Components of an ADR Program
Hopefully, your claim will go smoothly. However, if at any time you have an unresolved issue related to your workers compensation claim, or you wish to speak to a neutral third party, simply call the Ombudsperson. The Ombudspersons sole function is to answer questions, listen to your concerns, provide an unbiased explanation of the law, and resolve problems before they become formal disputes. The Ombudsperson has experience and expertise in the legal and medical issues surrounding workers compensation injuries. He or she will respond to your inquiries as soon as possible, usually within a few hours. Your dispute must go through the Ombudsperson before moving on to the other dispute resolution steps, which are mediation and arbitration.
If the Ombudsperson does not resolve your problem to your satisfaction, you can request mediation. A Mediator will be assigned to you within 3 working days. The Mediator will hold a joint meeting with you and the Claims Administrator to help find a solution that is mutually agreeable to all parties. Although the Mediator will make a recommendation to settle the dispute, you cannot be forced to accept their recommendations, or sign any documents giving up your rights.
Within 30 calendar days after the completion of the mediation, any party not satisfied with the outcome can request arbitration. The Arbitrator is like a worker’s compensation judge. The Arbitrator holds a hearing within 30 calendar days of referral to receive testimony from parties, witnesses, and considers all reports and other facts that are relevant to the dispute. Upon completion of the hearing, the Arbitrator will render a written decision within 10 workings days. Although the decisions of the Arbitrator are binding, they can be appealed to the office of the Appeals Board in San Francisco pursuant to California Code of Regulations Â§10865.
Medical Advice Nurse
A Medical Advice Nurse is available to respond to inquiries that require medical expertise beyond what the Ombudsperson knows.
Independent Medical Review (IMR) / Qualified Medical Examiner (QME):
Anytime a medical evaluation is required to resolve disputes related to compensability of claim, permanent disability evaluations, and all other disputes per California Labor Code Â§4060, 4061, and 4062, the evaluation will be completed by a qualified medical evaluator (QME) as specified in Labor Code Â§4062.1. When an injured worker or the OCIP requests a medical evaluation by a QME, the service provider will provide a panel of three QMEs (selected from QME list based on specialty) from which you can select one. Note: that if you utilize an MPN as your independent medical review, we can tailor the program around the MPN. Also, if all parties agree a Agreed Medical Examiner (AME) list can be developed and agreed to by all parties.
Frequently Asked Questions
What is an ADR Carve-Out Program?
ADR stands for Alternative Dispute Resolution. The California Workers Compensation Division allows employers and labor unions to “carve out” alternative ways to deliver benefits and resolve disputes in lieu of utilizing the State system. These replace the State system for processing claims. This system allows unions and employers to alter the adversarial culture of the workers compensation claims process.
How will an ADR Carve-Out Program improve the processing of my Workers Compensation claim?
The goals of the an ADR Program are to avoid unnecessary misunderstandings/disputes/litigation, reduce delays encountered in the State system, improve communication between the injured workers and Claims Administrator (adjuster), and increase satisfaction among injured workers.
What are the components of the ADR Program?
An ADR Program usually has four components – ombudsperson, mediation, arbitration, and advice nurse. Any dispute or problem must first be submitted to the Ombudsperson who will try to resolve it for you. If the Ombudsperson is unsuccessful, the Ombudsperson will advise you of your right to mediation and provide you with the appropriate form to request mediation. If mediation is unsuccessful, the Ombudsperson will advise you of your right to arbitration and provide you with the appropriate form to request arbitration. The Ombudsperson may also refer you to an advice nurse if you have questions regarding your medical care that require medical expertise beyond what the Ombudsperson knows.
What is the role of the Ombudsperson?
If at any time you have an unresolved issue with the Claims Administrator or you want an unbiased explanation of your benefits or the law, the Ombudsperson is available to address your concerns. You must contact the Ombudsperson before you can move on to the other dispute resolution steps, be it mediation or arbitration.
What is mediation?
If your dispute can not be resolved at the Ombudsperson level, you can request mediation. If mediation is requested, the Service Provider will refer your dispute to a Mediator who will hold a joint meeting with you and the Claims Administrator. The purpose is to engage the parties in discussions and help find a solution that is acceptable to both parties. Although the Mediator can make recommendations to settle the disputes, you cannot be forced to accept these recommendations or sign any documents giving up your rights.
What is arbitration?
Any party not satisfied with the outcome of the mediation may request arbitration. If arbitration is requested, the Service Provider will refer the dispute to an Arbitrator who is a California judge (either active or retired) experienced in issues related to workers’ compensation. The Arbitrator will hold an arbitration hearing within 30 days, in which both parties have an opportunity to present witnesses and evidence relevant to the dispute and to engage in cross-examination. The Arbitrator then renders a binding decision within ten working days.
What if I am not satisfied with the Arbitrator’s decision?
Any party not satisfied with the Arbitrator’s decision can appeal by filing a Petition for Reconsideration with the Appeals Board in San Francisco pursuant to California Code of Regulations §10865.
Who are the Mediators and Arbitrators?
We normally suggest utilizing a retired workers compensation judges to act as mediators and arbitrators. This helps the process by having them be able to communicate to the injured workers during mediation as to the next steps if a resolution cannot be achieved. For arbitrations, the retired judge provides the necessary guidance and experience since this is a formal hearing.