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The 8th Thing That A Claims Investigator Needs…

from their worker's compensation or disability claims adjuster/examiner is a complete copy of

The Claim Notes or Adjuster's Notes on the Claim(s) under investigation

The claim notes on a file or companion files of the claimant can be a treasure trove of information that a claims investigator can utilize in process of their investigation.  Information for interviews or for surveillance.   Among the things the investigator may learn by reviewing the claim's notes are:

• Summaries of interviews taken by the adjuster with the claimant, witnesses, the employer, and/or medical providers which contain representations being made by each party in relation to the claimant, the incident, and/or the injury.
• Current disability/medical treatment status.
• When was the last time the adjuster or claims personnel had contact with the claimant, the employer, a witness, the medical provider(s).
• Is there any legal representation on the file?
• Are payments being provided to the claimant?
• Is the claim accepted, denied, or partially denied?
• What body parts are accepted and what parts are denied?
• Possible notation of prior claims history of the claimant.
• The adjuster's summary and current and past plans of action.  Where is the adjuster directing the claim towards?  What is the goal?
• Is there a third party or product that caused or contributed to the incident and resulting injuries?  Who is the third party?
• What injuries is the claimant claiming?

Need Help?

Why you may need the services of a professional private detective?

1. Concern about the well being of a loved one.

2. Suspect that you or a loved one may have become a victim of fraud.

3. Protection for yourself, a loved one, and/or your business from physical, emotional or financial harm.

4. Information about a business and/or an individual so you may make an informed decision about your business, your family, and/or your personal life.

July 24, 2015 - Private Investigator Day

For Immediate Release
Thursday, July 23, 2015
LONG BEACH CALIFORNIA

PRECISION DETECTIVE SERVICES

Endorses National and International Private Investigators Day






Professional Private Investigators provide a fundamental and vital role in society today.

Professional Private Investigators have proven time after time to be an extremely valuable asset to society.

National Private Investigators Day is this Friday July 24th, commemorating the birth year of Eugene Francois Vidocq, the very first Private Investigator who founded the first known detective Agency in 1833.

Professional, licensed private investigators (P.I.s) in this area are joining an estimated 80,000+ private investigators internationally and across the United States in observing National Private Investigators Day on July 24, 2015.

“We believe our aim is the Passionate Search for the Truth, and this has at least two applications,” said PRECISION DETECTIVE SERVICES owner, Ryan Clock. “First, while modern entertainment has portrayed our justice system as expedient and error free in less than an hour, the reality is much different. Both civil and criminal cases can take months, even years, to resolve. Post convictions are being overturned based on new modern evidence. These cases have all required the exhaustive and diligent work of private professional investigators who passionately search for the truth’.

“Additionally, National Private Investigators Day is a time to demonstrate to the public the value of professional private investigators. Professional private investigators often find themselves working with attorneys, families, law enforcement officials, insurance companies, business owners and individuals to conduct background checks, find missing persons and absconders of child support, reuniting families, prevent fraud and abuse, help provide for safe work environments and defending the Constitutional rights of criminal defendants or pursuing the rights of those harmed by the negligence of others.” Ryan said.

“Most private investigators are professionals who are licensed, receiving continuing education and specialized certifications, to assist their clients at some of their most difficult times. These efforts and accomplishments need to be understood and supported by lawmakers and the general public. The public's perception of P.I.s has improved over the years, but still has room to grow."

“Today’s professional private investigators have varied backgrounds – from law enforcement and criminal justice, to insurance adjusting and information technology. These take considerable and unique talents, as well as extensive training and investigative experience.” These include:
• Gathering evidence for civil and criminal court cases;
• Performing background checks to protect businesses from hiring people who have seriously misrepresented their professional credentials;
• Keeping insurance costs from increasing by documenting cases of insurance fraud; and
• Assisting the public when they feel they have no place to turn for assistance.

Thank you for joining us on this important day of recognition for professional private investigators.

Respectfully,

Ryan D. Clock
Owner / Qualified Manager
PRECISION DETECTIVE SERVICES
CA PI 26879
562-502-7053
gettruth@precisiondetective.com

"The Truth Is Out There! Let Us Help You Find It!

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Digital Investigations: An Inside Look - Training, Saturday, January 24, 2015

Digital Investigations: An Inside Look, January 24, 2015 https://t.co/5u5KFjgkJe

— Ryan D. Clock (@PrecisionPI) December 23, 2014

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Yours Truly,
The Precision Detective

The 7th Thing That A California Investigator Needs…

from the worker's compensation adjuster is the last issued

Primary Treating Doctor's Progress Report (Narrative or PR-2)
or last medical report delineating any temporary or permanent work restrictions 

The Primary Treating Physician's (PTP) Progress report or (PR-2) is the standardized medical report format that a PTP is to report medical findings to the insurance company or designated claims administrator.  The PTP may submit a narrative report in lieu of the PR-2 form; however, pursuant to Title 8 California Code of Regulations Section 9785(f)(8), "If a narrative report is used, it must be entitled 'Primary Treating Physician's Progress Report' in bold-faced type, must indicate clearly the reason the report is being submitted, and must contain the same information using the same subject headings in the same order as Form PR-2."  The PTP must file a PR-2 or the narrative report at minimum of every forty-five days to the claims administrator.  The report is only to be filed by the Primary Treating Physician (PTP).  Secondary Treating Physician's must submit reports to the PTP in the manner requested by the PTP.  In a California Worker's Compensation claim there can only be one designated PTP.  The injured worker or the injured worker's attorney must select a Primary Treating Physician at the commencement of their claim.  The injured worker may change their PTP during the course of their claim; however, excessive changes are frowned upon.  The PTP is the only one of an injured worker's treating physicians that is technically able to determine an injured worker's disability, unless a dispute is initiated that requires an evaluation of the injured worker by a Qualified Medical Examiner or an Agreed Medical Examiner.

The PR-2 or appropriate narrative report can provide the claims investigator valuable information when conducting interviews, completing background investigations, and surveillance investigations.  The form is essentially separated into nine (9) sections of information.

In the first section the PTP must check the box or state in the narrative the reason that the report is being filed.  The options for the physician are as follows:

• Periodic report (required 45 days after last report)
• Change in treatment plan
• Released from care
• Change in work status
• Need for referral or consultation
• Response to request for information
• Change in patient's condition
• Need for surgery or hospitalization
• Request for authorization
• Other

The second section provides the patient's (injured worker's) demographics:

• Last name
• First name
• Middle Initial
• Sex
• Address
• City, State, & Zip Code
• Occupation
• Social Security Number
• Phone number

The third section provide the claims administrator's demographic and claim information:

• Name of the claims administrator
• Claim number
• Claims administrator address
• Claims phone number
• Claims fax number
• Employer name
• Employer phone number

The forth section is where the PTP relays what the injured worker's subjective complaints are relating to their experience of their claimed injury(ies).  Comments may include the frequency and intensity of any pain, numbness, or other physical symptoms.  This section may also include when and how these symptoms are increased or decreased such as with certain physical activities.  In addition, the clinician may describe what limitations as a result of their injury(ies) the injured worker has relayed to them.  The claims investigator can take the representations that the injured worker makes here and compare them with what the injured worker states in an interview with the investigator or perhaps what is depicted in surveillance video of the injured worker.

The fifth section is where the PTP includes any significant findings via their examination or review of records which are objective in nature.  Things such as tenderness, loss of strength, loss of range of motion, x-ray findings, other diagnostic testing findings (i.e. MRI, CT Scan, EMG/NCV, etc..).

The sixth section is were the PTP provides their diagnoses with associated ICD-9 coding. This is a section where the investigator may ascertain or confirm the claims injuries and/or body parts/systems claimed injured by the claimant.

The seventh section is the treatment plan section.  In this section, the PTP is to describe the medical treatment rendered to date, any current treatment, and any recommended future treatment.  The treatment plan should be described by the PTP listing the method, frequency and duration of the treatment.  The PTP should state the names of any contributing secondary treating physicians or the names of recommended consultations.  If there is any change in a previously prescribed treatment plan, the PTP must also describe the change and the reason for the change.  In this section, the investigator, may gain clues and leads for additional investigation for medical records at other facilities that may be obtained by the claims administrator or worker's compensation defense attorney.  In addition, this naming of other facilities may also serve the surveillance investigator in obtaining additional locations where surveillance may be undertaken.

The eighth section is the work status or disability section.

This section will indicate the injured worker's current disability status.  If the box "Remain off-work until ____" is checked than the injured worker is Temporarily Totally Disabled (TTD) and unable to work within the open labor market.  If the box is checked "Return to modified work on ________ with the following limitations or restrictions" the injured worker is Temporarily Partially Disabled (TPD).  This means they may return to some form of work within the prescribed work restrictions or limitations.  When conducting an interview of the injured worker, the investigator can determine if the injured worker is aware of their temporary work restrictions and question them on their compliance with the work restrictions prescribed by their PTP.  For the surveillance investigator, they may comment upon the injured worker's compliance with the work restrictions and to their physical observance of the them during discreet surveillance.  If the box is checked "Return to full duty on __________ with no limitations or restrictions" the injured worker is released to return to full duty work without limitations or restrictions.

The final or ninth section of the PR-2 is states the name and demographics of the PTP, their signature, and includes the mandated fraud declaration language pursuant to California Labor Code Section 139.3.  The demographics of the physician include the following:

• California License Number
• Place signature executed at
• Date of signature
• Name of physician
• Address of the physician's practice
• Phone number of the physician's practice
• Medical specialty of the physician

The PR-2 or PTP narrative progress report is another valuable resource for a claims investigator to utilize in the process of their investigation.

Thank you for reading the latest posting of this blog.  If this is your first time reading our blog, please check out our prior postings.  If this information was helpful to you, I encourage you to follow the blog and share it with your networks (see below for easing sharing).  You may also choose to follow my agency by liking the Facebook page at www.fb.com/PrecisionDetectiveServices.  You may also follow me on Twitter at @PrecisionPI.

Join us for the Los Angeles Sheriff Candidates Forum on April 23, 2014 at 7pm in City Hall. http://t.co/wJhs2wf01T http://t.co/z951yqe2ji

— HawaiianGardens City (@HawaiianGardens) April 22, 2014

L.A. District and South Bay/Long Beach District Election Meeting - @calipiorg @SecureView3 @SusteenTweet http://t.co/dzaNHWvTm7

— Ryan D. Clock (@PrecisionPI) April 23, 2014

The 6th Thing That A California Investigator Needs…

from their worker's compensation adjuster/examiner is an

EDEX and a Claims Index Report

So what is an EDEX?  EDEX stands for Electronic Data Exchange System.  This system is employed by the California State Division of Worker's Compensation as a means for permissible end users to request and receive data through purchase regarding worker's compensation cases that are under the jurisdiction of the California Worker's Compensation Appeals Board (WCAB).  The Worker's Compensation Appeals Board is the judicial administrative board that hears and resolves disputes on worker's compensatio cases between an applicant and the defendant insurance company or employer.  The WCAB also issues awards for benefits to those applicant's that are entitled to those benefits.

When I say "under the jurisdiction" of the WCAB, I mean only cases in which pleadings have been filed with the board (i.e. Application for Adjudication, Stipulation with Request for Award, Compromise & Release, etc.).  EDEX will only have data on cases in which these have been filed.  EDEX will not have any data on any claim that has not been filed with the WCAB.  Claims not filed with the WCAB may include incident only files (no medical treatment, no lost time), medical only files, files that do not have any settlement, and other new or ongoing indemnity claim files in which the claimant and the claims administrator may or may not be represented and have not filed any of the initiating documents named above.

Investigators may obtain the EDEX report from their adjuster clients but may also obtain them directly from the authorized approved vendors if they have a permissible reason.  See the vendors below (http://www.dir.ca.gov/dwc/edex.html)

Information brokers::

Company

Phone #

Fax #

Website Address

CompData EDEX & EAMS Services

P.O. Box 729
Seal Beach
CA 90740

(562) 493-4000

(562) 493-1550

http://www.compdataedex.com

Computer Services Group

1927 Harbor Blvd. #395

Costa Mesa, CA 92627

(800) 798-1880

(949) 646-7029

http://www.csg2000.com

EDEX Information Systems, Inc.

P.O. Box 665
Jackson, CA 95642

Toll-free

(866) GET-EDEX

(866) 438-3339

(209) 231-6700

http://www.edexis.com

Grey Wolf Laboratories Wolf Schubert

4006 Claitor Way
San Jose CA 95132

(408) 904-8731

http://greywolflabs.com

wolf.schubert@greywolflabs.com

Medical Lien Management, Inc.

P.O. Box 6829

Norco, CA 92880

(951) 808-3054

(760) 406-4807

http://www.dwcexchange.com/info@dwcexchange.com

SpeedComp EDEX & EAMS Services

P.O. Box 6886
Malibu, CA 90264-6886

(310) 457-3300

(310) 457-0500

http://wcabonline.com

Workcompcentral

1320 Flynn Rd.
Ste. 403
Camarillo, CA 93012

Toll-free

(866) WRK-COMP

(866) 975-2667

(805) 484-9322

http://www.workcompcentral.com

Inquiries are made with the EDEX system by submitting the claimant's Social Security Number and/or WCAB Case number (aka EAMS Number).  EDEX data can provide the following information:

Claimant's Name

Claimant's Date of Birth

Claimant's Gender

ADJ (EAMS #) or legacy WCAB Case Number

Body Parts Claimed

WCAB Current Case Status

The last five recent significant case events with dates.

A list of any hearings both past and future.

The official address record for each party to the case filing

Claims administrator

Insurance company if different from the claims administrator

Claimant's attorney

Defense attorney

Applicant's attorney or representative

Lien claimants

WCAB Jurisdictional Location (i.e. San Jose, San Francisco, Los Angeles, San Diego, etc.)

Date of the claimed injury

Type of injury (i.e. specific injury, cumulative trauma, occupational illness/disease)

The above vendors offer access to EDEX information as a fee for service.

The Division of Worker's Compensation also has a "free" public search tool to obtain similar information above but it is more limited in what it provides and depending on the credibility of the search criteria may not provide all available results.  This free search tool is called the EAMS (Electronic Adjudication Management System).

Information about the tool and its capabilities can be found at the following link:  (http://www.dir.ca.gov/dwc/eams/EAMS_PublicInformationSearch.htm)

The following is language is taken from the California DWC's Website regarding the public search tool:

"Requestors can search on all cases, including archived cases. If the case is archived the archived box will be checked on the general case information screen. If a Disability Evaluation Unit (DEU) case exists, the DEU box will be checked on the general case information screen. This is for informational purposes only—no DEU information is provided through this search.

Other criteria include:

Minimum search criteria is the EAMS case reference number or injured worker name

Partial name search is allowed

Date of birth, city, and ZIP code can be used with injured worker first and last name to refine search

Search result will be limited to 50 body part codes, active participants and events.

Since search results are limited to 50 it is best to be as specific as possible when searching. If the EAMS case number is not known, but the legacy case number is known, the EAMS and legacy case number lookup tool can be used to find the EAMS case number."

The search tool may be accessed by the following link:  https://eams.dwc.ca.gov/WebEnhancement/

On this screen the requester of the information must provide their information.  Their first and last name, a Uniformed Assigned Name (UAN) if one was assigned, their e-mail address, and then select a reason for their inquiry.  A private investigative firm will not likely have a UAN.  You would not have a UAN unless you have requested one.  These UANs are usually reserved for attorneys, law firms, insurance companies, and/or claims administrators.

After entering your information and clicking submit you will be brought to the next screen.  There are two tabs:  Case Search and Lien Search.  For the purposes of this blog posting we will only be presenting the Case Search tab.  There are six search fields.  Three of the search fields have an asterisk next to them.  At minimum you must enter an EAMS Case number or claimant's first and last name.  If you are searching by name you may input a partial name in either or both the first name or last name field.  The public information tool differs from the EDEX search in that you cannot search by Social Security Number.  In addition, as with all databases, if the incorrect information is initially entered or misspelled than it will be more difficult to find the information that you are looking for.

CLAIMS INDEX:

Obtaining a claims index report is a means to not only uncover prior worker’s compensation injuries but also uncover other personal injury claims that the claimant may have been involved with such as auto accidents, slip and falls, property claims, and general liability claims.   The claims index often also called ISO Claims Index because ISO is the largest vendor for this service.  The claims index is a database that many insurance companies and third party administrators subscribe to.  These members submit data on claims they receive from their insured, claimants and or third party claimants to add to the database.  Later they can search the database for claims history that may be pertinent to a current claim for the purposes of combating fraud, abuse, and mitigating loss on future claims that are filed.  One of the downsides of the index system is that not all insurers and claims administrations provide their claims data to the data base.

When a claim is submitted by an insurer or third party administrator the system searches the database and pulls claims information that matches any individual information or a combination of information submitted.  For example hits will be generated if there are matches in the claimant’s name, claimant’s address, claimant’s phone number, claimant’s date of birth, Vehicle Information Number, Vehicle license number, tax identification number, other parties to the loss, and/or the claimant’s Social Security Number.

Typically claims index information is only available to insurers, self-insured entities, and third party claims administrators.  That is why this information should be obtained from your client insurer, self-insured employer, or third party administrator.

For more information on the ISO Claims Index check out the following link: http://www.iso.com/Products/ISO-ClaimSearch/ISO-ClaimSearch-Facts-and-Figures.html

Why are the EDEX & the Claims Index Important for the Investigator?

Can be used to identify possible fraud.  Can be used with questioning a claimant regarding prior claims and injuries to see if they are forthcoming regarding those claims prior to asking them directly about them.  Can identify claims history that may not necessarily uncover fraud, but provide an apportionment to a preexisting disability.  Can be used to identify prior or concurrent employment.

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The 5th Thing That A California Investigator Needs…

from the claims adjuster is a...

Photograph Of The Claimant

Well if the adjuster does not have a photograph or copy of a photo ID of the claimant try to obtain one from the employer when you interview them.  In my investigations, I prefer to interview the employer contact or claimant's supervisor first prior to interviewing the claimant.  If the employer and the adjuster does not have a photograph available, obtain a physical description of the claimant prior to interviewing them from the employer.  Once you meet the claimant in person it is always best practice to verify your interviewee by viewing then scanning, copying or taking a photograph of the claimant's drivers license or other state photo identification.  I also recommend that you take current photograph of the claimant if they will allow you.  This is because some state photo identification cards have outdated photographs.  Be sure to also document the claimant's description, including what they wore for the interview in your investigation notes and in your report.

Below are some of the reasons you need to obtain a recent photograph of the claimant in the process of your worker's compensation investigation:

• To establish the identity of the claimant.
• To provide pre-subrosa intelligence to the surveillance investigator to aide in the quick identification of the claimant during a surveillance assignment.  This will reduce any wasted time and money trying to identify the right subject of the surveillance.
• For the adjuster or defense attorney to verify the claimant's identity at their deposition, medical appointments, and at WCAB appearances.
• To assist the investigator with their online investigations (i.e. Social Networking Searches) to identify the claimant in photographs, in profile pictures, and in online videos.  

If you would like to contribute any other reasons you feel that is necessary to obtain a photograph of the claimant, please share your thoughts in the comment section below.

Don't miss the next post in this blog series!  Subscribe to the blog below by clicking on the link "Subscribe by e-mail" and you will receive an e-mail notification each time there is a new post to The Precision Detective Blog.

I like to use what I call a bridge camera with a high optical zoom like the Nikon above for my investigation photo needs.  A bridge camera has the best of both worlds (the small size and high optical zoom for this type of point and shoot & the versatility of the SLR).

The 4th Thing That A California Investigator Needs…

to obtain from their claims adjuster [on a litigated claim] in the process of their worker’s compensation investigation is the:

Application For Adjudication Of Claim

The Application For Adjudication Of Claim, hereafter "Application" is the state form that an injured worker/claimant or their representative must file with the nearest local office of the California Worker's Compensation Appeals Board (WCAB).  The filing of the Applicant grants jurisdiction of the WCAB over the injured worker's/claimant's claim.  Once the Application is filed at the board the injured worker/claimant is often now called "the Applicant" by the work comp professionals.


One or more Applications are usually filed by the applicant's attorney after they are retained by the applicant to represent their interests against the claims administrator/insurer/employer before the WCAB.  However, there are some instances in which the claims administrator will file the Application in behalf of the injured worker with or without their consent or a service provider (aka Lien Claimant) may also file an Application if they have provided services related to an injured worker's compensation injury and they have not been paid in full or in part and they are seeking the WCAB's assistance in resolving the dispute.


To initiate proceedings before the WCAB for the collection of worker's compensation benefits the Applicant Employee or Lien Claimant must file the Application For Adjudication Of Claim with the WCAB within one year of the date of injury or within one year from the expiration of the period covered by payment of any worker's compensation benefits***, or within the last date in which benefits were provided (Labor Code Section 5405).  This section of the Labor Code is often referred to as the Statute Of Limitations Defense section.


The Application can be used by the investigator to inform and direct their investigation into the Applicant and their claims.  The Application may be used with other documents obtained or other non-document evidence obtained in the course of the investigator's investigation to corroborate the Applicant's claims or perhaps bring to light inconsistencies in the Applicant's claim.  The Application informs its reader about the employee demographics, their claims that includes the nature of injury(ies) they are claiming (cumulative versus specific), their claimed date(s) of injury(ies), their claimed employer at time of injury, the body parts or systems they are claiming injury or illness to, the claims administrator and/or insurance company(ies) claimed to have worker's coverage for one or more of the claimed injuries, and the Applicant's claimed earnings at the time of injury.


In addition, the Application informs its reader as to what disability the Applicant is claiming (see section or paragraph 4) and whether or not they were paid worker's compensation disability benefits for those disability periods.  Section or paragraph 6 inquire if State Disability or Unemployment Insurance Benefits have been paid to the Applicant.  Paragraph or section 7 inquires if medical treatment was provided to the Applicant and whether or not the employer or insurance carrier had provided the medical treatment.  If the employer or insurance carrier was not providing treatment, the Applicant may have been receiving medical treatment from their personal health insurance or State Medical Program (Medi-Cal) if hey are uninsured.   This informs the adjuster/examiner that they can possibly expect a Lien to be filed by EDD (Employment Development Department) in section 6 or by Medi-Cal Program or the Applicant's personal health insurance company as reflected in section 7 medical section.  Answers to section 6 and 7 will also provide the investigator of possible additional leads of information to pursue such as obtaining copies of benefit applications and medical information and records submitted to these respective programs that reflects what the Applicant has claimed to those program administrators and the respective medical providers they used in order to obtain those benefits from those programs.  The Application will tell you if the employee has filed any other Applications at the WCAB in section 8.  Finally, section 9 tells the adjuster or investigator what issues are disputed between the Applicant and the Claims Administrator/Employer.


Overall, the Application For Adjudication Of Claim is another resource available to the investigator for information that will inform and direct the investigator's investigation into the claim(s) of the injured worker/Applicant that will go towards the evidence needed by the adjuster so that they can make the proper decision regarding the Applicant's eligibility and extent of benefit due if eligible.

***  The Five (5) Benefits of California Worker's Compensation Benefits are

1.  Temporary Disability Benefits
2.  Permanent Disability Benefits
3.  Medical Treatment Benefits
4.  Supplemental Job Displacement Benefits
5.  Death Benefits

The 3rd thing that a California investigator needs…

to obtain from their claims adjuster in the process of their worker’s compensation investigation is the:

Doctor's First Report of Injury or Illness (Form 5021)

Within five days of an injured worker's initial medical examination, for every occupational injury or illness, the injured worker's Primary Treating Physician, hereafter referred to as the PTP must complete and issue this form.  If the injured worker changes their PTP, their new PTP will also need to complete this form.  The PTP must then send two copies of this report to the employer's workers' compensation insurance carrier or their worker’s compensation claims administrator.  If the physician fails to file a timely report it may result in assessment of a civil penalty against the physician.

The PTP is defined in the California Code of Regulations Title 8 Section 9785(a)(1) as, "the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter."  This PTP is the sole physician who is responsible for determining the injured worker’s disability status and managing the medical treatment.  A further description of the duties of the PTP can be found Title 8 CCR Section 9785.

The PTP can initially be selected by the employer, usually the physician at their designated industrial condition.  This is especially the case if the injured worker has not pre-selected their own personal physician prior to the date of the injury or the onset of illness.  If the injured worker has not predesignated their own personal physician to treat them in case of a work related injury and their employer has a State approved Medical Provider Network (MPN) in place, then the injured worker is required to treat with a physician within the Medical Provider Network.  If by chance the injured worker’s personal regular physician is in the MPN then the worker may select their physician.

Now we come back to the form itself.  The form is divided into twenty-seven sections.  The first twenty-six sections are numbered.   The final section has the doctor’s information and signature.  There is a wealth of information that can be obtained from a careful review of this document by the investigator.  This information can refute or corroborate other information obtained through your investigation.  While all the information may be important, I suggest the investigator focus on sections 5 through 26.  In these sections, you will uncover what the injured worker told the doctor, the date of time of the injury, where they were injured and how they were injured.   In box 16, the medical provider has to disclose whether or not they have treated the injured worker before.  Box 17 will list the injured worker’s subjective complaints (i.e. pain, numbness, dizziness, etc.).  Boxes 18 – 24 list the physician’s findings on their examination of the injured worker.  Things like objective findings (i.e. loss of range of motion, x-ray or MRI results, laboratory results, etc.), the physician’s diagnosis including assigned ICD-9 Diagnosis Codes, and whether or not the physician in his opinion feels that the diagnoses rendered are consistent with injured worker’s account of the injury.  Thereafter, the physician must disclose if there are any current conditions that will impede or delay the injured worker’s recovery from their work injury.  This is a place where the physician may disclose a non-work related condition such as diabetes, a condition which often slows down an injured worker’s recovery from an injury.  The physician then is to describe what treatment was rendered during the office visit (box 23) and then advise if any further treatment is recommended to cure or relieve the effects of the injury or illness (box 24).  In box 26, the physician has to provide the injured worker’s work status (the injured worker’s ability to return to work).  The physician will indicate if the worker is able to return to their regular job or whether or not temporary work restrictions are necessary and what those restriction are.  If the injured worker is not capable of returning to any work at the time of the evaluation, the physician will likely just write in this section either “off work” or “TTD” which means Temporary Total Disability.  Finally, the physician must sign the report, type or print their name and address and their degree (MD, DO, DPM, etc.), their medical license number, their Federal Tax Identification number, and their office or direct telephone number.

As a side note, the more claimant profile and background that you provide to the assigned adjuster/examiner regarding the claim you are investigating, the better their estimate will be for the claim’s reserves or the money that an adjuster allocates to a claim file for reasonable anticipated benefit and/or expense payments on that file.  This will make the actuaries, the employer’s, the insurance companies, and the state regulatory agencies happier when a claim is properly adjusted according to the principle of anticipated probable financial outcome.

If you have any questions or comments about the information contained in this blog, you can enter it in the section at the end of the post that says "Post A Comment."  If you have any ideas about future topics you can e-mail them to me directly at GetTruth@precisiondetective.com.

Please feel free to share this information with your friends or colleagues.

Stay tuned for the next installment of this California Worker's Compensation series by

The Precision Detective

The 2nd thing that a California investigator needs…

The 2nd document that a worker's compensation investigator should obtain from the claims adjuster before beginning their investigation is a completed Form 5020, known as the Employer's First Report of Injury or Illness.

Employer's First Report of Injury or Illness (Form 5020)

California law requires all employers to report to their claims administrator within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident or requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition to the completing of the 5020, every serious injury, illness, or death must be reported immediately by telephone or other means to the nearest office of the California Division of Occupational Safety and Health.  Once the Form 5020 is reported to the claims administrator, the claims administrator must report the information contained in the document to the California Department of Insurance via EDI (Electronic Data Interchange) per Title 8, California Code of Regulations Section 14002.

It is important for the investigator to note that this form contains confidential information that should only be disclosed to persons who are entitled to this information as per CCR Section 14300.35, 14300.30, & 14300.40.  The investigator should make sure they protect the confidential information from being disclosed to a party who is not permitted to view or learn of the information.

The Employer's First Report can provide the investigator a wealth of information to assist them in developing their investigation into the facts of the incident which resulted in injury or illness.  The form contains 39 boxes of information divided into three sections:  The Employer, The Injury or Illness, & The Employee.

In the employer section, the investigator should pay particular attention to box 4 and box 6.  Box 4 tells the reader of the document the nature of the employer's business.  Box 6 tells of the reader the type of employer (i.e. Private Employer or various public employers).  The nature of the employer's business (i.e. restaurant, hotel, construction company, etc.) will inform the investigator what range and types of employees the employer likely has working for them.  Knowledge of the employer type will assist the investigator in identifying possible special issues that will need to be investigated to provide the information to the adjuster so they may make the appropriate determinations on liability and benefit eligibility.  These issues may include (applicability of Educational Code Benefits, applicability of presumptions of injury for certain employee types, applicability of Labor Code Section 4850 benefits, etc.)

The second section is the injury or illness section (boxes 7-29).  This sections contains a wealth of information that can be used in the process of investigation.  Of course, I recommend the investigator verify the information contained in the document with the person who completed the document as well as independently corroborate the information from other sources.  This section tells the investigator and/or the claims adjuster the basic information relating date and time of injury, place of injury, whether or not there was any lost time, has the employee returned to work, when was the employer's first date of knowledge of the injury, whether or not any chemicals or equipment was involved in the injury, description of the activity the injured worker was performing at the time of injury, a description of how the injury or exposure occurred, the name of the physician or medical facility that treated the injured worker, and whether or not the employee was treated in the emergency room or if they were hospitalized overnight.  All of the information is crucial to the proper adjusting of a California Worker's Compensation claim.

The final section of the 5020 is the employee section (boxes 30-39).  The employee section provides basic demographic information for the injured worker that includes their name, date of birth, Social Security Number, address, phone number, employee status, usual work hours, occupational title, date of hire, salary/wages, and whether the injured worker is eligible for other means of compensation (i.e. tips, lodging, meals, bonuses).

The investigator should obtain a copy of this document from the employer if they did not receive one from the claims adjuster.

The Employer's First Report of Injury or Illness is one of the documents mandated by state law and regulation to be housed in a paper or electronic claim file and available for inspection by state regulatory audit agencies.

Should any of the readers have any questions about this document, please feel free to post your question to the blog or e-mail me directly.  Thank you for your interest in this subject.

Stay tuned for the next installment of this California Worker's Compensation Claim Investigator Series.  Should you wish to be notified of any new postings on this blog, please subscribe on the right hand column.

Leaving No Stone Unturned!

Ryan D. Clock, The Precision Detective

The 1st thing that a California investigator needs…

Welcome to the first installment of the California Worker's Compensation Blog Series for claims investigators and worker's compensation claims professionals,

" The 9 Things An Investigator Needs From Their Claims Adjuster "

The first thing an investigator needs to obtain from their claims adjuster or the employer if not available from the claims adjuster is the injured claimant's worker's compensation claim form or (DWC - 1) & Notice of Potential Eligibility .

DWC-1 (Click Here to View and/or Save Form for Reference)

California Labor Code Section 5401(a) states as follows:

"Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, which injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits under this division to the injured employee, or in the case of death, to his or her dependents."

Labor  Code Section 5402(a) states that "(a) Knowledge of an injury, obtained from any source, on the part of an employer, his or her managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400."

The California Worker's Compensation Claim Form (DWC-1) is the cornerstone form of the California Worker's Compensation System.  The filing of this form is meant to start the process into determining whether a claimant's claim for benefits will be accepted.  The provision of the claim form by the employer to a suspected injured worker and that injured worker's submission of that completed claim form to the employee begins the 90 day period in which the claims administrator has the opportunity to investigate the facts of the claim and make a determination whether to accept a claim or deny a claim in whole or in part.

The claim form (DWC-1) can provide the introductory information into the nature of the claim being made by the claimant or injured worker.  The claim form package including the notice of potential eligibility is divided basically into three sections.  The first section is the Notice of Potential Eligibility.  The notice of potential eligibility contains information in English & Spanish addressed to the injured worker regarding their rights and responsibilities under California Worker's Compensation law and describes benefits that the injured worker may be eligible for.  The second section is the employee’s section of the actual claim form, sections 1 through 8.  This section is only to be completed only by the employee or their authorized representative.  The third and final section is the employer’s section, sections 9-18.  The employer is to complete this section only after the employee has completed sections 1 through 8.  The employer is then to return a fully completed document copy to the injured worker and then also provide a copy to the employer's claims administrator.

It is imperative for the investigator and claims adjuster to verify the information contained in the Employee's Claim Form to make sure it is correct.  I recommend that an investigator and/or claims adjuster discuss the contents of the form with the persons who completed the form to verify the forms accuracy.  I also recommend that if a recorded statement is being taken of the claimant, that the claimant acknowledge on the recording what parts of the form that they completed and to acknowledge in the negative or affirmative that they read and understand the document inclusive of the Notice of Potential Eligibility Language.  Furthermore, I also make it a habit to have the claimant acknowledge the anti-Fraud statement which states as follows:

“Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony”.


This may elicit a guilty conscience for those claimant’s who may be misrepresenting their claims in whole or in part and may cause them to rethink the filing of their claim.


Join me next week for the next installment in this series to find out the 2nd thing you need prior to starting your investigation.


Until then,


Ryan D. Clock, The Precision Detective

New California Worker's Compensation Investigation Blog Series Announced

In my experience as a California Worker's Compensation Senior Claims Examiner I have learned that having the most appropriate and the most correct information is imperative in order to begin and end an investigation into a worker's compensation claim.  As a result, I have come up with at least 9 things an investigator needs from the claims adjuster prior to completing their AOE/COE or other associated worker's compensation claims investigation.


Therefore, I will be beginning this week I will be writing a weekly blog series entitled,

" The 9 Things The Investigator Needs From Their Claims Adjuster "

So come join this Truth Slueth weekly as I unpack these 9 things by subscribing or following my blog.  You can do so by signing into blogger, subscribing to the RSS feed, or subscribing by e-mail below.


Along the way you will have opportunity to make comments and/or ask some questions about the week's topic.  We can share personal stories as well as personal challenges.  I may also be able to provide you some insight into the realm of the claims adjuster and insight into why they do the things that they do or why they do not do the things you would expect them to do.


You can find me on twitter at @PrecisionPI, on Facebook as Long Beach Private Detective.  My website is currently under construction, but you can find it at www.precisiondetective.com.  You can click on any of the tabbed links above to take you those sites directly.


I look forward to seeing you participate in this and future blog series and posts.  Should you require more detailed response to a questions or require a consultation, you can reach me by phone at 562-502-7053 or at GetTruth@PrecisionDetective.com.


Get Truth!


The Precision Detective, Ryan D. Clock (PI 26879)

Welcome to the Precision Detective Blog

Welcome to my blog, "The Precision Detective Blog"!

Please come back later for some great content on issues facing the private investigator and the client's of private investigators, how to obtain the services of a reputable private investigator, stories from the field, and other exciting information.