Provision of Benefits and Investigation Without a Claim Form

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PROVISION OF BENEFITS AND INVESTIGATION WITHOUT A CLAIM FORM

Even if an employer's duty to provide a claim form is triggered, asking an employee in the current environment to complete a claim form for a COVID-19 claim is not always practical or even advisable. Lack of immunity in most people invites easy transmission of the coronavirus among employees, so employers should not put workers in situations in which they must meet with potentially infected co-workers. And because the research is not definitive about how long the coronavirus can survive on various surfaces, employers and claims adjusters cannot be certain that claim forms handled by injured workers are safe.

However, even though it may not always be possible to request that an employee complete a claim form, this does not excuse the employer from investigating a claim and providing benefits based on that investigation if required.

FILING A CLAIM FORM IS NOT A PREREQUISITE FOR BENEFITS

An employee is not required to file a claim form to receive workers' compensation benefits (see "Sullivan on Comp" Section 6.6 Filing Claim Form and Effect on Rights). California Code of Regulations, Title 8, § 10137 states, "Nothing in this article shall abrogate the duty of an employer to provide timely compensation to an injured worker, even if the employee has not completed and filed the form required by Labor Code Section 5401 and this article."

If an employee alleges that he or she contracted COVID-19 on an industrial basis, an employer should either ask the worker to sign the claim form electronically or simply forgo the signature altogether, and complete the form on the employee's behalf.

The employer also must consider that some employees may not be able to complete a claim form even if they want to –– some employees might not have the ability to receive or complete the form electronically. In the worst cases, the employee could be unable to complete a claim form due to hospitalization and quarantine because of the coronavirus. If the employer knows that the employee is alleging that his or her COVID-19 is industrial, it must begin investigating the claim, and pay all required benefits.

DUTY TO INVESTIGATE REGARDLESS OF CLAIM FORM

Generally, filing the claim form puts the burden on the employer to investigate a claim promptly, and to determine whether to contest liability. The investigation must be completed within 90 days. But because an employer may be required to provide benefits even if a claim form is never filed, its duty to investigate also may be triggered without the form being filed. As described above, the standard for an employer's knowledge of a work-related injury is high. If it is met, however, or the employer knows that a claim is being made, the duty to investigate is triggered.

CCR § 10109(a) requires a claims administrator to "conduct a reasonable and timely investigation upon receiving notice or knowledge of an injury or claim for a workers' compensation benefit." So, an employer's duty to investigate a claim isn't triggered only by "a claim for benefits"; it's also triggered by "notice or knowledge of an injury," regardless of whether a claim is filed.

In an accepted claim, there's also a duty to proactively provide benefits owed, and to investigate what benefits might be owed. CCR § 10109(b) states, "A reasonable investigation must attempt to obtain the information needed to determine and timely provide each benefit, if any, which may be due the employee." It also states, "The administrator may not restrict its investigation to preparing objections or defenses to a claim, but must fully and fairly gather the pertinent information, whether that information requires or excuses benefit payment."

As explained by the appeals board in The Romano Trust v. The Kroger Co. dba Ralph's Grocery, Co., "The Labor Code does not permit a defendant to bury its head in the sand in order to dodge its obligations." Failure to reasonably investigate a need for benefits could result in audit penalties, and per Romano, for the worst offenses, the appeals board could refer the case to the Audit Unit. Failure to conduct a reasonable investigation also could result in a penalty for unreasonable delay in payment of benefits pursuant to LC 5814 (see "Sullivan on Comp" Section 13.20 Unreasonable Delay –– Duty to Investigate).