What to Do If Workers’ Comp Is Denied

By Kenton Koszdin Law Office on May 3, 2023 | In Social Security Disability

What to Do If Workers’ Comp Is Denied

Was your workers’ comp claim denied? You have options, and a skilled Los Angeles workers’ compensation lawyer can help you learn about them. Many people opt to pursue an appeal of a decision to secure the medical care and benefits they’re entitled to. Our legal team can help you determine the right course of action.

Our decades of combined experience with California workers’ comp laws give us keen insight into your situation. We can craft a compelling case to review the denial of your claim or file a workers’ compensation lawsuit on your behalf if necessary.

18 Reasons Your Los Angeles Workers’ Comp Claim Is Denied

Workers’ compensation denial reasons are numerous. The denial letter often contains the reasons your employer or their claims administrator denied your claim. If you haven’t heard about your claim or you believe the denial reason is in error, contact an experienced workers comp attorney.

1. You Weren’t Injured at Work

If an accident left you injured at work but not work-related — if you were not completing your job duties at the time — your claim could be denied. If there were no witnesses, you were hurt during a recreational activity while on break, or the employer wasn’t notified, the claims administrator may determine the injury wasn’t work-related.

2. You Didn’t File Your Claim Within the Required Timeframe

california workers compensation appeal process

California law limits the reporting time for workers’ compensation claims. If you fail to notify your employer within the required time, you may be denied. The company, in turn, has a short window of time to investigate the incident. If you don’t file in time, it’s an easy answer to “Why would a workers comp claim be denied?”

3. You Were Under the Influence of Drugs or Alcohol

If you were drinking or on drugs when the accident happened, your employer is under no obligation to extend workers’ compensation benefits to you. In fact, your employer is within their legal rights to require a drug test after an accident for any workers’ compensation claim.

4. You Didn’t See Your Employer’s Approved Medical Provider

You may wonder why would workers’ comp be denied if a licensed physician, but not your employer’s physician, determined your injuries were caused by a work accident or were work-related.

Your employer’s insurance company requires that you be seen by its approved doctor before it approves a worker’s comp claim. Your employer will provide a list of approved physicians.

5. You Never Obtained Medical Care

Can workers’ comp be denied if you don’t go to the doctor but have an incident report of being injured at work? If you don’t have medical records supporting your claim, the insurance company may deny or minimize your claim. Even if you think the injury is minor, seeing a doctor starts the paper trail you need for your claim.

6. Your Workers’ Compensation Claim Paperwork Wasn’t Filed on Time

workers compensation appeal process

A clerical error or a delay on your employer’s part in filing the workers’ compensation claim can lead to a denial of the claim. Alternatively, perhaps you didn’t report the injury or work-caused medical condition to your employer in time. Either reason affects the processing of your workers’ compensation claim.

7. You Were Roughhousing, Playing a Practical Joke, or Fighting

Horseplay or violence at work that leads to injury often means that those involved will be denied workers’ compensation coverage for injured workers. If you’re playing pranks or messing around, you won’t be considered working and therefore won’t be covered under workers’ comp. If you are hurt in a fight but deemed the aggressor, you won’t be covered, either.

8. You Have a Pre-Existing Condition

Sometimes you can get workers’ compensation coverage if you can prove that a pre-existing condition was aggravated or worsened because of your work duties or toxic exposure. Many other times, though, the insurance company may use a previous injury or illness as grounds to deny that your claim is work-related.

9. Your Employer Questions Your Workers’ Comp Claim

Your employer has the right to dispute your claim, whether because they don’t want the cost associated with treating you and paying for disability or because they generally believe your claim is spurious.

They may dispute certain details or say that you weren’t actually working, especially if there were no witnesses or surveillance footage of the incident.

10. You Aren’t Represented by a Skilled Workers’ Compensation Attorney

You don’t need a lawyer to file a workers’ compensation claim, but if it’s denied, a lawyer’s advice increases your chances of a successful appeal. If your case gets to the point where you need to take legal action to receive the benefits you’re entitled to, then you will likely need a lawyer to file and argue the suit.

11. Your Injury Doesn’t Meet California State Guidelines

Although workers’ comp is state-mandated and overseen, it’s not state-funded. Instead, it is a type of insurance coverage. Some psychological conditions or cumulative traumas may not be covered, for example, even if your job or workplace contributed to them. Alternatively, your injury may not be severe enough to warrant a claim.

12. You Filed the Claim After You Quit or Were Fired

appeal a denial of workers comp benefits california

A former employee seeking workers’ comp insurance coverage is an automatic red flag for the insurance company and employer. It may be argued that you only filed the claim to “get back” at the company. If you were fired in retaliation because of a workers’ comp claim, though, you may have legal grounds to sue your employer.

13. You Didn’t Cooperate During the Workers’ Comp Claims Processing

The insurance company may claim you’re uncooperative if you don’t give them a written statement or sign certain documents. Injured workers do have the right to consult with a lawyer first — this isn’t being uncooperative. An insurance company may drag its feet or try to deny your claim in this case, but they don’t have grounds to do so.

14. Your Employer or the Insurance Company Made a Mistake or Are Stonewalling You

You may have done everything correctly to receive your workers’ comp benefits but still aren’t getting your medical coverage and benefits. Perhaps your employer didn’t fill out their paperwork right or made a mistake. Maybe the insurance company is looking for reasons to deny your claim or evade making payments. A lawyer can investigate on your behalf.

15. Your Claim Is Within the 90-Day Investigation Window

California employers have 90 days to investigate any workers’ comp claim. If you aren’t getting benefits, it may be that you’re still within that investigation window. Injured workers cannot file an appeal for their workers’ comp claims until after the 91st day from reporting the accident.

16. An MPN Doctor Clears You to Physically Perform a Modified or Alternate Form of Work at Your Place of Employment

If the MPN doctor clears you to return to work in a modified role or determines that you can do any other type of job for your employer, then you may not be eligible for disability benefits through workers’ comp. You can either accept the offered job or get a second medical opinion and contest the initial assessment.

17. Your Injury Was Not Evaluated by a Panel Qualified Medical Evaluation or an AME

Most workers’ comp insurance companies require all claimants to undergo a Panel Qualified Medical Evaluation or be examined by an Agreed Medical Evaluator (AME). Absent a medical opinion from one of these, your claim could be denied. Often, your own physician’s diagnosis may not be enough proof of your workers’ comp injury.

18. Your Check Is in the Mail

Sometimes your benefits are delayed simply because of postal issues. During the holiday and tax season especially, the USPS experiences delays in getting letters and packages to the intended recipients. If you have yet to receive your check at least five days after the expected date, please contact us so we can verify the check was sent.

Your Options When Your Los Angeles Workers’ Comp Claim Is Denied

Don’t give up on workers’ comp claims benefits just because you were initially denied. Follow our steps to appeal a workmans’ comp denied claim:

  • First, note the denial reason in your workers’ compensation claim form.
  • Contact the claims adjuster if you believe there was a clerical error.
  • Gather all medical records and other paperwork, like a workplace incident report.
  • Retain copies of all medical bills and invoices from your treatment.
  • Follow through with all recommended aftercare and medical appointments.
  • Jot down any witnesses to your injury to give your lawyer.

All of these items are used by a qualified workers’ compensation attorney as evidence in your appeal or when it’s time to file a lawsuit.

Appealing Your California Workers’ Comp Claim Denial

California law provides several avenues for injured employees to appeal a denied workers’ compensation claim. Filing an appeal can be tricky, though; a skilled workers’ compensation lawyer can guide you through the California workers’ compensation appeal process, including gathering all needed evidence and arguing on your behalf.

Petition for Reconsideration

The first step in appealing a denied workers’ comp claim is filing a Petition for Reconsideration with the local LA Workers’ Compensation Appeals Board. You have only 20 days from the date you received the claim denial or 25 days from the denial issuance letter date, so act quickly.

Perhaps you and your workers’ comp lawyer believe that the workers’ comp judge didn’t have all the necessary evidence to evaluate your claim, or perhaps you have new evidence that better supports your claim.

Examples of this would be a witness that your employer didn’t know about before or video evidence of the accident that surfaced after your initial claim was denied.

Once you file, the Appeals Board has 60 days to accept the petition and hear your appeal; if you don’t get a response after that, you can consider your Petition for Reconsideration denied and move on to the next step.

However, if the Board accepts your Petition, then they will either affirm the initial denial, reject the initial denial, or amend the initial decision.

State Appellate Court Appeal

california workers comp appeals

If you don’t get a resolution from your Petition for Reconsideration, then you and your attorney can appeal to the California Appellate Court. Your attorney will file a writ of review within 45 days of your Petition’s rejection. It’s unusual for the Appellate Court to overturn the board’s decision on a California workers’ compensation claim, though.

Appeal to the California Supreme Court

Once you’ve exhausted the others, a final option in the workers’ compensation appeal process is appealing the Appellate Court’s decision. The California Supreme Court rarely hears workers’ compensation appeals, but if you have a strong case, your experienced workers’ compensation attorney may appeal.

What Are My Chances of Winning My Workers’ Compensation Appeal?

We’re often asked how many workers’ comp cases are denied but won on appeal. Because each case is so unique, giving a quantifiable answer is hard. Once your claim is denied, you can improve your chances of winning by:

  • Gathering all available evidence
  • Avoiding any activity that would contradict your claim of being seriously injured
  • Not making or giving any statements without your attorney’s approval
  • Following your lawyer’s advice

These tips can help increase your chances of winning your appeal.

Get Skilled Legal Advice for Your Los Angeles Workers’ Comp Appeal

Have you or a loved one had your workers’ comp claim denied in California? We can help! The knowledgeable legal team at Kenton Koszdin Law Office answers all your questions about the appeals process and works tirelessly to help you receive the benefits and care you’re entitled to.

Our focus is on helping people who have been injured in the workplace and looking into denials of any benefits claim, including disability and medical expenses. Contact us today at (818) 293-4980 for a free consultation about your California workers’ compensation claim.

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