Documente Academic
Documente Profesional
Documente Cultură
insurer conducts an audit or physical examination of the employers books a few months after policy
expiration. Insurers must then submit updated USRs, typically tracking developments in claim value
estimates, annually for nine more years, as necessary.
Premium Disputes
With these basic processes, laws, and procedures in mind, categories of common premium disputes
begin to emerge. Most premium disputes involve one (or more) of the following five issues:
1. Did the insurer use the correct USRP employment or industry classification(s), and therefore apply the
correct pure premium and deviated rates? If not, did the employer, agent, or broker report the wrong
classification(s)? Did the insurer use the wrong ones? Did the WCIRB assign the wrong ones? WCIRB
classification assignment changes that increase premium are usually not retroactive. Insurance Code
11753.2(b). By contrast, the USRP states that payroll reallocation among existing classifications on a policy
is retroactive to the policys inception. The USRP directly governs data reporting only, not premium.
Nevertheless, given this rule, courts are likely to find additional premium owed under these
circumstances unless the facts support contract law defenses.
2. Did the insurer report to the WCIRB, and use for premium calculation purposes, the correct amount of
payroll? Did the employer keep proper payroll records? If not, what is the appropriate remedy? How did
the insurer treat overtime, bonuses, expense reimbursement, housing allowances, and benefits? Did the
employer improperly characterize employees as independent contractors, or did the insurer treat
contractors as employees where the policyholder didnt obtain certificates of insurance from the
contractors?
3. Was/were the WCIRB-issued experience modification(s) correct? Did it/they reflect incorrect
classifications and/or payroll? Did it/they fail to recognize an ownership change, thus incorporating or
failing to incorporate certain data?
4. Did the insurers improper claims handling (inadequate investigation, passive acceptance of the
employees doctors evaluation, failure to pursue subrogation, etc.) result in the reporting of overstated
claim value estimates? Did the insurer fail to send to the WCIRB an USR update reflecting a WCAB take
nothing claim determination, or crediting an allocation or subrogation recovery? If so, one or more
experience modifications would have been too high. The result would have been excessive premium and
possible Cal/OSHA assessments, as discussed above.
5. Did the insurer previously accept the employers current arrangements on prior-year audits, but has
now changed its opinion of classifications, employment status, recordkeeping sufficiency, etc. and
therefore seeks substantial additional premium?
Insurers often point to CERP and USRP language to justify their additional premium demands, but these
regulations only pertain to data reporting requirements. Ordinary contract defenses such as estoppel,
custom and practice, laches, and negligence of the insurers agent and/or contract premium auditor may
protect the policyholder from an additional premium invoice, even if the CERP/USRP requires the insurer
to file a corrected USR with the WCIRB. Nevertheless, as discussed below, it may be necessary to navigate
CERP and/or USRP issues in an administrative setting before raising defenses in court.
Administrative Review
It is often difficult to determine whether an employer must or even should file an administrative appeal
with the WCIRB, or with the insurer, or concurrently with both, and then demurrer to a premium
collection action rather than simply filing a complaint, cross-complaint, or answer in court. Since failing to
file a timely administrative complaint may ultimately prove fatal to a cause of action or defense, counsels
initial false step may prove the first one toward a malpractice action.
A party may appeal a WCIRB or insurer decision to the Insurance Commissioner. Insurance Code 11737(f),
Title 10, California Code of Regulations, 2509.40. The Commissioners decision can then be appealed to
the Superior Court by seeking a writ of administrative mandamus under Code of Civil Procedure 1094.5
and Insurance Code 11754.5. The Courts have made it clear, however, that the Commissioner has broad
discretion in interpreting workers compensation premium rules. Simi Corporation v. Garamendi 109 Cal
App 4th 1496, 1 Cal Rptr 3d 207 (2003).
Employment Status Issues
Employers pay workers compensation premium for their employees only, not for independent
contractors. Similarly, experience modifications reflect wages paid to, and injuries sustained by,
employees only. It would therefore make sense that any premium dispute involving the alleged
employment status of workers would require administrative review. This is not the case, however.
If the dispute is whether individuals are employees, neither the WCIRB nor the Insurance Department will
determine whether the payroll an insurer reports to the WCIRB and the WCIRB uses for experience rating,
and which the insurer also uses to charge premium, is correctly reported and used. The Commissioners
right to refuse making this determination is currently being litigated. Whether insurers can use the
disputed payroll to calculate premium should not be an administrative issue, except perhaps on the
theory that an insurer violates its filed rating plans by doing so. The courts may nevertheless require that
administrative expertise be brought to bear on the issue under either the administrative exhaustion or
primary jurisdiction doctrines. Jonathan Neil & Associates, Inc., v. Freddie Jones 33 Cal 4th 917; 94 P.3d
1055; 16 Cal Rptr 3d 849 (2004)
Claim-Valuation Disputes
As the California Supreme Court noted in 2001, numerous Court of Appeals decisions have sanctioned
civil claims against workers compensation insurers alleging that their misconduct resulted in unjustifiably
higher premiums. State Compensation Insurance Fund v. Superior Court (Schaefer Ambulance Service,
Inc) 24 Cal 4th 930, 103 Cal Rptr 2d 662.
Its well-established, though, that that there is no administrative remedy concerning an insurers
substantive handling and valuation of workers compensation claims. This is so even though claimshandling directly affects the WCIRB-issued experience modification, which the insurer must use to
compute premium. Claims handling and valuation disputes that affect workers compensation premium
are a matter for the courts. Lance Camper Manufacturing Corp. v. Republic Indemnity Co. 44 Cal App 4th
194, 51 Cal Rptr 2d 622 (1996), Tricor California, Inc. v. SCIF, 30 Cal App 4th 230, 35 Cal Rptr 2d 550 (1994).
Punitive damages are recoverable for bad faith claims-handling causing inflated premium. A policyholder
who suspects claims-mishandling or improper valuation often experiences an initial challenge in gaining
access to the insurers claim file. Labor Code 3762 sets forth employer rights in this area.
Arthur J. Levine, Ph.D., J.D., CPCU, ARM - Workers Compensation Insurance Premium Attorney and Expert
Witness/Consultant
Copyright Arthur J. Levine, Ph.D., J.D., CPCU, ARM
More information about Arthur J. Levine, Ph.D., J.D., CPCU, ARM
Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended
to provide legal advice as individual situations will differ and should be discussed with an expert and/or
lawyer. For specific technical or legal advice on the information provided and related topics, please
contact the author.