The Workers' Compensation system, which was adopted during the second decade of the 20th Century, is based on an agreement between employers and employees. Ideally, treatment is to be provided promptly, however the experience of injured workers in California varies based on how responsive employers and their insurance claims representatives are.
Workers' Compensation benefits are insured and adjusted primarily by insurance companies and those employers secure enough to self-insure their liability. Many Workers' Compensation insurance carriers in California have their claims adjusted by a Third-Party Administrator (TPA), a company that administers injury claims and related services under contract with an insurance company, insurance fund and/or self-insured employers.
The TPA earns income by commissions from insurance premiums or by charging specific fees for services. The concept is a specialized TPA will be more efficient and cost effective in their administration versus a larger insurance carrier that is focused on national or international coverage in multiple specialties (auto, business, health, etc.).
"A well run TPA can expedite claims and provide an improved level of services and benefit delivery," says Adam Dombchik, managing partner of the Workers' Compensation law firm of Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP (GEK). "However, as with most for-profit services, TPAs will focus on cost cutting and savings over service. This means the needs of injured workers often are ignored or intentionally delayed and denied as part of cost containment or by the lack of available services, such as access to medical specialists or diagnostic imaging."
TPAs will often delay and deny injury claims or requests for medical treatment to avoid the cost of properly investigating an injury claim or providing adequate medical care, forcing an injured worker to litigation to obtain basic benefits.
Such delay/denial tactics require the assistance of an attorney simply to obtain basic benefits such as medical treatment and time-loss coverage. Having legal counsel anticipating and pushing back on the TPA from the onset of the claim is necessary to avoid substandard care and forced return to work before the person has recovered from the injury. An attorney can properly set up the claim from the very beginning, navigate the "delay" period, obtain relevant records to support the claim, and help expedite benefits and obtain treatment.
At GEK we are dedicated to ensuring injured workers receive the full range of benefits to which they are entitled. Contact us via our website--www.geklaw.com--or call us at 213-939-7000; we're here to help.
