In California, Certain COVID-19 Claims Now Deemed ‘Work Related’ Unless Proven Otherwise. 

In early May, California Governor Gavin Newsom issued Executive Order N-62-20. This order creates a presumption that if employees contract COVID-19 while working outside their homes during the period of March 19, 2020 to July 5, 2020, their Workers’ Compensation claim is automatically compensable.

This is a rebuttable presumption, however, meaning it can be overturned if there is enough evidence to support that the employee’s claim for COVID-19 is not work related. Here are some best practices on how employers can approach COVID-19 claims.

How to handle COVID-19 claims?

It’s not recommended to take a blanket approach toward providing claim forms during the pandemic. Employees could potentially assume they need to complete this form, even if they haven’t been exposed to COVID-19. Regardless, once the form is submitted, a claim is created and you can’t undo the process.

If an employee believes they have COVID-19, direct them to their personal health physician (if they are not indicating it is work related). If the employee is indicating their claim is work related, direct them to your occupational clinic.

Some clinics have telehealth capability while others will be able to direct the employee to an appropriate facility. If there are any issues, the adjuster will be able to assist in coordinating care for work related allegations.

When to provide a DWC-1 claim form to the employee and report a claim:

  • A claim form must be provided if an employee asks for one.
  • A claim form must be provided if an employer receives knowledge, from any source, that (1) the employee was diagnosed with COVID-19 and (2) either it is work-related, or the employee is claiming it is work-related.
  • Claim forms must be provided to the employee within 1 business day. If appropriate a claim form can be mailed to the employee and proof of service should be documented.
  • If the requirement to provide a claim form has been met, report the claim immediately so that the carrier has time to investigate the claim. If the claim is questionable, indicate so when reporting and advise you will be submitting additional information shortly.

Complete your employer level investigation as soon as possible—the insurance carrier only has 30 days from your knowledge of a claim to make a compensability decision. 

Questions to ask:

  • Do they meet all 4 criteria for a COVID-19 presumption?
  1. Did the employee test positive or were they diagnosed within 14 days after performing work at the employer’s direction?
  2. Is the date of injury/illness between March 19, 2020 to July 5, 2020?
  3. Were they working outside of their home or residence?
  4. Was the diagnosis from a California licensed physician, and was the diagnoses confirmed by further testing within 30 days of that diagnosis?
  • When did the employee first begin having symptoms?
  • Do you have any knowledge of whether the employee may have come in contact with COVID-19 outside the work place?
    • Do they have any family members or friends who may have been exposed?
    • Have they traveled at all within the last 30 days?  Locally?  Internationally?
    • Is there any information showing it could have been contracted elsewhere?

What to provide the insurance carrier:

  • After completing your investigation, provide a clear and concise summary of why you believe the employee’s claim for COVID-19 may be compensable or non-compensable, along with any supporting documentation/evidence
  • Provide a description of the employee’s job duties for the 30 days leading up to the diagnosis
  • Provide the employee’s work schedule for the 30 days leading up to the diagnosis
  • Provide a list of safeguards in place to maintain a safe work environment (PPE, Training, Temperature Checks, etc.)
  • If known provide the employee’s personal health insurance plan information
  • Advise the adjuster of any paid sick leave benefits the employee qualifies for

Keep investigating, even though the carrier only has 30 days to issue a decision, the Executive Order does allow for a denial to still be issued based on information learned after the 30 day period.

If you have questions related to the the topics covered above, please don’t hesitate to contact me.

About Kevin Mui

Kevin Mui has been working in the insurance field for the past decade specializing in Workers’ Compensation and risk management across multiple industries. He mitigates the costs of potential and existing claims with preventative risk management techniques, and provides ongoing claims advocacy for his clients. Kevin has a background in financial advising and obtained his Life & Health license, along with the Series 6 and 63 securities licensing. He graduated from the University of California, Riverside with a Bachelor’s of Science in Business Administration.

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