How to File an Appeal

How To File An Appeal Under California Insurance Code Sections 11737(F), 11752.6(C), 11753.1(A) And 11753.1(B)

File an Appeal

Complete the Workers' Compensation Insurance Policy Appeal form and attach a Proof of Service for Workers' Compensation Appeal.

Remember: Before you submit an Appeal to the Administrative Hearing Bureau, you must submit a Complaint and Request for Action to your insurer or the WCIRB. California Code of Regulations, title 10, sections 2509.43, 2509.44 and 2509.45

The insurance carrier or the WCIRB must acknowledge your complaint and provide you with a written decision on your complaint that addresses each issue you raised. The insurance carrier and the WCIRB also must provide you with a notice of your appeal rights. You may then appeal the adverse decision by your insurance carrier or the WCIRB to the Insurance Commissioner by completing the Workers' Compensation Insurance Policy Appeal form.

Time for Filing Written Appeal to Commissioner.

Reference California Code of Regulations, title 10, section 2509.46.
The appeal must be filed within 30 days after insurance carrier serves you with:

1. a rejection of review of the Complaint and Request for Action or
2. a decision rejecting the Complaint and Request for Action or
3. a decision on reconsideration.

However, if the insurer or WCIRB fails to serve a written decision within the time specified in the regulations, the appeal must be filed within 120 days after you served the Complaint and Request for Action on the insurance carrier or WCIRB or within 60 business days after you served the insurance carrier or WCIRB with a Request for Reconsideration.

Form of Appeal and Information Required.

Reference California Code of Regulations, title 10, section 2509.47
An appeal shall be in writing and must include:

1. The name, address, telephone number, and fax number of the appellant;
2. the name, address, telephone number, and fax number of the appellant's representative, if any;
3. copies of correspondence between the appellant and the insurer and/or WCIRB regarding the subject of the appeal, to include complaints, responses, inquiries, initial decisions, Complaints and Requests for Action, acknowledgements, notices, and the written decisions of insurers and/or WCIRB;
4. a statement as to why the appellant believes the insurer's or WCIRB's decision or action is wrong;
5. any documents that support the appellant's position, which are reasonably available at the time of the filing of the appeal and upon which the appellant intends to rely at the hearing. The documents should be marked consecutively as provided in California Code of Regulations, title 10, section 2509.62(c));
6. a statement that the appellant has or has not filed a complaint with the Department of Insurance's Consumer Services Division requesting review of the same transactions, actions, or omissions which constitute the subject matter of the appeal. If such a complaint has been previously filed or is pending, the appellant shall provide the CDI's assigned file number.

Filing Requirements.

Reference California Code of Regulations, title 10, section 2509.48
An original and one copy of the appeal and two copies of supporting documents must be filed with the Insurance Commissioner at the following address via U.S mail or personal delivery:

Administrative Hearing Bureau
California Department of Insurance
1901 Harrison Street, 3rd Floor Mailroom
Oakland, Ca 94612

Service of the Appeal.

Reference California Code of Regulations, title 10, section 2509.49
The appellant shall serve a copy of the appeal on each respondent named in the appeal at the same time the appeal is filed with the Insurance Commissioner. Service of the appeal should be directed to the office designated by the insurance carrier or WCIRB for the receipt of appeals. If the WCIRB is not the named respondent, Appellant is instructed to serve a courtesy copy of the appeal by mail on the WCIRB. All served documents shall be accompanied by a copy of a Proof of Service. Service by first class mail, registered mail or mail delivery service is complete at the time of deposit with the carrier.

Service on the Insurance Carrier: Your insurance carrier is required to provide you with an address to which you may send your Complaint and Request for Action or Appeal from a decision on a Complaint and Request for Action. This information typically may be found in your insurance policy documents. However, you also may find the name and address of the persons your insurance company designated to receive Complaints and Requests for Action and Appeals on the CDI's website under the Consumer Tab/Licensee Information/Workers' Compensation Company Contacts.

Service on the WCIRB: Use the addresses for submitting the documents described.

Complaints and Requests for Action:

• Workers' Compensation Insurance Rating Bureau
  1901 Harrison Street, 17th Floor 
  Oakland, CA 94612
  Attention: Complaints & Requests for Action

Appeals:

• Brenda Keys, Senior Vice President - Legal
  Workers' Compensation Insurance Rating Bureau
  1901 Harrison Street, 17th Floor
  Oakland, CA 94612

Representation during the Appeal Process.

Reference California Code of Regulations, title 10, section 2509.52
An appellant may, but need not, be represented in the proceedings before the Insurance Commissioner. A representative need not be an attorney.