You Do Not Have to Accept Workers’ Compensation Denials: Learn What Legal Recourse Might Be Available to You
If your workers’ compensation claim has been denied by your employer’s insurance carrier, there are actions you can take – and DLC Law at (626) 285-8815 can help you. Keep reading to learn what your options are and then contact us to speak with a Board Certified Workers’ Compensation Specialist by the State Bar of California.
Requesting a hearing before a judge on the Workers’ Compensation Appeals Board
You can appeal a claim denial in California by requesting a hearing before a judge on the Workers’ Compensation Appeals Board. The judge can hear both sides of the issue at the hearing (which is similar to an informal trial) and decide whether the insurance company must accept your workers’ compensation claim.
Why are worker’s compensation claims turned down?
For a variety of reasons, workers’ compensation insurance companies refuse claims. Some insurance firms regularly refuse early workers’ compensation claims in the hopes that many wounded workers would quit the case rather than pursue it.
Other insurance firms will accept genuine claims but refuse to cover claims they don’t feel they should. The following are some valid reasons why a workers’ compensation claim may be denied:
- Your injury was not work-related (i.e., it was not caused by work-related activity and did not occur during work-related tasks
- Your injury was caused by your employment with another company
- Your injuries did not require medical care
- You did not require time off from work as a result of your injury
Fighting a workers’ compensation claim denial
You’ll need to request a hearing before the Workers’ Compensation Appeals Board to get the insurance company to accept your workers’ compensation claim (WCAB). Yours will be a “trial on the preliminary issues” because your disagreement with the insurance company is about whether your claim is “compensable” — that is, whether your injury is covered by worker’s comp and whether the insurance company is liable for the claim.
You (or your lawyer) will need to file a Declaration of Readiness to Proceed in order to obtain a hearing before a WCAB judge (DOR). However, you must first file an Application for Adjudication of Claim, which is part of your formal claim and provides you with a worker’s compensation case number. As your attorney we will take care of all of this on your behalf.
Conference of priority
If the insurance company denies your claim because it doesn’t believe your injury “arose out of employment” that is, your injury was not likely caused by your work activity or happened “in the course of your employment” that is, the activity that caused your injury was not work-related, the WCAB judge will schedule Priority conference. If your claim was refused by the insurance carrier due to either of these issues, mark the boxes “Priority Conference” and “AOE/COE” on your Declaration of Readiness to Proceed form.
If your rejection wasn’t based on the above issues—for example, if the insurance company doesn’t feel you require medical treatment or are entitled to temporary disability benefits for time off work—a pre-trial conference may be set after you file the Declaration of Readiness to Proceed form. A notice of hearing should arrive in the mail, including the date, time, and place of the hearing. The workers’ compensation judge will assist you in resolving the question of whether the claim should be accepted or refused during the conference.
If the dispute cannot be resolved, the court will order a trial — or, if additional information is required before a trial can proceed, the judge will set up a “discovery plan” to gather evidence to resolve the issues in your case. In that instance, the court may call a status conference to determine if the evidence uncovered is sufficient.
The pre-trial meeting is where many disagreements over whether a claim should be accepted or refused are resolved, and most claims that reach this stage are accepted by the insurance company.
If the insurance company is refusing your claim due to medical concerns, you’ll need to contact a doctor to have your injuries or sickness examined before a compensability hearing. You can obtain a med-legal examination from another doctor if you are dissatisfied with your treating physician’s assessment. If your insurance company is dissatisfied with your treating doctor’s opinion, you may be asked to submit to a med-legal examination by another doctor.
If you don’t have an attorney, you can pick from a list of Qualified Medical Evaluators (QMEs). If you have a workers’ compensation attorney, your lawyer and the insurance company may agree to pick a medical examiner together (AME).
Obtaining legal assistance
If your claim has been refused (that is, the insurance company contests your claim’s compensability) and your injury is serious, you should consult a worker’s compensation attorney as soon as possible. If you lose on the compensability issue, you won’t be eligible for any workers’ compensation benefits, such as payment for medical treatment, lost wages, or a monetary award for a permanent disability that makes it difficult for you to compete in the job market.
Workers’ compensation attorneys in California are paid on a contingency basis from any workers’ compensation claim you obtain (i.e., if you do not win an award, the lawyer is not paid). Contact DLC Law at (626) 285-8815 to see how we can help.