Reasons As To Why Claims Get Denied & How To Appeal: 

Denial Reasons:

Are you asking yourself why your recent claim got denied? Or maybe how to avoid getting your claim denied in the coming weeks? The state of California does a good job at protecting workers who are injured on the job. However, many workers’ compensation claims are denied due to mistakes, attempts to avoid responsibility, or a variety of other reasons. 

If your workers’ compensation claim has been denied or you’re looking to avoid denial, take a look at some common reasons as to why claims get denied: 

  1. Failure to Report Due Date: The injured employee may fail to report the injury to their employer within the required timeframe, or fail to file a workers’ compensation claim within the time limit specified by their state’s laws. After an injury occurs you also have a short period of time to complete all of your documents and turn them into the correct individuals. If you do not act quick enough, the insurance company is more likely to deny your claim. Generally, in California, you have 30 days to give your employer written notice of the injury.
  2. Injury Was Not Work-Related: If the injury did not occur in the course and scope of employment, or if it was the result of the employee’s own misconduct or negligence, the claim may be denied.
  3. Pre-Existing Condition: If the injury is related to a pre-existing condition, the workers’ compensation claim may be denied.
  4. Insufficient Medical Evidence: Insufficient medical evidence is a common reason for the denial of workers’ comp benefits.The medical documentation may not support the employee’s claim for workers’ compensation benefits, or the injury may be disputed by the employer or the workers’ compensation insurance carrier.
  5. Failure to Follow Treatment Plan: If the employee does not follow the recommended treatment plan, or fails to attend scheduled medical appointments, the workers’ compensation claim may be denied. Also, if you miss your medical appointments and do not reschedule them, the insurance company will likely view this as evidence that you no longer need care because your injuries no longer affect your ability to work. In other words, it’s important to go to your medical appointments so there is clear documentation of your injury.
  6. Filing a Claim After Termination: If the employee was terminated or laid off prior to filing a workers’ compensation claim, the claim may be denied.
  7. Incomplete or Inaccurate Information: If the employee’s claim is incomplete, inaccurate, or contains conflicting information, the workers’ compensation claim may be denied.
  8. Not Serious Enough: The key aspect of a workers’ compensation case is whether or not the injury and/or illness in question prevent the claimant from performing their job. In some cases, they may experience a partial loss of ability whereas in other cases, there is a complete loss of ability that can be either temporary or permanent.
  9. Employer Disagreements: Your employer may choose to dispute your claim. Oftentimes, these disputes are for valid reasons, such as; intoxication or workplace violence. However, in other cases, employers just want to avoid higher insurance payments in the future. 

If your benefits have already been denied, you still have a right to appeal, and many benefits are granted in the appeals process.

Appeal Process Overview:

It’s important to note that the appeal process is time-consuming and complex, speaking to an attorney prior to taking any of these actions is highly recommended and will make your journey much easier.

Here’s an overview of the process for appealing workers’ compensation denials in the state of California:

  1. File a Claim Form: You will need to file a claim form with the California Division of Workers’ Compensation (DWC) to appeal the denial. The claim form is called an “Application for Adjudication of Claim” and can be obtained from the DWC website or your local DWC office.
  2. Request a Hearing: Once your claim form is filed, you will need to request a hearing before a workers’ compensation judge. You can do this by filing a “Declaration of Readiness to Proceed” form with the DWC.
  3. Attend a Mandatory Settlement Conference: Before the hearing, you will be required to attend a mandatory settlement conference with a workers’ compensation judge. This conference is an opportunity for you and the insurance company to try to settle the case without going to trial.
  4. Attend a Trial: If the case is not settled at the settlement conference, it will proceed to trial before a workers’ compensation judge. At the trial, you and the insurance company will have the opportunity to present evidence and arguments in support of your respective positions.
  5. Appeal the Decision: If the judge issues a decision that you disagree with, you have the right to appeal to the Workers’ Compensation Appeals Board (WCAB). The WCAB is a higher level of review and can overturn, modify, or affirm the judge’s decision.

If any of these resonate with your situation, speak to Solov and Teitell about your options. It truly is best to have a workers’ comp lawyer handle your claim from start to finish to avoid mistakes and present the strongest possible claim.

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