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What to Do if Workers’ Compensation Claim Is Denied

Posted on March 21, 2024 in Workers' Compensation

Workers’ compensation is a no-fault insurance system in California that enables injured employees to obtain financial benefits for their medical bills and lost wages after an accident that takes place within the course and scope of their employment. If you file a workers’ comp claim and it gets denied, don’t lose hope. You can appeal the decision with help from a Los Angeles workers’ compensation attorney.

Common Reasons for Workers’ Comp Claim Denials

The first step is understanding the reason why your workers’ compensation claim was denied. Insurance companies are required to give claimants a specific reason for a denial in writing. Read your denial letter carefully to understand the grounds for the decision. You may also need to contact the insurance company or your employer to clarify any misunderstandings.

Common reasons include:

  • Insufficient evidence or proof of losses
  • Missing information
  • Missed filing deadline
  • Failure to properly report the injury
  • Failure to seek prompt medical attention
  • Lack of coverage for the condition
  • Dispute over the cause of the injury
  • Pre-existing injury or medical condition
  • Allegations of horseplay, misconduct or intoxication
  • Employment status or classification dispute

An experienced workers’ comp attorney can provide valuable insights into why your claim might have been rejected. A lawyer can seek a more detailed explanation of the denial from an insurer or employer. It may be possible to reverse the insurance company’s decision by providing the additional information needed or correcting issues with paperwork.

Appeal the Rejection

If you or your attorney cannot clear up the issue and reverse the denial through communications with the insurance company, you can proceed with the official appeals process. Begin by filing an initial appeal with the California Workers’ Compensation Appeals Board (WCAB). Do this by filling out and submitting the specific forms available on the WCAB website. 

You will need to fill out a Petition for Reconsideration, then mail or deliver it in person to one of WCAB’s district offices. You have a time limit of one year from the date that you receive your letter of denial to file this petition. Upon receipt, the WCAB will review the petition and case thoroughly to determine if the decision should be reversed based on the evidence provided.

The investigative process may involve you attending a hearing and appearing before a judge from the WCAB. The judge will hear your evidence and testimony as well as evidence from the insurance company before deciding to deny or request your Petition for Reconsideration. If it is denied, you can proceed to file a Writ of Review with the California Court of Appeals for a second review of your case.

Contact an Attorney

Appealing a rejected workers’ compensation claim in California can be complex. As an injured worker, you must abide by nuanced rules and regulations when filing a claim and appealing a rejection. Just one misstep could jeopardize your ability to recover financial compensation for your work injury.

Do not wait to consult with an attorney if your workers’ compensation claim in California has been denied. Time is of the essence, as you only have a specific window of time to appeal a denied claim. It is important to contact an experienced workers’ comp attorney as soon as possible. For a free case review, contact Rose, Klein & Marias LLP at (866) 674-5150.