Workers’ compensation in California is designed to provide insurance coverage for workers who are injured or become ill due to conditions at work. Medical bills and lost wages are supposed to be paid without the employee needing to prove the employer was at fault. In turn, the employer cannot claim workers were negligent and responsible for their own injury. Sounds simple. Unfortunately, it can get complicated when the insurer denies the claim.
Reasons Workers Comp Claims are Denied
Rarely, the reason for a denial of a claim is simply because some paperwork was missing or a form filled out incorrectly. That is an easy fix. There are some insurers who are known to deny almost all claims under a theory that the worker will be intimidated and not pursue compensation after the denial. There are other common reasons why insurers deny workers’ compensation claims. The most common reasons are:
- The insurer claims the injury or illness was not work-related or did not happen while the employee was engaged in work-related duties.
- The injury occurred while the worker was working for a different company.
- The injury was not serious enough and you should not have required medical treatment.
- The injury was not serious enough and you should not have missed time off from work.
If your initial claim for damages is denied, you should contact a worker’s compensation attorney who will know what to do and help you find your way through the legal maze.
Workers Comp Appeals Process
Pay careful attention to the date on the letter you receive denying your claim. It should explain to you how you can file an appeal and tell you when the deadline for filing it is. Deadlines are often short and there is generally no exceptions. You miss the deadline, you lose your right to appeal.
In California, there are several steps to the appeals process. The first one is to request the Worker’s Comp Appeals Board (WCAB) to grant you a hearing that will be presided over by a workers’ compensation judge. The request is made by filing an Application for Adjudication of Claim. Your case will then be assigned a case number.
Next, you file a Declaration of Readiness to Proceed (DOR). A pre-trial conference may be held with you, the insurer and the judge with a goal to settling the issue. If you and the insurer cannot resolve the dispute, a trial will be calendared.
Before trial, if the denial was due to the insurer questioning your medical needs, you will need to have your medical situation evaluated by a treating physician. The insurer will almost certainly order an exam by a doctor of their choice. If you have an attorney, the attorney and your insurer will be able to choose a medical examiner jointly with your insurer. If you do not have an attorney, you will be allowed to choose a physician from the insurers list of qualified medical examiners.
At trial, which you are required to attend, your attorney and the insurer will present evidence. Witnesses will be called to testify. After the trial, the workers’ compensation judge will issue a written opinion either granting your claim or upholding the insurer’s denial. The decision is generally handed down within 30 to 90 days after the end of the trial. If either you or the insurer objects to the judge’s written decision, you can Petition for Reconsideration.
A Workers’ Compensation Attorney Can Help
If your initial claim was denied, whether or not you receive any compensation for your injuries depends on the success of your appeal. If you lose your appeal, you will be responsible for paying all your medical bills. You will not receive any reimbursement for wages you lost due to the time you had to be off of work due to your injury. If you need physical or job rehabilitation, you will have to pay for it yourself.
With so much at stake, you need the assistance of experienced workers’ compensation attorneys to pursue your claim through the appeals process. The law does not allow them to charge you unless you win your case and then they are limited to a percentage of the amount you are awarded.