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Claims Investigation

Your claims adjuster is supposed to investigate your claim in good faith. 8 CCR §10109 imposes a continuing duty to investigate and to "conduct a reasonable and timely investigation upon receiving notice or knowledge of an injury or claim for a workers' compensation benefit."

Further, "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."he requirement that "Insurers, self-insured employers and third-party administrators shall deal fairly and in good faith with all claimants, including lien claimants" is not always honored.

It is important to cooperate with reasonable requests for medical information and the details of how you were injured. Failure to cooperate can lead to delay and denial of your claim. If in doubt, seek legal advice.

You should be aware that your social media pages are likely to be scrutinized as part of claims investigation, that investigators may become your Facebook "friends" in order to spy on you, and that many injured workers are put under surveillance. A jury convicted a California prison worker of insurance fraud when evidence showed: She told her doctor on a pain questionnaire that her pain made it “impossible to write or type” and that her pain was “excruciating following any activity.” The defendant also posted nearly 200 updates on her Facebook account during this time period as well.

Also, the Nurse Case Manger (NCM) sometimes acts as an investigator for the adjuster. Be careful what you say, and do not allow the NCM into the treatment room when you meet with your doctor. You have a right to privacy.

It is important not to do anything you told claims people or doctors you cannot do. You do not want to be hit with felony charges

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