Who Handles My Workers’ Compensation Claim in California?

Claims Adjuster vs. Claims Examiner vs. Claims Administrator

If you have filed a workers’ compensation claim in California, you are likely dealing with someone from the insurance company but their title might be claims adjuster, claims examiner, or claims administrator. These terms can be confusing, especially because they are often used interchangeably.

Understanding who is managing your claim and what authority they have can help you respond more effectively and protect your rights.

Claims Adjuster

A claims adjuster is usually the person you speak to most often. They handle the day-to-day management of your claim.

Their responsibilities include:

• Reviewing the DWC-1 claim form
• Authorizing or denying medical treatment
• Issuing temporary and permanent disability payments
• Communicating with your doctors
• Coordinating Qualified Medical Evaluator (QME) appointments
• Sending benefit notices and settlement offers

The adjuster works for the insurance company, a third-party administrator, or a self-insured employer, and their goal is to manage the claim efficiently, often with a focus on cost control.

Claims Examiner

In most cases, a claims examiner performs the same duties as a claims adjuster.

The term is more commonly used by third-party administrators (TPAs) or self-insured employers, but the role is nearly identical. Like adjusters, examiners review evidence, manage payments, and approve or deny treatment.

Note: If your paperwork or claim correspondence refers to a “claims examiner,” you can generally treat that person as your claims adjuster.

Claims Administrator

The claims administrator is the organization or entity responsible for overseeing the claims process. This could be:

• An insurance carrier
• A third-party administrator (TPA)
• A self-insured employer’s internal claims department

In some cases, “claims administrator” may also refer to a supervisor who oversees claims adjusters and examiners. Regardless, the claims administrator has the legal responsibility to ensure the claim is handled according to California workers’ compensation laws.

Why This Matters

These roles all impact your access to benefits. For example:

• If the adjuster or examiner delays treatment or denies a benefit, it is the administrator who is ultimately responsible.
• Miscommunication with any of these individuals can lead to missed deadlines, reduced benefits, or inaccurate medical evaluations.
• Knowing the difference helps you understand who to contact, and whether to escalate an issue.

What to Do If There Is a Problem

If you believe your claim is being mishandled, whether by a claims adjuster, examiner, or administrator, you have options:

• File a complaint with the California Division of Workers’ Compensation
• Request a hearing before a workers’ compensation judge
• Contact a workers’ compensation attorney to help you communicate with the insurance company and protect your rights

We Can Help

At the Law Offices of Norman J. Homen, we work directly with insurance adjusters and administrators every day. If your claim has been denied, delayed, or underpaid, we can step in and ensure the right people are held accountable.

Contact us today for a free consultation.