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.

How To Appeal A Denied Workers Comp Claim in California?

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 worker’s 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 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.

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. 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

In order 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 right to hire a workers’ comp attorney 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.

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 worker’s compensation appeals board to have a decision made by a workers’ comp judge reviewed and reconsidered following a trial. You may file a Petition for Reconsideration if you believe the judge ruled incorrectly or unfairly due to an error. The petition should be filed as soon as you receive the judge’s decision to avoid missing the deadline. Keep in mind that your employer or the insurance company can also file a petition if the judge rules in your favor.

Can a Mental Health Condition Be Covered Under Workers’ Comp in California?

A mental health condition or psychiatric injury 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: the mental condition must be properly diagnosed and require medical treatment or cause disability.

You must have spent at least six months, continuous or intermittent, working for your employer unless your condition was the result of a sudden and extraordinary work condition. You must then provide evidence to 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 claims 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.

Choose English Lloyd & Armenta

The process of appealing a denied workers’ comp claim in California can be frustrating and somewhat complex, but 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.

Contact English Lloyd & Armenta for assistance 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. Act now to protect your rights.