In this guide8 sections
The most common problems with California workers’ comp adjusters are delayed treatment approvals, late or miscalculated disability checks, unanswered calls, utilization review denials, unpaid mileage and pressure to settle early. Each has a legal deadline or rule behind it, and most can be pushed forward with written requests, the right form or a hearing. If a delay is unreasonable, the law allows a penalty of up to 25% of the delayed benefit, capped at $10,000.
Key takeaways
- Your adjuster works for the insurer or employer, but must investigate your claim fully and fairly and deal with you in good faith (Cal. Code Regs., tit. 8, §10109).
- Temporary disability (TD) is generally due within 14 days and then every two weeks. Late payments are generally increased by 10% automatically (Labor Code §4650).
- A timely utilization review (UR) denial is challenged through Independent Medical Review (IMR), which you must request within 30 days.
- No workers’ comp settlement is valid until a workers’ comp judge approves it (Labor Code §5001).
- Put every request in writing and keep a log. Your records are your leverage.
What your adjuster is required to do
The adjuster (also called the claims administrator or claims examiner) handles your claim for the insurer, a self-insured employer or a third-party administrator. California’s claims-handling rules still set a baseline. Under 8 CCR §10109, the claims administrator must conduct a reasonable and timely investigation, gather information that supports paying benefits as well as information that doesn’t, look at other benefits your claim suggests may be owed, and deal fairly and in good faith with you.
Other key deadlines apply from the start. Once you turn in a claim form, the employer must authorize treatment within one working day, up to $10,000, until the claim is accepted or rejected. If the claim isn’t rejected within 90 days, the injury is presumed covered (Labor Code §5402(b), (c)).
The six most common problems and what to do
| Problem | The rule | What to do |
|---|---|---|
| Treatment delayed | Routine UR decision within 5 business days, never more than 14 days after the doctor’s recommendation; 72 hours if urgent | Confirm your doctor sent an RFA; ask for the decision in writing; consider an expedited hearing |
| TD late or wrong amount | First payment within 14 days, then every two weeks; 10% automatic increase if late | Request your payment history and wage calculation in writing |
| No response to calls | Duty of timely investigation and good faith | Switch to email or letters; contact a DWC Information and Assistance officer |
| UR denial | IMR request within 30 days of service of the UR decision | File the IMR form sent with the denial; ask your doctor for supporting records |
| Mileage unpaid | Medical travel reimbursed at the state rate | Use the DWC mileage form; contact I&A if unpaid after 60 days |
| Pressure to settle | Every settlement needs a judge’s approval | Don’t sign until you understand your rating and future medical needs |
1. Delayed medical treatment
Most treatment goes through utilization review. Your treating doctor submits a Request for Authorization, and the claims administrator generally must decide a routine request within 5 business days of getting the information it needs and never more than 14 days after the doctor’s recommendation. Urgent requests must be decided within 72 hours (Labor Code §4610(i)). If no decision arrives, or the adjuster ignores approved care, you may be able to ask a judge to order it through an expedited hearing.
2. Late or miscalculated disability payments
TD is generally two-thirds of your average weekly earnings, within limits set each year. For injuries in 2026, the TD minimum is $264.61 and the maximum is $1,764.11 a week. The first payment is generally due within 14 days after the employer knows about the injury and disability, and later payments every two weeks. A late payment is generally increased by 10% automatically (Labor Code §4650).
Wage errors are common. Average weekly earnings can include overtime and earnings from all your employers, and adjusters sometimes use only base pay from one job. Check the math with our workers’ comp benefits calculator and see temporary disability benefits.
3. Poor communication
Unreturned calls can stall everything else. Move to writing: email or letters create a record of what you asked for and when. If the problem is a pattern of claims-handling violations, you can file a complaint with the DWC Audit Unit using its complaint process. The Audit Unit tracks complaints and enforces claims-handling laws, but it doesn’t resolve benefit disputes. Those go to the Workers’ Compensation Appeals Board (WCAB).
4. Utilization review denials
A UR reviewer can deny or change your doctor’s request without examining you. If the UR decision was made on time, the way to challenge it is IMR, and you must request IMR within 30 days after service of the UR decision. The denial letter should include the IMR application form. Ask your treating doctor to explain in the record why the treatment is needed. Learn more about independent medical review.
5. Mileage reimbursement
Travel to your doctor, physical therapy, the pharmacy and medical-legal exams is reimbursable. As of July 1, 2026, the rate is 76 cents a mile. The DWC’s mileage reimbursement form tells you to send the original to the insurance company, keep a copy and, if your travel costs aren’t paid within 60 days, contact the Information and Assistance officer. See mileage reimbursement for workers’ comp appointments.
6. Pressure to settle cheaply
An adjuster may call with an offer before your doctor has found you permanent and stationary, or before you understand your permanent disability rating. No compromise or release is valid until a workers’ comp judge or the appeals board approves it (Labor Code §5001), and the WCAB must look into whether a settlement is adequate. A compromise and release usually closes your future medical care, so the stakes are high. Read should I accept my workers’ comp settlement offer? before you sign.
A hypothetical example
Carlos hurts his back on a construction site. His TD checks come every three weeks instead of every two, and each is based on his $28 base rate, though he regularly worked overtime. He starts emailing the adjuster instead of calling, asks for a written wage calculation, and attaches his pay stubs showing overtime. If the adjuster still doesn’t correct the rate, a judge can decide the correct TD amount, and the late payments may carry the automatic 10% increase.
Penalties for unreasonable delay
When payment of any benefit is unreasonably delayed or refused, Labor Code §5814 allows the judge to increase the delayed amount by up to 25%, or $10,000, whichever is less. That covers treatment, TD and other benefits. A penalty isn’t automatic. You or your lawyer must raise it, and the judge decides whether the delay was unreasonable.
Keep a claim log
- Date, time and summary of every call, and the adjuster’s name
- Copies of every email, letter, RFA, UR decision and IMR filing
- Every TD check with the dates it covers and the date it arrived
- Pay stubs from all jobs for the year before your injury
- Mileage forms and the date you sent each one
Frequently asked questions
Can I get a different adjuster?
The insurer decides who handles your file, so you generally can’t pick your adjuster. You can ask a supervisor to step in, put your requests in writing and use the hearing process when deadlines are missed.
Who do I complain to about my adjuster?
For claims-handling violations, the DWC Audit Unit accepts complaints. For a dispute over benefits, such as treatment or TD, the WCAB decides. The DWC’s Information and Assistance Unit gives free information to injured workers.
Does my adjuster have to tell me about all my benefits?
The claims administrator must investigate fully and fairly, including other benefits your claim suggests may be owed, and deal with you in good faith. Don’t rely on the adjuster as your advisor, though. The adjuster works for the payer.
What if my TD check is late?
A late TD payment is generally increased by 10% automatically. If delays continue, a judge may award a penalty of up to 25% of the delayed amount, capped at $10,000, under Labor Code §5814.
Should I give the adjuster a recorded statement?
You may be asked to. Stick to facts you know, don’t guess about medical issues and ask for a copy. If you have a lawyer, talk to them first.
Talk to a California workers’ comp lawyer
Employees First Labor Law represents workers exclusively, including injured workers dealing with difficult adjusters. We offer free virtual consultations to review your claim log, benefit payments and options. Contact us online or call (310) 853-3461.
This article is general information about California law as of 2026, not legal advice for your situation. Reading it does not create an attorney-client relationship.
