3550 Wilshire Blvd., Los Angeles, CA 90010
310-555-5500

Current Workers' Compensation News & Articles

Authored By Workers' Compensation Attorneys

Workers’ Compensation Claim Denied? Here’s What to Know!

Accidents that occur at the workplace are bound to happen sooner or later, no matter how cautious you are. When you get involved in one, that’s the time when you think about filing a workers’ compensation claim.

But what if your claim comes back?

In other words, what if your claim was denied?

Is There a Way Out? The Short Answer Is Yes

States requirements for workers’ compensation claims may differ, but generally, employers need to have coverage of insurance to mitigate the average risk for the industry they are operational in.

Even if your claim comes back denied, there are recourse options. One of them is appealing the workers’ compensation claim through the state board.We will discuss the appeals process below.

Why Did You Get Denied Anyway?

But before we move to appeals, you should know why your worker’s compensation claim was denied. You need to find out why it was denied so you are better equipped for an airtight appeal. The denial letter explains why you were denied the workers’ compensation claim. Some examples of denial might be that you didn’t meet the eligibility criteria.

Maybe you were fooling around on the job and got injured, or not present at the workplace when the injury occurred. Here are four probable reasons why your workers’ compensation claim for benefits was denied.

1.The Employer Disputed the Claim

You may bring the workers’ compensation claim to the employer but they may deny it, saying that it didn’t happen in the business’ premises or say that you were being casual or fooling around at the time that the accident happened or something along those lines.

2.There Wasn’t Any Medical Treatment Done

When you want to become eligible for workers’ compensation benefits, sometimes, medical treatments need to be done and the receipts for those treatments need to be presented as well.

3.The Type of Injury You Have Cannot Be Compensated

Workers’ compensation claims for accidents at the workplace may be easy to prove, but the same is not true for stress related injuries. These are harder to prove in many states. California, however, has separate stress-related injury coverage.

Two more interrelated reasons for denial may be that the injury isn’t reported to your supervisor in time and the worker’s compensation claim wouldn’t have been filed in time. Both these times are determined by the state laws.

Appealing for Your Worker’s Compensation Claim

If your claim was denied, the denial letter should show the reason why your claim was denied. After receiving this letter, you have the legal right to challenge the rejection. Your letter should also mention the deadline to file your appeal. You can file your appeal in a corresponding Department of Industrial Relations office.

To have your case heard   by a judge, you will need to submit an Application for Adjudication of Claim. Your application should be filed at the office in the county where you live or your accident or injury occurred. It is also important that you submit your application to the other parties involved. In a majority of situations, this will be your workplace claims administrator.

Once the DWI office has received your appeal, you will be given notice that your application was filed. This notice will also include your case number. It is important that you keep your assigned case number on every document that relates to your case.

In order to obtain a hearing before a judge, you will need to file a Declaration of Readiness to Proceed. You will be scheduled for a case hearing known as a mandatory settlement conference.

How You Can Prepare For Your Hearing

During your scheduled hearing, the court judge will discuss the claim with you and your claims administrator in an attempt to reach a resettlement. If a settlement cannot be reached at the mandatory settlement conference, you will have to prepare documents that highlight your dispute. The judge will then schedule a date for a trial where you will have the opportunity to present evidence and witnesses to testify on your behalf.

The following are important documentation you may have the opportunity to present during a hearing or trial, however, you should know that depending on the specifics of your case, some documentation or information may be inadmissible.

1. Your Medical Record

Soon after you have been injured at work or have made the discovery of your ailment, you will need to seek medical care and treatment. If you do not treat your condition with a certified medical care professional, you run the risk of having a claim denial.

Delaying treatment can also be very damaging to your case. Simply waiting a few days after your injury can imply that either you did not have a serious injury or you made your injury worse by not seeking immediate medical care.

During your hearing, you can have a doctor provide a medical evaluation of your case. In many cases, this evaluation will be determined by a doctor recommended by the workers’ compensation insurance company.

2. Accident Report

If your injury occurred while you were at work, it is likely that you will file an accident report immediately after the accident report. This is important to demonstrate when the claims adjuster has denied you coverage for benefits by stating that your injury did not occur while you were at work.

When your injury was caused over a period of time, such as an illness or motor-skill ability, you will also need to notify your employer as soon as you are aware of the ailment. In the State of California, workers’ compensation claims need to be filed under a certain period of time. If your ailment has passed this period of time, you may be allowed an exception if you file a claim as soon as you found out about the ailment.

3. Unpaid Medical Bills and Other Treatment Expenses

Suffering an injury or ailment while you’re on the job can be very costly. Depending on the type of injury or sickness you have developed, you may need to undergo numerous medical treatments that may involve surgical procedures. Under your initial workers’ compensation claim, some of your medical treatments may be covered. If your claim was denied, you will need to pay for these costs out-of-pocket. Keep a record of your medical expenses so that you may fight for the compensation you deserve.

4. Record of Your Loss of Wages

If you sustained a serious and debilitating injury or illness, it is highly likely that you will not be able to return to work. The sudden loss of wages can put a large financial strain, which may affect your entire family. At your hearing, you should be prepared with a copy of prior pay stubs that indicate the amount of wages you have lost.

5. Your Employment Record

If your condition involves a sickness or injury that has developed over time, it is important to demonstrate an employment record that might demonstrate the progression of your ailment.

After You Have Been Denied Workers’ Compensation, Hire the Legal Services of a Qualified Attorney

Appealing a denied workers’ compensation claim is quite often a complex matter that involves many state regulations that could affect the outcome of your case. For instance, there are specific documents you may need to provide during your hearing and you may also need to provide a copy of these documents to the claims adjuster. Fortunately, you do not have to deal with the complexities of appealing a workers’ compensation claim – you have the right to hire an attorney who can represent your case and fight on your behalf.

If you are preparing to file an appeal for a rejected workers’ compensation claim, you will need to make sure you file the claim before the state imposed deadline. Although many workers’ compensation claim denials can happen because of a small misunderstanding or clerical error, that could be resolved without having to appeal, it is important that you speak to a qualified attorney who can protect your rights. A skilled workers’ compensation attorney will review your case and help you fight for the benefits you deserve.

The Los Angeles Workers’ Compensation Attorney is dedicated to protecting the rights and interests of injured workers. The firm has an established track record of successfully representing injured employees who have been denied workers’ compensation claims or have not been paid the full amount of benefits they deserve. The process after the appeal can be complex, and you need all the help you can get. So gather your relevant documents as evidence to address the denial. This evidence may be the medical receipts, a time stamp sheet showing you were, in fact, at work on that day or similar evidence. When your case will be bought before an administrative law judge at a hearing, consider getting  help from a workers’ compensation lawyer as well. Contact the Los Angeles Workers’ Compensation Attorney for a free case evaluation.