Notices from the Insurance Company – What do they mean?

There are many forms that you will receive from the insurance company during your claim. What do these all mean? Here is a quick summary of some common forms which are sent:

Denial of Benefits Letter

Your employer’s insurance company will notify you in writing if your claim is denied. There are several reasons your claim could be denied. The insurance company might deny your claim if the insurer doesn’t believe you suffered a work-related injury, that you need medical treatment, or that you need time off work due to your injury.

Employer’s First Report of Occupational Illness or Injury

This form, DLSR 5020, Employer’s First Report of Occupational Illness or Injury, administered by the California Department of Labor Statistics and Research, is being phased out. Employers will soon need to file a new electronic employer’s report of occupational illness or injury with the DWC over its new electronic filing system, Workers’ Compensation Information System (WCIS).

Your employer must file this form, or its replacement first report of injury (FROI), within five days of finding out about a workplace injury that required treatment beyond basic first aid or caused you to miss work beyond the day of injury. The report includes information about the time and location of the injury and a description of how it happened, as well as whether you were using any equipment, materials, or chemicals when the injury occurred. You might want to follow-up with your supervisor or employer about the timely submission of the DLSR-5020 form.

Doctor’s First Report of Occupational Illness or Injury

Your doctor, or the doctor who you are sent to see for your work-related injury, is supposed to submit form DLSR 5021, Doctor’s First Report of Occupational Illness or Injury, to your employer and/or your employer’s insurance company within five days of your initial examination. The doctor will include in the report your complaints, any objective findings (results of physical examination or x-rays), a diagnosis, any treatment rendered, and whether you have restrictions on returning to work.

It’s important to tell the doctor about any body part that was injured or is experiencing pain so it can be noted in the doctor’s first report. If you were seen and treated by your personal physician, you may want to remind the doctor to submit the DLSR-5021 form if your doctor isn’t familiar with California’s workers compensation system.

Permanent and Stationary Report

When your treating physician determines that your medical condition is not likely to significantly improve with further medical treatment, your doctor will declare that you have reached maximal medical improvement (MMI), formerly known in California as “permanent and stationary,” or “P&S.” Reaching MMI means that your temporary disability payments will end and your medical treatment may stop, and the doctor will assess whether you have any remaining physical impairment or permanent disability that limits your ability to work.

At this point, your doctor is required to fill out Form PR-4, “Primary Treating Physician’s Permanent and Stationary Report,” called a “P&S report” for short, reporting your diagnosis, impairments, and limitations in detail. In addition, Form PR-4 requires the treating doctor to give an opinion on whether your injury was the result of a work-related injury and whether any permanent disability was caused by other factors than your work-related injury or illness. You should receive a copy of your P&S report within two to three weeks of your last doctor’s visit. You should carefully review the report to see if you agree with the doctor’s findings.

Stipulations with Request for Award

If you’ve suffered any permanent disability or lasting impairment to your ability to work, the insurance company will send you a form called Stipulations with Request for Award to try to get you to settle your claim. This agreement, also called a “settlement by stips,” allows you to be paid weekly permanent disability payments for a period of time, depending on the severity of your injury, and preserves your right to have the insurance company to pay for any future medical costs as a result of your injury. Before you agree to sign a Stipulations with Request for Award settlement, make sure you have educated yourself about what your permanent disability rating should rightfully be, or consult a worker’s comp attorney to determine whether your rating is fair and the offer is reasonable in your circumstances. In addition, consider whether you’d rather collect your settlement in small weekly payments or as a lump sum, as with a Compromise and Release, below.

Compromise and Release

Like the settlement agreement above, the Compromise and Release form settles your workers’ comp claim with your employer’s insurance company, but unlike a settlement by stipulation, in a compromise and release you are paid your permanent disability benefits in a lump sum.

In addition, if the insurance company believes you may need future medical care, it will offer you a lump sum in exchange for your giving up your right for the insurance company to pay for future medical care. If you are considering agreeing to a Compromise and Release and are not represented by an attorney, consider consulting a worker’s compensation lawyer to make sure that you are being offered a fair amount for your permanent disability and that you don’t underestimate your need for, and the cost of, future medical treatment.