What Is a Claims Adjuster in a California Workers’ Compensation Case?

In a California workers’ compensation case, a claims adjuster is the representative from the insurance company who is responsible for managing your claim. Their role includes reviewing your case, approving or denying benefits, coordinating medical care, and determining how much compensation you may receive.

The claims adjuster is often your main point of contact once a claim has been filed. While they may seem helpful, it is important to remember they work for the insurance company, not for you. Their job includes controlling costs, which can affect the decisions they make about your benefits.

What Does a Claims Adjuster Do?

A claims adjuster has several responsibilities, including:

• Reviewing the claim form (DWC-1) and supporting medical records
• Authorizing medical treatment and coordinating with healthcare providers
• Determining eligibility for temporary and permanent disability benefits
• Sending benefit notices about delays, approvals, or denials
• Requesting evaluations by Qualified Medical Evaluators (QMEs) when there are disputes
• Negotiating settlements with injured workers or their attorneys

Can a Claims Adjuster Deny Treatment or Benefits?

Yes. The claims adjuster has the authority to approve, delay, or deny medical treatment, disability payments, and other benefits. Some common reasons they may give for denial include:

• The injury did not happen at work
• The medical treatment is not considered necessary under the Medical Treatment Utilization Schedule (MTUS)
• There is a pre-existing condition
• The worker did not file the claim on time

If your treatment or benefits are denied, you have the right to dispute the decision through the Division of Workers’ Compensation (DWC).

Do You Have to Speak With the Claims Adjuster?

Yes, you will likely have to communicate with the claims adjuster about your injury and treatment. However, be cautious about what you say. Avoid guessing or downplaying your symptoms. Claims adjusters often take detailed notes and may use your statements to limit your benefits later in the process.

If you are represented by an attorney, your attorney will handle most communication with the adjuster on your behalf.

What If the Claims Adjuster Is Not Responding or Treating You Unfairly?

Delays, poor communication, or unfair denials can significantly affect your recovery and financial stability. If the claims adjuster is not responding or mishandling your case, you may need legal assistance to move your claim forward.

Get Help With a Difficult Workers’ Compensation Claim

If you are having problems with a claims adjuster or are unsure about your rights, the Law Offices of Norman J. Homen is here to help. We handle communication with the insurance company and fight to ensure injured workers receive the care and benefits they deserve. Contact us today for a free consultation.