What Is a Claims Administrator in a California Workers’ Compensation Case?
In a California workers’ compensation case, a claims administrator is the person or organization responsible for handling a workers’ compensation claim on behalf of the employer. This can be someone who works for an insurance company, a third-party administrator (TPA), or an employer who is self-insured.
The claims administrator plays a central role in the claims process. They review documents, communicate with injured workers and medical providers, and determine whether to approve or deny benefits.
What Does a Claims Administrator Do?
The claims administrator oversees the entire life of a workers’ compensation claim, including:
- Receiving and reviewing the DWC-1 claim form
- Authorizing medical treatment and assigning doctors within the medical provider network (MPN)
- Coordinating with claims adjusters who manage daily claim activity
- Issuing benefit notices regarding temporary disability, permanent disability, or denials
- Managing payments for medical care and wage replacement
- Monitoring deadlines and compliance with California workers’ compensation regulations
In larger organizations, the claims administrator may supervise multiple claims adjusters.
Is a Claims Administrator the Same as a Claims Adjuster?
Not exactly. The claims adjuster typically handles the day-to-day management of a claim, while the claims administrator is responsible for ensuring the overall claims process complies with legal and regulatory standards. In some cases, especially in smaller organizations, one person may fill both roles.
How Does the Claims Administrator Affect Your Case?
The decisions made by the claims administrator can directly impact your access to:
- Medical treatment
- Temporary or permanent disability benefits
- Supplemental job displacement benefits (SJDB)
- Settlement options
They are required to follow the rules set by the California Division of Workers’ Compensation (DWC) but are also working to minimize costs for the employer or insurer. This sometimes results in delays or disputes over medical care or benefit eligibility.
What Can You Do If There Is a Dispute With the Claims Administrator?
If you believe the claims administrator is mishandling your case or violating your rights, you can:
- Request a hearing before a workers’ compensation judge
- File a complaint with the Division of Workers’ Compensation Audit Unit
- Seek representation from a workers’ compensation attorney
Need Help Dealing With a Claims Administrator?
If you are facing delays, denials, or lack of communication from the claims administrator, legal guidance can help protect your rights. At the Law Offices of Norman J. Homen, we represent injured workers across California and hold claims administrators accountable. Contact us today for a free consultation.
