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California Workers' Compensation Administrative Penalties for the 1994 (Part 4)

By Edited Nov 13, 2013 0 0

The following are the Workers Compensation Administrative Penalties for California for the year 1994.

§ 10111.1 Schedule of Administrative Penalties for Injuries on or After January 1, 1994

(d)  The following Group D violations carry penalties of up to $5000;

(1) The penalty for each denial of all liability for a claim without documentation supporting a factual, medical, or legal basis for the denial is specified in this subsection.

In order to avoid a penalty, the denial must state a legal, factual or medical basis recognized by applicable law and documented by information in the claim file.  An employee's purported waiver of benefits in a compensable case is not a ground to deny liability.

The penalty is based on the class or classes of benefits potentially payable if benefits were provided.  The total penalty shall be determined by applying the penalty assessment amount listed in [i] for gravity, subtracting the amount listed in [ii] for good faith if applicable, and increasing or decreasing the penalty as applicable for history and frequency as set forth in [iii] and [iv];

[i] For a claim involving potential for medical treatment only the penalty is $3,500;

For a claim involving potential for medical treatment and either temporary or permanent disability the penalty is $4,000;

For a claim involving potential for medical treatment and both temporary and permanent disability the penalty is $4,500

For a claim involving potential for medical treatment, temporary disability, permanent disability and vocational rehabilitation the penalty is $5,000;

For a claim involving potential for death benefits the penalty is $5,000

[ii] The penalty will be reduced by $1,000 for good faith if there was a reasonable attempt to investigate the claim.

[iii] Reduction or increase of the penalty for history shall be based on the following;

An audit subject having no prior Audit Unit history will receive a $500 reduction;

An audit subject having a prior Audit Unit history of no more than on audited unsupported denial will receive a $500 reduction;

An audit subject having a prior Audit Unit history of more than one audited unsupported denial but no more than 5% of audited denials as unsupported will receive no reduction or increase for history;

An audit subject having a prior Audit Unit history of more than one audited unsupported denial and more than 5% of audited denials as unsupported will receive a $500 increase.

[iv]  Reduction of the penalty for frequency shall be based on the following;

An audit subject having no more than one audited unsupported denial will receive a $500 reduction;

An audit subject having more than one audited unsupported denial but no more than 5% of audited denials which are unsupported will receive no reduction or increase for frequency;

An audit subject having more than one audited denial and more than 5% of audited denials which are unsupported will receive an increase of $500

[v] The total amount assessed for a denial shall be reduced by 50% if the claim was accepted after the denial without evidence that the acceptance was the result of litigation or of the claim's selection for audit.

(2)  The penalty for each failure to comply with, show good cause for non-compliance with, or contest, within 30 days of receipt, any written request or order of the Administrative Director or Audit Unit which is not specified in subsections (b)(1), (c)(1), or (d)(5) of this section is;

$500 if there was compliance in more than 30 but not more than 40 days from receipt of the request or order;

$1000 if there was compliance in more than 40 but not more than 60 days from receipt of the request or order;

$2,500 if there was compliance in more than 60 but not more than 90 days of receipt of the request or order.

$5000 for failure to comply within 90 days of receipt of the request or order.

(3)  The penalty for each failure by a claims administrator to provide a claim form within one working day of receipt of a request from an injured worker or the worker's agent is:

$500 if the claim form was provided in more than 1 but not more than 5 working days from receipt of the request, if benefits were being provided to the employee at the time of the request;

$1000 if the claim form was not provided within 5 working days of receipt of the request, if benefits were being provided to the employee at the time of the request;

$3000 if the claim form was provided in more than 1 but not more than 5 working days from receipt of the request, if benefits were not being provided to the employee at the time of the request;

$5000 if the claim form was not provided within 5 working days of receipt of the request, if benefits were not being provided to the employee at the time of the request.

(4) The penalty for each failure to comply in full with any final award or order of the Workers' Compensation Appeals Board or the Rehabilitation Unit within 20 days of service, allowing an additional five days for service by mail, is;

$500 for full compliance in more than 20 but not more than 35 days from the date of service, or for any late payment or failure to pay interest due;

$1000 for full compliance (other than a late interest payment) in more than 35 but not more than 60 days from the date of service;

$2,500 for full compliance (other than a late interest payment) in more than 60 but not more than 90 days from the date of service;

$5000 if there was not full compliance (other than failure to pay interest) within 90 days of the date of service.

(5)  The penalty for each failure to produce a legible paper copy of a claim file as required by Section 10107 or at the time specified by the Administrative Director is:

$100 if the file was produced not more than 3 days late;
$250 if the file was produced more than 3 but not more than 14 days late;
$500 if the file was produced more than 14 but not more than 29 days late;
$1000 if the file was produced more than 29 days late but not more than 40 days late.
$2,500 if the file was produced more than 40 days late but nor more than 90 days late.
$5000 if the --- was produced more than 90 days late or was not produced.

(e) The penalties otherwise applicable under subsections (a) through (d) of this section shall be modified by any applicable provision of this subsection (e). However, the method of modifying penalties for unsupported denials is set forth in Section 10111(d)(2) and Section 10111.1(d)(1) and is not governed by this subsection (e).

For more information on California Workers’ Compensation benefits, see the following articles:

California Workers' Compensation: What to Do If You are Injured at Work
California Workers' Compensation: Permanent Disability Benefits
California Workers' Compensation: Temporary Disability Benefits

 


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