If you were injured at your place of work or while carrying out any duties that benefitted your employer/were covered in the scope of your work, you will likely be covered by your employer’s workers’ compensation insurance. Workers’ compensation is a no-fault system (meaning you do not have to prove that anyone was negligent) that provides eligible employees with medical benefits, wage replacement benefits, and retraining/job rehabilitation benefits.
However, workers’ compensation claims are sometimes denied—but that does not mean you are out of options. You can still file an appeal through your state’s board of workers’ compensation. If you believe your workers’ compensation claim was wrongfully denied, we encourage you to contact our workers’ compensation attorneys. Filing an appeal is a complex legal process; it’s important that you have an attorney on your side who can help you at each stage of the process.
Why Was My Workers’ Compensation Claim Denied?
There are many reasons a workers’ compensation claim may be denied. Sometimes, claims are denied due to errors on application forms or because employees miss important deadlines in reporting their injuries and filing their claims. Other times, workers’ compensation claims are denied because an employer disputes the validity of the claim or argues that the employee’s injuries are no work-related. Before moving forward with an appeal, you should understand why your workers’ compensation claim was denied.
Some of the most common reasons for claim denials include:
- You failed to report the injury in time: After sustaining an injury at work, it’s important that you report it to your employer (or supervisor) as soon as possible. In any case, in California, you must report a work-related injury within 30 days of it occurring and you must report a work-related condition within 30 days of receiving a diagnosis from a qualified medical provider.
- Your claim was not filed in time: Once again, it is critical to be aware of deadlines. In California, your employer is required to provide you with a workers’ compensation claim form (Form DWC-1) within one working day of you reporting the injury/illness. You have one year from the date of the injury (or diagnosis) to file your workers’ compensation claim in California.
- Your employer disputes your claim: In some cases, an employer might dispute the claim. For example, he or she might say that the accident occurred outside of work, was not work-related, was caused by your own negligent actions, or involved some other disqualifying set of circumstances.
- The injury you sustained cannot be compensated: Some injuries, including those that are stress-related, can be harder to prove than others. Additionally, injuries sustained at company events, such as holiday parties, may not be covered. It’s important that you understand whether or not your injury is a qualifying one; contact our workers’ compensation attorneys for more information.
- You did not seek medical treatment: Failing to seek medical treatment after a work-related injury could result in issues with your claim. Your employer/employer’s insurance company may use this as grounds to disqualify you from benefits, citing the fact that you didn’t see a doctor as evidence that you did not sustain an injury or that your injury was not serious.
- There is not enough evidence to support your claim: Sometimes it is not entirely clear whether or not an injury happened at work or during the course of one’s work-related activities, which can result in a denial of your claim.
Remember, although these are common reasons for workers’ compensation claim denials, all of the above reasons can be disputed. You may file an appeal if your claim was denied, regardless of the reason. However, it’s important that you work with an attorney who can help you understand whether you should appeal a claim denial or if your claim was truly denied for valid reasons.
Appealing a Denial of Your Workers’ Comp Claim
To begin the process of appealing your denial (or settling any other related dispute, such as early termination of benefits), you will need to request a hearing before the Workers’ Comp Appeals Board (WCAB). To request this hearing, your attorney will need to file both an Application for Adjudication of Claim and a Declaration of Readiness to Proceed (DOR) form. Typically, this must be done within one year of the date of injury, the last day on which you received medical benefits, and/or the date of temporary disability benefits termination.
After your attorney has filed the Application for Adjudication of Claim and DOR, you should receive a notice of hearing that will tell you the date, time, and the location of the conference. The workers’ comp judge will attempt to help you resolve the issues regarding your claim during this conference and, if the issue cannot be settled, he or she will set the matter for trial. If more information is necessary, the judge might also set up a discovery plan to gather evidence.
In most cases, disputes over workers’ comp claims are settled during the pre-trial conference.
Why Work with an Attorney?
Appealing a denied workers’ compensation claim is your right—but it is not an easy task. The process involves a significant amount of paperwork and you must meet various deadlines if you do not wish to have your appeal thrown out. A workers’ compensation attorney can not only assist you with the practical details of filing an appeal but can also provide you with professional legal advice and guidance regarding how to proceed.
If your workers’ compensation claim was denied, you do not have to settle for this outcome. The Orange County workers’ compensation attorneys at Alvandi Law Group, P.C. can guide you through the process of appeals to help ensure you receive your benefits.
Contact our firm today to request your free consultation.