proceedings were commenced within that period, it has been finally determined that no person is entitled to dependency death benefits pursuant to the proceedings that were commenced within that period.

history: (History: Amended by Stats. 2018, Ch. 734, Sec. 2. (SB 1086) Effective January 1, 2019.)


citation: LAB § 5407

text:
The period within which may be commenced proceedings for the collection of compensation on the ground of serious and willful misconduct of the employer, under provisions of Section 4553, is as follows:

Twelve months from the date of injury. This period shall not be extended by payment of compensation, agreement therefor, or the filing of application for compensation benefits under other provisions of this division.

history: (History: Amended by Stats. 1972, Ch. 618.)


text:
The period within which may be commenced proceedings for the reduction of compensation on the ground of serious and willful misconduct of the employee, under provisions of Section 4551, is as follows:

Twelve months from the date of injury. However, this limitation shall not apply in any case where the employee has commenced proceedings for the increase of compensation on the ground of serious and willful misconduct of the employer.


citation: LAB § 5408

text:
If an injured employee or, in the case of the employee’s death, any of the employee’s dependents, is under 18 years of age or incompetent at any time when any right or privilege accrues to such employee or dependent under this division, a guardian or conservator of the estate appointed by the court, or a guardian ad litem or trustee appointed by the appeals board, may, on behalf of the employee or dependent, claim and exercise any right or privilege with the same force and effect as if no disability existed.

No limitation of time provided by this division shall run against any person under 18 years of age or any incompetent unless and until a guardian or conservator of the estate or trustee is appointed. The appeals board may determine the fact of the minority or incompetency of any injured employee and may appoint a trustee to receive and disburse compensation payments for the benefit of such minor or incompetent and his family.

history: (History: Amended by Stats. 1979, Ch. 730.)


citation: LAB § 5409

text: The running of the period of limitations prescribed by this chapter is an affirmative defense and operates to bar the remedy and not to extinguish the right of the employee. Such defense may be waived. Failure to present such defense prior to the submission of the cause for decision is a sufficient waiver.


citation: LAB § 5410

text: Nothing in this chapter shall bar the right of any injured worker to institute proceedings for the collection of compensation within five years after the date of the injury upon the ground that the original injury has caused new and further disability. The jurisdiction of the appeals board in these cases shall be a continuing jurisdiction within this period. This section does not extend the limitation provided in Section 5407.

history: (History: Amended by Stats. 2014, Ch. 217, Sec. 6. (AB 2732) Effective January 1, 2015.)


text: Should any party to a proceeding institute proceedings to reduce the amount of permanent disability awarded to an applicant by the appeals board and be unsuccessful in such proceeding, the board may make a finding as to the amount of a reasonable attorney’s fee incurred by the applicant in resisting such proceeding to reduce permanent disability benefits previously awarded by the appeals board and assess the same as costs upon the party instituting the proceeding for the reduction of permanent disability benefits.

history: (History: Added by Stats. 1971, Ch. 1558.)


citation: LAB § 5411

text: The date of injury, except in cases of occupational disease or cumulative injury, is that date during the employment on which occurred the alleged incident or exposure, for the consequences of which compensation is claimed.

history: (History: Amended by Stats. 1973, Ch. 1024.)


citation: LAB § 5412

text: The date of injury in cases of occupational diseases or cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his present or prior employment.


citation: LAB § 5413

text: A determination of facts by the appeals board under this chapter has no collateral estoppel effect on a subsequent criminal prosecution and does not preclude litigation of those same facts in the criminal proceeding.

history: (History: Added by Stats. 1995, Ch. 158, Sec. 2. Effective January 1, 1996.)


citation: LAB § 5430

text: This chapter shall be known and may be cited as the Workers’ Compensation Truth in Advertising Act of 1992.

history: (History: Added by Stats. 1992, Ch. 904, Sec. 1. Effective January 1, 1993.)

path: 4. WORKERS' COMPENSATION AND INSURANCE > 2.3. Workers’ Compensation—Truth in Advertising


citation: LAB § 5431

text: The purpose of this chapter is to assure truthful and adequate disclosure of all material and relevant information in the advertising which solicits persons to file workers’ compensation claims or to engage or consult counsel or a medical care provider or clinic to consider a workers’ compensation claim.

chapter: 2.3. Workers’ Compensation—Truth in Advertising


citation: LAB § 5432

text:
(a) Any advertisement which solicits persons to file workers’ compensation claims or to engage or consult counsel or a medical care provider or clinic to consider a workers’ compensation claim in any newspaper, magazine, circular, form letter, or open publication, published, distributed, or circulated in this state, or on any billboard, card, label, transit advertisement or other written advertising medium shall state at the top or bottom on the front side or surface of the document in at least 12-point roman boldface type font, except for any billboard which shall be in type whose letters are 12 inches in height or any transit advertisement which shall be in type whose letters are seven inches in height and for any television announcement which shall be in 12-point roman boldface type font and appear in a dark background and remain on the screen for a minimum of five seconds and for any radio announcement which shall be read at an understandable pace with no loud music or sound effects, or both, to compete for the listener’s attention, the following:NOTICEMaking a false or fraudulent workers’ compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine. (b) Any television or radio announcement published or disseminated in this state which solicits persons to file workers’ compensation claims or to engage or consult counsel to consider a workers’ compensation claim under this code shall include the following spoken statement by the announcer of the advertisement: “Making a false or fraudulent workers’ compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.” (c) This chapter does not supersede or repeal any regulation which governs advertising under this code and those regulations shall continue to be in force in addition to this chapter.

(d) For purposes of subdivisions (a) and (b), the notice or statement shall be written or spoken in English. In those cases where the preponderance of the listening or reading public receives information other than in the English language, the written notice or spoken statement shall be in those other languages.


citation: LAB § 5433

text:
(a) Any advertisement or other device designed to produce leads based on a response from a person to file a workers’ compensation claim or to engage or consult counsel or a medical care provider or clinic shall disclose that an agent may contact the individual if that is the fact. In addition, an individual who makes contact with a person as a result of acquiring that individual’s name from a lead generating device shall disclose that fact in the initial contact with that person.

(b) No person shall solicit persons to file a workers’ compensation claim or to engage or consult counsel or a medical care provider or clinic to consider a workers’ compensation claim through the use of a true or fictitious name which is deceptive or misleading with regard to the status, character, or proprietary or representative capacity of the entity or person, or to the true purpose of the advertisement.

(c) For purposes of this section, an advertisement includes a solicitation in any newspaper, magazine, circular, form letter, or open publication, published, distributed, or circulated in this state, or on any billboard, card, label, transit advertisement, or other written advertising medium, and includes envelopes, stationery, business cards, or other material designed to encourage the filing of a workers’ compensation claim.

(d) Advertisements shall not employ words, initials, letters, symbols, or other devices which are so similar to those used by governmental agencies, a nonprofit or charitable institution, or other entity that they could have the capacity or tendency to mislead the public. Examples of misleading materials include, but are not limited to, those that imply any of the following:

(1) The advertisement is in some way provided by or is endorsed by a governmental agency or charitable institution.

(2) The advertiser is the same as, is connected with, or is endorsed by a governmental agency or charitable institution.

(e) Advertisements may not use the name of a state or political subdivision thereof in an advertising solicitation.

(f) Advertisements may not use any name, service mark, slogan, symbol, or any device in any manner which implies that the advertiser, or any person or entity associated with the advertiser, or that any agency who may call upon the person in response to the advertisement, is connected with a governmental agency.

(g) Advertisements may not imply that the reader, listener, or viewer may lose a right or privilege or benefits under federal, state, or local law if he or she fails to respond to the advertisement.

history: (History: Amended by Stats. 1999, Ch. 83, Sec. 135. Effective January 1, 2000.)


citation: LAB § 5434

text:
(a) Any advertiser who violates Section 5431 or 5432 is guilty of a misdemeanor.

(b) For the purposes of this chapter, “advertiser” means any person who provides workers’ compensation claims services which are described in the written or broadcast advertisements, any person to whom persons solicited by the advertisements are directed to for inquiries or the provision of workers’ compensation claims related services, or any person paying for the preparation, broadcast, printing, dissemination, or placement of the advertisements.


citation: LAB § 5450

text: The Division of Workers’ Compensation shall make available to employees, employers and other interested parties information, assistance, and advice to assure the proper and timely furnishing of benefits and to assist in the resolution of disputes on an informal basis.

history: (History: Amended by Stats. 1994, Ch. 1097, Sec. 19. Effective January 1, 1995.)

chapter: 2.5. Administrative Assistance

path: 4. WORKERS' COMPENSATION AND INSURANCE > 2.5. Administrative Assistance


citation: LAB § 5451

text: Any party may consult with, or seek the advice of, an information and assistance officer within the Division of Workers’ Compensation as designated by the administrative director. If no application is filed, if the employee is not represented, or upon agreement of the parties, the information and assistance officer shall consider the contentions of the parties and may refer the matter to the appropriate bureau or unit within the Division of Workers’ Compensation for review and recommendations. The information and assistance officer shall advise the employer and the employee of their rights, benefits, and obligations under this division. Upon making a referral, the information and assistance officer shall arrange for a copy of any pertinent material submitted to be served upon the parties or their representatives, if any. The procedures to be followed by the information and assistance officer shall be governed by the rules and regulations of the administrative director adopted after public hearings.

history: (History: Amended by Stats. 1994, Ch. 1097, Sec. 20. Effective January 1, 1995.)


citation: LAB § 5453

text: After consideration of the information submitted, including the reports of any bureau or unit within the Division of Workers’ Compensation which have been received, the information and assistance officer shall make a recommendation which shall be served on the parties or their representatives, if any.

history: (History: Amended by Stats. 1994, Ch. 1097, Sec. 22. Effective January 1, 1995.)


citation: LAB § 5454

text: Submission of any matter to an information and assistance officer of the Division of Workers’ Compensation shall toll any applicable statute of limitations for the period that the matter is under consideration by the information and assistance officer, and for 60 days following the issuance of his or her recommendation.

history: (History: Amended by Stats. 1994, Ch. 1097, Sec. 23. Effective January 1, 1995.)


citation: LAB § 5455

text: Nothing in this chapter shall prohibit any party from filing an application for benefits under this division. In any proceeding pursuant to such application, the admissibility of written evidence or reports submitted by any party pursuant to this chapter, or Section 5502, shall be governed by Chapter 5 (commencing with Section 5700).

history: (History: Amended by Stats. 1983, Ch. 142, Sec. 109.)


citation: LAB § 5500

text:
No pleadings other than the application and answer shall be required. Both shall be in writing and shall conform to forms prescribed by the appeals board in its rules of practice and procedure, simply but clearly and completely delineating all relevant matters of agreement and all issues of disagreement within the jurisdiction of the appeals board, and providing for the furnishing of any additional information as the appeals board may properly determine necessary to expedite its hearing and determination of the claim.

The amendment of this section made during the 1993 portion of the 1993–94 Regular Session shall apply to all applications filed on or after January 1, 1994.

Notwithstanding Section 5401, except where a claim form has been filed for an injury occurring on or after January 1, 1990, and before January 1, 1994, the filing of an application for adjudication and not the filing of a claim form shall establish the jurisdiction of the appeals board and shall commence proceedings before the appeals board for the collection of benefits.

history: (History: Amended by Stats. 1994, Ch. 1118, Sec. 9. Effective January 1, 1995.)

chapter: 3. Applications and Answers

path: 4. WORKERS' COMPENSATION AND INSURANCE > 3. Applications and Answers


text:
(a) The appeals board shall establish uniform district office procedures, uniform forms, and uniform time of court settings for all district offices of the appeals board. No district office of the appeals board or workers’ compensation administrative law judge shall require forms or procedures other than as established by the appeals board. A workers’ compensation administrative law judge who violates this section may be subject to disciplinary proceedings.

(b) The appeals board shall establish uniform court procedures and uniform forms for all other proceedings of the appeals board.

history: (History: Amended by Stats. 2011, Ch. 559, Sec. 15. (AB 1426) Effective October 7, 2011.)