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If you receive a notice of denial, it doesn’t mean that your claim for workers’ compensation benefits is over. Unfortunately, it does mean that it may take longer for you to receive the benefits you need. If your claim was denied, your claims administrator has decided that your injury or illness is not covered under workers’ compensation policies in California. You should receive a decision and have a complete understanding of why your claim was denied before moving forward.
You can challenge the determination of the claims administrator by filing an appeal with the Division of Workers’ Compensation. To file a case, you will need to fill out and submit an Application for Adjudication of Claim. Once that has been filed, you will need to file a Declaration of Readiness to Proceed document to ask that your case be heard in front of a judge.
You do not have to have an attorney for the appeals process, but securing the services of an attorney might help. An attorney who understands workers’ compensation laws in the state can speak on your behalf, file the appropriate forms, and expedite the process.
Each claims case is heard at a Division of Workers’ Compensation Office by a judge and is called a “mandatory settlement conference.” During the hearing, you, your attorney, the judge, and the claims administrator or his/her attorney will present information regarding the case. If the case reaches no settlement at this time, the case will move to trial.
The reason that your claim was denied might be a simple matter to resolve. After a hearing with a judge, the claims administrator may agree to re-evaluate your claim in a new light. Your claim might have been denied because the physician’s notes were unclear regarding your injury or your representation of the accident did not accurately reflect the severity and long-lasting consequences.
For chronic pain, claims can become more complex. You may be filing a claim for years of repetitive motion-related injury, but if asked about a specific injury date, you may not list one particular date. Other claim denials may result from issues that seem suspicious to the case administrator. Unfortunately, it’s impossible to fully recreate events in a claims application. Miscommunication or misreading is often to blame for a claim denial.
A notice of delay is not necessarily an indicator that your case will be denied, but it may prolong the process and require significant back-and-forth communication to clarify the details of the claim. If there is a delay and an investigation into your claim, you are entitled to $10,000 in treatment costs. Once the administrator approves your claim, you can access the remainder of your benefits through the policy.
Although you are not required to obtain legal counsel for workers’ compensation claims, you may want to consider a consultation. If your claim is delayed or denied, the presence of legal counsel can improve the communication process and speed up the claims processing time. In some cases, the basis for a denial may not be legal. The only way to ensure that your claim is complete and properly evaluated by claims administrators may be to secure the representation of a workers’ compensation attorney.
The attorneys at DiMarco | Araujo | Montevideo understand that this may be a difficult time. Going back and forth with claims administrators may make recovery difficult. Our team can speak with insurance representatives on your behalf and provide you with peace of mind. For more information about our workers’ compensation practice, please contact our Orange County office today.