Workers’ compensation is an important system for eligible employees. It’s designed to protect them if they get hurt or sick as a result of their work. In California, an employee who is approved for worker’s compensation can receive benefits like temporary disability, permanent disability, and medical treatment coverage. If you are denied workers’ comp, you may be wondering how to appeal a denied workers’ comp claim in California.
Understanding the Type of Denial
When you begin the process of a workers’ compensation claim, you may get a lot of mail about the process, and it can be hard to tell what each one means. Sometimes, the denial isn’t a full denial. Review the letter to assess which of the following it is:
- Delayed claim. A delayed claim is not a denial. Often, an insurer will issue a claim delay when more information is needed from you or another party, or more time is required to make their decision.
- Medical treatment denial, or utilization review (UR). UR helps ensure that the treatment you are getting is medically needed for your illness or injury. If the medical treatment is denied, it doesn’t mean your entire claim is necessarily denied. Instead, it means the treatment recommended by your doctor is determined not to be medically needed. Your doctor can request another review, or there is a process for filing a complaint with the Division of Workers’ Compensation if you think the UR company is not following state rules.
- Denied claim. If the claim itself was fully denied, then you can begin the following steps for appealing the denial.
From 2015 to 2021, there were nearly 57,000 hospitalization reports from workplaces throughout the U.S. In California in 2023, there were 472,500 recordable nonfatal workplace injuries and illnesses. Employees in all industries face potential hazards on the job and deserve to be fairly compensated when they are hurt. Unfortunately, insurers make the process difficult on purpose to avoid paying fair claims. Understanding the process can help you protect your rights.
What Rights Do You Have During a Claim Denial Investigation?
Your employer is required to provide you with a claim form within one workday of being informed of your injury or illness. Filing this form is the crucial beginning to your workers’ compensation claim, and it also ensures you protect your rights. Some of these rights include:
- A presumption that your injury was caused by your employment and should therefore be compensated if you do not receive an acceptance or a denial within 90 days of providing your employer with completed forms
- An increase in your disability payments if you do not receive them on time
- Up to $10,000 in medical treatment under certain guidelines while your claim is under investigation
There are some limitations to these rights, and it can help to hire a workers’ comp lawyer to better uphold your rights during this process.
Understand the Reason for the Denial
If you’re going to appeal your denied workers’ comp claim, you should first understand why it was denied. An insurance company may deny your workers’ comp claim if:
- You lack evidence that the injury or illness is work-related
- You failed to report the injury or illness or file a claim before the 30-day deadline
- They believe the injury or illness was a pre-existing condition
- There are inconsistencies in your report
If your denial letter cites a specific reason for the denial, note it and be sure to address it when you file an appeal. If the explanation for the denial isn’t sufficient, you can request a more thorough explanation from the insurer.
File an Application for Adjudication of Claim
If you want to appeal the denial of your claim and present your case before a judge, you have to start by filing an Application for Adjudication of Claim at the Division of Workers’ Compensation (DWC) office in the county where your injury occurred or your county of residence.
This is the first step in the appeals process and must be done as soon as possible. There is a statute of limitations to commence proceedings within one year. You should receive a notice that your application was filed, and you have been given a case number.
File a Declaration of Readiness to Proceed
To get a hearing with a judge, you will have to file a Declaration of Readiness to Proceed, which is confirmation that you intend to proceed with your appeal. A mandatory settlement conference will be scheduled for you and your claims administrator. You can represent yourself at this hearing, but you are also within your rights to hire a workers’ comp lawyer to represent you. A workers’ compensation attorney may be more equipped to argue your case.
Attend the Mandatory Settlement Conference (MSC)
At the MSC, the judge will attempt to have you and the claims administrator work out a settlement agreement. This gives you the chance to resolve the issue without going to trial. Both sides will have the opportunity to discuss the case with the judge and then negotiate a settlement. This is where a legal professional can be helpful. They can handle negotiations on your behalf and ensure the terms of any settlement agreement benefit you.
If a settlement can’t be reached at the MSC, the judge will schedule a trial date with a different judge. At this point, your lawyer will need to prepare a full case, including any supporting documents, medical evidence, and witnesses who can testify on your behalf.
Present Your Case at Trial
At the trial, both parties will be able to present their evidence, call witnesses, and make their arguments. This process can take months, depending on how complex your case is, and thorough preparation is key. Having experienced legal representation at this stage is crucial to the outcome of your case. After the trial, the judge will issue a written decision either approving your claim or denying it.
Even after this, there may still be options for countering a denial by a workers’ compensation judge through a Petition for Reconsideration. However, this Petition has to be filed within 20 days of the decision being made.
FAQs
Can I Apply for State Disability Insurance Benefits While My Workers’ Compensation Appeal Is Pending?
If your workers’ comp claim was denied and your injury prevents you from working during the appeals process, you may be eligible to apply for State Disability Insurance (SDI) benefits. SDI can give you a temporary partial wage replacement while you appeal the workers’ comp decision. If your appeal is approved, however, you will not be able to receive workers’ comp benefits while receiving SDI, as SDI is only for employees with non-work-related injuries.
What Is a Petition for Reconsideration?
A Petition for Reconsideration is a legal request made to the workers’ compensation appeals board to have a decision made by a judge reviewed and reconsidered following a trial. You may file this Petition if you believe the judge ruled incorrectly or unfairly due to an error. File the Petition as soon as you receive the decision to avoid missing the deadline. Know that your employer or the insurance company can also file if the judge rules in your favor.
Can a Mental Health Condition Be Covered Under Workers’ Comp in California?
A mental health condition can be covered under workers’ comp in California. However, proving a work-related psychiatric injury is generally more challenging. There are certain criteria you must meet.
First, the mental condition must be diagnosed and require medical treatment or cause disability. You must have spent at least six months working for your employer unless your condition was the result of a sudden work condition. You must then prove your condition was predominantly caused by actual work events.
How Does a Workers’ Comp Settlement Work?
When you agree to a settlement from the claim’s administrator, typically, this means you agree to accept periodic payments or a lump sum to resolve the case. Usually, after a case is settled, it is closed, and you waive the right to pursue future claims or further benefits. It’s important to make sure any settlement you agree to covers the cost of current and future medical treatments, particularly if your injuries are permanent or long-term.
Hire a Workers’ Comp Lawyer You Can Trust: Choose English Lloyd & Armenta
The process of appealing a denied workers’ comp claim in California can be frustrating and somewhat complex. It’s important to be aware of your options. If you understand the reasons you were denied, file the proper paperwork, and fully prepare for negotiations or hearings, you can increase your chances of receiving approval. You can also increase your chances of success with legal support.
Contact English Lloyd & Armenta for assistance in navigating the appeals process. We can help you prepare for your hearing and potential trial and ensure you receive the benefits you’re entitled to. Our firm has served Southern California for nearly 45 years, and we are proud to fight for employee rights. Act now to protect your rights.
