Figura 1: Flujo de Reclamo de Compensación de Trabajadores
EMPLOYER Injury report to Employer
INJURY
The Insurance Company must pay the first installment of compensation, if injured worker misses more than 7 days from work that is immediate and continuous with 14 days after the employer has knowledge. Additional payment made bi-weekly until employee returns to work or benefits are exhausted.
INSURANCE COMPANY Employer required to report to Insurance Company within 7 days of knowledge.
INSURANCE COMPANY Pays Claim.
YES
NO
DENIAL The Insurance Company must deny a claim within 120 days. The Insurance Company is required to pay benefits until the date the claim is denied.
ACCEPT DENIAL OF THE COMPENSABILITY OF THE CLAIM
Case Closed
YES
NO
PETITION for BENEFITS If the employee disagrees, he/she may within 2 years from the date of accident file a Petition for Benefits. (NOTE: The 2-year limit pertains only to contesting the compensability of the claim.)
CARRIER RESPONSE The Insurance Company must pay or respond to the Petition within 14 days of receipt of the Petition specifically denying those benefits they will not provide.
MEDIATION Mediation is held within 130 days of filing the Petition.
Final Hearing (Within 90 days after the Pre-Trial Hearing)
Workers’ Compensation Judge
Pre-Trial Hearing
SETTLED?
NO
YES
Case Closed
ACCEPTS DECISION
Case Closed
YES
NO
An appeal must be filed within 30 days from the date the WC Judge signs the order.
1st District Court of Appeal
Page 17
Book Code: CFL10SE24
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