Can You Appeal a Workers’ Comp Decision in California?

Workers’ compensation claims do not always go in favor of the claimant. In fact, a good percentage of them do not. By some estimates from insurance groups and workers’ compensation boards, upwards of 33% of workers’ compensation claims will be denied upon the first review, with variances based on location, industry, and claim type.

Does a 33% denial rate mean that one-of-three injured workers are not getting the workers’ compensation benefits they deserve? Thanks to a legal process known as an appeal, this is not the case. Appeals allow a workers’ comp claimant the chance to ask for a second review of their case to see if the denial was unjustified or reached through a legal error. Every state has a unique appeals process, but we will take a quick look at how California handles workers’ compensation denials and appeals in this entry.

Requesting a Hearing Before an Appellate Board

As mentioned, denials happen all the time. Insurance companies can deny claims involving injuries unrelated to the claimant’s work, injuries that required no medical attention, or injuries that simply are not covered by the workers’ comp policy in question. But that does not mean that every denial is based correctly on one of these reasons.

When an injured worker or their workers’ comp lawyer suspects a claim denial was unreasonable, the denial can be appealed to the California Workers’ Compensation Appeals Board (WCAB) to arrange an appellate hearing. A WCAB judge will be assigned to the hearing, during which arguments will be brought forth by the claimant and the insurance company. If the hearing ends in the claimant’s favor, then the judge can approve the workers’ comp claim. If the judge believes the injured worker is in the wrong and sides with the insurer, then the case might be eligible for appeal up to a Circuit or Superior Court.

What is a Priority Conference?

Insurance companies most commonly deny workers’ comp claims because they do not think the claimant’s injuries arose out of employment (AOE) or happened in the course of employment (COE). AOE means that the insurer thinks the claimant was hurt in a way unrelated to their work duties, and COE means the insurer thinks the claimant was not hurt at or due to their work at all.

Denials based on AOE/COE disputes are so common that they can be handled through a priority conference. Rather than preparing the issue to go to trial for a complicated legal session and resolution, a priority conference allows for a much quicker conclusion to be drawn. A priority conference will usually be scheduled within a matter of weeks or less, and the decision to accept or deny the claim can be made then and there.

If you need to appeal a denied workers’ comp claim, then there is a high likelihood that you will also be headed for a priority conference based on an AOE/COE denial. It is important to work with a workers’ compensation attorney who is familiar with these specific types of cases and conferences.