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?

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.

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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