Reasons for Claim Denial
Claims can be denied for several reasons, including but not limited to:
Insufficient Evidence:
The insurer may argue there is not enough medical evidence linking the injury to the workplace.
Discrepancies in the Claim:
Inconsistencies between the injury report and medical records, or delays in reporting the injury, can lead to a denial.
Non-Work-Related Injuries:
The insurer may claim that the injury occurred outside of work or is related to a pre-existing condition.
Late Reporting:
Failing to report the injury promptly can result in a denial. California law typically requires employees to notify their employer within 30 days of the injury.
Employment Status Disputes:
If there is a question about whether the claimant was an employee or independent contractor, this can impact the claim’s validity.
Steps to Handle a Denied Claim
If your workers' compensation claim is denied, you should take the following steps to seek a resolution:
Review the Denial Notice:
Carefully read the denial notice sent by the insurance company. It should explain the reasons for the denial and the evidence considered. Understanding the basis of the denial is crucial for addressing the issue.
Request a Case Conference:
Contact the claims adjuster or your employer to discuss the denial. A case conference can sometimes resolve misunderstandings or provide an opportunity to submit additional information.
Obtain Legal Representation:
Consider consulting with a workers' compensation attorney, especially if the denial involves complex issues. An attorney can provide expert advice, represent you in proceedings, and help gather the necessary evidence to support your claim.
File an Application for Adjudication:
Submit an Application for Adjudication of Claim to the Workers' Compensation Appeals Board (WCAB). This formally begins the appeal process and allows for your case to be reviewed by a judge.
Attend a Mandatory Settlement Conference (MSC):
The WCAB will schedule a Mandatory Settlement Conference, where you and the insurer will discuss the possibility of settling the claim without a trial. This step can often lead to a resolution.
Prepare for Trial:
If the case is not settled during the MSC, it will proceed to trial. Gather all necessary documentation, including medical records, witness statements, and any other evidence supporting your claim. An attorney can help prepare and present your case effectively.
Appeal the Judge’s Decision:
If you disagree with the judge’s decision, you have the right to appeal. File a Petition for Reconsideration with the WCAB within 20 days of receiving the decision.
Resources and Support
To assist you through the process, consider the following resources:
California Department of Industrial Relations - Division of Workers' Compensation:
If you disagree with the judge’s decision, you have the right to appeal. File a Petition for Reconsideration with the WCAB within 20 days of receiving the decision.
Workers' Compensation Appeals Board (WCAB):
Offers guidance on filing an appeal and the adjudication process. WCAB Information
California Applicants' Attorneys Association (CAAA):
A professional organization that can help you find experienced workers' compensation attorneys. CAAA
This memo provides an informational guide to understanding denied claims under California's workers' compensation system and it is not intended as legal advice. For any specific legal advice or assistance, please contact our highly competent and knowledgeable attorneys.