There are several reasons why California workers’ compensation claims are denied, from missed deadlines to questions about whether an injury was work-related. Below are some of the most common reasons workers’ compensation claims are denied in California:
You have just 30 days from the date of your injury to report it to your employer. If you miss this deadline, you could lose the right to pursue benefits. This is true even if you have a completely legitimate claim involving an injury that is easy to prove is work-related.
There is also a deadline for filing a workers’ compensation claim – you must file a claim form within one year of the date of your accident, or the date you became aware of a work-related illness. If you miss the deadline, you might lose the right to pursue benefits.
Sometimes claims are denied because claimants were doing things that automatically disqualify them for workers’ compensation benefits. For instance, workers can be denied benefits for injuries that occurred when they were under the influence of drugs or alcohol. Workers could also be denied if their injury occurred during a fight they intentionally started or if they were injured as the result of a crime for which they were convicted.
Workers’ compensation applies to injuries that occur at the place where you work. This means if the injury occurs while you are commuting to or from work, it typically will not be covered by the workers’ compensation system. An exception to this is if you were off-site conducting business for your employer, like running to the bank to cash a check for your employer. Another exception could be if you were paid for your commute time.
Employers and workers’ compensation insurance companies may try to argue that your injury was preexisting and not a result of a workplace accident.
However, it is important to understand that you might not be disqualified from workers’ compensation benefits just because of a preexisting injury. If your injury was aggravated by your job, you could be entitled to compensation for the aggravation of your preexisting injury.
You should strongly consider working with a denied workers’ compensation claim lawyer who can work to ensure you receive fair compensation for the aggravation of your injury. Insurance companies may try to minimize your amount of benefits by saying the majority of the aggravation of your injury was the result of something outside of work.
You could have been participating in some sort of off-duty recreational activity with other people from work when the injury occurred. Generally, this type of injury would not be covered by the workers’ compensation system. However, if you were expected to participate as part of your job, you may be entitled to benefits.
Sometimes it is very difficult to fight a claim denial, such as if a deadline was missed. However, many of the other situations explained above are complicated. This is why you could benefit from having a denied workers’ compensation claim attorney at your side when you try to fight the denial of your claim.
When a workers’ compensation claim is denied, the applicant has the right to file an appeal. However, appealing a denied workers’ compensation claim is a complex process with many steps. Our denied workers’ compensation claim lawyers have detailed knowledge of this process, the paperwork that needs to be filed, deadlines, and what it takes to overturn a denial.
California law requires applicants to file this application with the California Workers’ Compensation Appeals Board (WCAB) within one year of the date of the injury or the date medical treatment ended.
You must file the Application for Adjudication of Claim at the Department of Workers’ Compensation (DWC) office in the county where you live or the county where the injury took place.
The application asks workers to provide basic information about themselves and their injuries, including:
A denied workers’ compensation claim lawyer can assist you in filling out this form and ensure it includes all the relevant information that could help overturn the denial of your claim.
Once your application is submitted, the DWC office will send a notice to confirm your application was received and filed. This notice will have an assigned case number started with the letters ADJ with a sequence of numbers. Make sure to include your case number on all documents and correspondence in your case.
Your employer can file an answer to your application within 10 days. Once that happens, you and your attorney, along with your employer can engage in discovery. In other words, both parties can begin preparing for a hearing by collecting evidence and preparing what they will present at the hearing.
State law requires both parties to attempt to settle the case before taking the next step of filing a Declaration of Readiness, which means both sides are ready for a hearing before a judge. The declaration asks you to identify the principal issues in your case, such as future medical treatment, temporary disability, permanent disability or employment. There is also a narrative section for you to explain the specific, genuine, good faith efforts you have made to resolve the dispute.
The hearing to resolve your dispute is also called a mandatory settlement conference, and it will be scheduled within 30 days of filing a Declaration of Readiness. At this conference, you will appear before a judge who will discuss the issues in your case and attempt to reach a settlement.
The two types of workers’ compensation settlements that can be agreed to are stipulations with request for award and compromise and release. This first involves a weekly amount of benefits. When these settlements are agreed to, claims administrators usually cover medical costs if care is still necessary. Compromise and release settlements do not pay out weekly benefits. Instead, you receive a lump sum that is meant to cover future medical care.
If you are unable to reach a settlement, the judge will schedule a trial before another judge. You are required to attend this trial. Both parties will present evidence and have witnesses testify. Within 30 to 90 days of the trial you will receive a written decision from the judge in the mail.
If the denial of your claim is not overturned, you can file a Petition for Reconsideration of the judge’s decision. You must file this petition within 25 days of receiving the judge’s decision in the mail. A denied workers’ compensation claim lawyer can help you add all the relevant information to the petition, including a statement of facts and a discussion of the law that applies to the situation.
The WCAB can decide not to accept your appeal within 60 days. However, if the appeal is accepted, the WCAB will either affirm, reject or amend the judge’s original decision or award. If you have additional evidence, you will be granted a hearing so these issues can be reviewed by the appeals board.
If your denial is upheld at this stage, your next option is to file a writ of review with the state appellate court. However, all the appellate court can do is consider if the decision from the appeals board was reasonable, based on the facts you presented. The writ of review must be filed within 45 days of the WCAB’s decision on your appeal.
Your only option after that is to file an appeal with the California Supreme Court. The court will decide whether or not to hear your case.
The denied workers’ compensation claim attorneys at our firm have in-depth knowledge of each stage of this process, including deadlines, filing requirements, and what we need to do to give you a chance of having a denial overturned. We are committed to pursuing the benefits you need for medical treatment and also to cover lost wages while you are unable to work.