Suffering an injury on the job can be a life-altering experience. Workers’ compensation benefits act as a crucial safety net for employees who suffer injuries or illnesses while on the job. In California, employers are required by law to provide workers’ compensation benefits to their employees, regardless of fault.
However, some employers and insurance companies may deny workers’ compensation claims for different reasons. A denied claim can be a frustrating experience for workers who are already dealing with the impact of their injury.
It is important for workers to know that they have options to appeal the denied claim and potentially receive the benefits they deserve. The appeal process can be challenging, but with the help of an experienced attorney, workers can proceed forward.
Reasons for denied claims
There are various reasons why your workers' compensation claim could be denied. Understanding these reasons can help employees avoid the risks of making a mistake and help protect their rights in the event of a work injury. Your workers' compensation claim may be denied for the following reasons:
- Pre-existing conditions: Your workers’ compensation claim may be denied if you had a pre-existing injury or illness that is non-work related. Your employer or insurance company may argue that the injury was caused by your pre-existing condition rather than a work-related activity.
- Failure to report injury or illness on time: When you are injured on the job in California, it is mandatory to report the injury to your employer. You must report it within 30 days; failure to do say can result in a denied claim.
- Missed deadlines: For a workers’ compensation claim, California workers must file within one year. If an employee fails to do so, their claim may be denied. There are other deadlines that apply to various stages of the process – which is why it’s important to have an attorney who knows the process handling your claim.
- Insufficient or lack of evidence: With all claims, it is critical to have strong evidence in support. This can include medical records, prescriptions, and anything that proves how your injury happened and the effects it has had on you. Without adequate evidence, your claim may be denied.
- Intoxication: If the employee was intoxicated at the time of the injury, and the insurance company can prove this was the cause of the injury, they can deny the claim on that basis.
- Intentional injury: If the insurance company can prove that you deliberately injured yourself, they can deny your claim. This also applies to injuries sustained in a fight that you started.
If your claim is denied for any of the reasons above, you do have options. A denied workers’ compensation claim doesn’t necessarily mean you won’t receive benefits. You can fight to reverse that decision by appealing the claim.
How to appeal a denied claim
If your claim has been denied by the insurance company, you can fight the denial through adjudication and appeal. Note that at any stage, it’s also possible to negotiate a settlement.
Requesting a hearing
The first step in the appeal process is requesting a hearing by filing a form to your county’s Division of Workers’ Compensation (DWC) office. This form is called the Application for Adjudication of Claim. The DWC may also request additional supporting documents to be sent in with your application. Once the DWC office has received this form your case will be assigned a number that begins with the letters “ADJ”.
Pre-hearing
Now you’ll be able to file a Declaration of Readiness to Proceed. This is how your hearing will be scheduled. With this form, you’ll have to select the type of hearing you want. In that section, you’ll want to choose “mandatory settlement conference” (MSC). You’ll also be able to provide details of any issues you have with your claim such as compensation amount.
You can also request to be re-evaluated by a qualified medical evaluator (QME) or an agreed medical examiner (AME). These licensed medical professionals can provide an objective assessment of your injuries. The re-evaluated assessment can carry significant weight in determining the legitimacy of your claim and provide valuable evidence to support your appeal.
Hearing
At the hearing, you and your claims administrator will appear before a judge. If you have an attorney, they will also be present. The goal of the MSC is to have both parties come to a settlement agreement. If this is the case, it will be put in writing and submitted to the workers’ compensation appeals board for approval. If your case is not settled, it has the option to go to trial.
Trial
If your case proceeds to trial, a judge will issue you a trial date. During the trial, you and your legal team will present your side. You may have witnesses testify in support of the case. This trial judge (different from the hearing judge) will issue a written decision between 30 and 90 days after the trial. The written decision will be sent to you via mail. If you still disagree with the judge's decision, you have further recourse through the WCAB.
Petition for Reconsideration through the WCAB
To continue with the appeal process, you must file a petition. This process is handled by the Workers’ Compensation Appeals Board (WCAB). You or your attorney will file a Petition for Reconsideration form with the WCAB within 20 days of the date the trial decision was issued. The form should include a detailed explanation of the issues you are disputing, as well as any supporting evidence or legal documents you wish to add.
After the petition is filed, a WCAB commissioner will review the case and issue a decision – legally, this is supposed to be within 60 days, but the WCAB often issues “grant and study” orders to functionally extend the deadline.
Appeals to State Court
If you disagree with the WCAB’s decision, then you can file a Writ of Review to appeal the case to the California Court of Appeal. Decisions of the California Court of Appeal can be further appealed to the California Supreme Court. Note that any issue mentioned in the Writ must have also been in the Petition for Reconsideration – the court’s job is to review the process of the WCAB’s decision, not to consider new evidence or new issues.
An attorney can explain whether filing an appeal to state court makes sense in your case.
How a workers’ compensation attorney can help you with your denied claim
There are many steps and different paths when it comes to facing a workers’ compensation claim dispute. The process can be complicated and confusing to navigate. That’s why many injured workers seek the help of an experienced California workers’ compensation attorney.
To employees who are appealing a workers’ compensation claim, an attorney can assist with any part of the process. Some ways a lawyer can be of help include:
- Provide expertise and legal advice
- Collect and present evidence
- Representation at hearings
- Negotiating settlements
- Filing appeals and other paperwork
If you’ve sustained an injury or illness on the job in California, get in contact with an attorney today. Don’t let a denied claim tear you down. Schedule a free consultation today.
