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<br />granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your
<br />request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon
<br />review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below.
<br />B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB,
<br />you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing,
<br />that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or
<br />offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request
<br />for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for
<br />review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your
<br />experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or
<br />12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later,
<br />except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of
<br />Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP).
<br />You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB,
<br />1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472
<br />(phone), 415.778.7272 (fax) and customerservice(a�wcirb.com (email).
<br />If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt
<br />of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action.
<br />After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether
<br />or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue
<br />a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB
<br />declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject
<br />your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C.,
<br />below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA
<br />94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax)
<br />and customerserviceawcirb.com (email).
<br />C. California Department of Insurance — Appeals to the Insurance Commissioner. After you follow the appropriate dispute
<br />resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the
<br />decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may
<br />appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of
<br />Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice
<br />rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no
<br />written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you
<br />sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance
<br />Commissioner is:
<br />Administrative Hearing Bureau
<br />California Department of Insurance
<br />1901 Harrison Street, 3rd Floor
<br />Oakland, CA 94612
<br />415.538.4243
<br />You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be
<br />affirmed, modified or reversed.
<br />III. Resources Available to You in Obtaining Information and Pursuing Disputes
<br />A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available
<br />at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B.,
<br />above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner
<br />pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway,
<br />Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at
<br />415.778.7159 (phone), 415.371.5288 (fax) and ombudsmanp_wcirb.com (email).
<br />B. California Department of Insurance — Information and Assistance. Information and assistance on policy questions can be
<br />obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions
<br />and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C.
<br />This notice does not change the policy to which it is attached.
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<br />HortaN
<br />RiskMmaganedDMsian
<br />REVIEWED & APPROVED BY. -
<br />Risk Management Analyst
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