Claims and Appeals
Claims
Benefits from the Supplemental Benefits for Industrial Injury Plan are not automatic. To apply for benefits, you must complete and sign the "Request and Application for Permanent Disability Advances Paid as Supplemental Benefits" form that you will receive from the Workers' Compensation Department upon becoming disabled due to an industrial injury.
If you submit a claim that is incomplete, you will be notified that an extension is needed and the additional information necessary to make a decision on your claim. Workers' Compensation (Claims Administrator) will provide this notice not more than 45 days after receipt of your claim. You will have 45 days to provide the other information necessary for the Claims Administrator to make a decision. The Claims administrator will make a decision on the claim within 30 days after receipt of this information or within 30 days after the expiration of your 45-day deadline to provide the information, whichever is earlier.
Once a full and complete claim has been submitted, the Claims Administrator may, due to matters beyond the Plan's control, extend its review of your claim for up to two additional 30-day periods if additional information is still needed. You must be notified before the end of the initial 45-day period, if an initial extension of up to 30 days is required and told why the extension is necessary and when the Claim Administrator expects to render its decision. If an additional 30-day extension period is required, you must be notified before the end of the first 30-day extension period and told why the second extension is necessary and when the Claim Administrator expects to render its decision.
If you believe you have been denied a benefit to which you may be entitled, you may appeal the claim to the Workers' Compensation Department within 45 days after you receive the denial by writing to the following address:
Pacific Gas and Electric Company
Workers' Compensation Department, B23H
Claim Administrator Appeals
Attention: Sr. Manager, Workers' Compensation Section
P.O. Box 7779
San Francisco, CA 94120-7779
No special form or format is required in submitting a written appeal; you may submit written comments, documents, records and other information relating to your claim. You may also request, free of charge, access to, or copies of, all documents, records and other information relevant to your claim for benefits. The review will take into account all comments, documents, records and other information submitted by you relating to your claim, without regard to whether such information was submitted or considered at the initial benefit determination. Please note, however, that it is the obligation of the Workers' Compensation Department to administer the Plan fairly, consistently, and in accordance with the provisions of the Plan.
If the Claim Administrator denies your claim, you will receive a written response which will include:
  • the specific reason(s) for the denial of the claim;
  • a reference to the Plan provision(s) which apply to the denial;
  • a description of any additional material or information necessary for a participant or beneficiary to perfect the claim and an explanation of why such material or information is necessary; and
  • a description of the Plan's review procedures and the time limits applicable to such procedures.