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How to Appeal a Denied Workers’ Comp Claim

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Archive: Jan 2021

How to Appeal a Denied Workers’ Comp Claim

The California workers’ compensation system is designed to provide compensation to those who sustain workplace injuries or illnesses. In most situations, those who sustain an on-the-job injury or illness are entitled to compensation for their medical bills, wage replacement, and possible disability benefits. However, there are times when workers’ compensation claims are denied by an insurer or an employer. Here, we want to discuss how you can appeal a workers’ compensation claim in California. These cases can be challenging and confusing for injury victims, and that you seek assistance from a skilled Orange County workers’ compensation attorney who can help you through this process.

Why would a workers’ compensation claim be denied?

There are many reasons why an employer or workers’ compensation insurance carrier could deny a claim. In many cases, a denial is legitimate. However, there are also times when a claim denial is not legitimate or when there has been a misunderstanding of the facts of the case.

Some of the legitimate and most common reasons that a California workers’ compensation claim may be denied include:

  • The injury was not work-related (caused by an activity outside of the workplace or that happened during a period of no work-related duties).
  • The injury was due to the victim’s work with another company.
  • The injury victim did not need any medical treatment in order to make a recovery.
  • The injury victim did not need any time off.
  • The victim was injured because they were impaired by alcohol or drugs.

How to appeal a California workers’ compensation claim?

In order to get an insurance carrier to accept the workers’ compensation claim, you will first need to request a hearing before the Workers’ Comp Appeals Board (WCAB). In order to request the hearing before this board, you or your attorney will need to file a form called a Declaration of Readiness to Proceed (DOR).

Before you file the DOR form, you will first need to file an Application for Adjudication of Claim. This is part of the process of filing your official workers’ comp claim and will give you a workers’ comp case number.

Priority conference

If the insurance carrier denies a claim because they do not believe the injury arose out of employment (AOE) or that the injury did not happen within the course of the employment (COE), the WCAB judge will expedite a conference date so the issues can be resolved quickly.

Pre-trial conference

A pre-trial conference will be scheduled for the claim if the denial was not based on AOC or COE issues. An example of this could be a denial based on the insurance carrier not believing you need the medical treatment or that you are not entitled to temporary disability benefits. You will receive a notice of a hearing date, time, and location. At the conference, the judge will try to resolve the issues between the parties. If the dispute cannot be resolved, the judge will set the matter for a future trial date. The judge will set up a discovery plan to produce evidence to help determine the facts of the case.

Medical evidence

Before a hearing about the compensability of a claim, and if the insurance carrier is denying a claim based on medical issues, you will need to be evaluated by a doctor. If you are unhappy with the evaluation of the treating physician, you can request an evaluation from another doctor. If the insurance carrier is unhappy with the evaluation of the treating doctor, they are allowed to submit a request to have another doctor evaluate you.

If you do not have an attorney helping with your claim, you will choose from a panel of qualified medical evaluators (QMEs). If you do have an attorney, then you and the insurance carrier will jointly choose an agreed-upon medical examiner (AME).

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How Long Does a Settlement Take After a Demand Letter is Sent?

Any person who sustains an injury caused by the careless or negligent actions of another individual, company, or entity deserves to receive compensation for what happened to. However, securing compensation can be complicated, particularly when dealing with aggressive insurance carriers. Even though most injury claims are resolved through a settlement with insurance carriers, it can take some time to receive compensation after a demand letter is sent. Here, we want to discuss what you can expect both before and after you send a demand letter to an insurance carrier.

What is a demand letter?

A demand letter is a letter that you or your attorney will send to an insurance carrier to request that they pay the compensation they owe. If you have suffered from an injury in California caused by the actions of another individual, business, or entity, then you are likely entitled to compensation. This could include coverage of your:

  • Medical bills
  • Lost wages
  • Out-of-pocket expenses
  • Property damage losses
  • Pain and suffering damages
  • Loss of enjoyment of life damages
  • …and more

Unfortunately, insurance carriers and at-fault parties often put up a fight in order to keep from paying out a settlement in a claim. When they fail to offer a fair compensation amount, a demand letter will typically be sent in an effort to recover the correct amount.

How long after a demand letter is sent before you receive the compensation?

After a demand letter has been sent to the insurance carrier, the exact response time will vary depending on the specific factors related to each particular case. Injury victims can expect to have an answer from the carrier within a few weeks, but this process can take several months.

There are various factors that could delay a demand letter response from the insurance carrier, and some of the issues may have nothing at all to do with the letter itself. The insurance adjuster may be dealing with many cases at once, which means you will not receive a speedy response.

Additionally, the insurance claims adjuster may be spending more time reviewing your case and the evidence they have received. Insurance carriers will usually conduct their own investigation into each case, especially if the claim is for a fairly high dollar amount.

Even when the insurance carrier responds, there is no guarantee that they will respond favorably. There are a few ways a demand letter response may play out:

  • They may agree to the demand letter amount and pay the claim.
  • They may respond with a lower counter-offer.
  • They may deny the claim altogether.

What if the other party refuses to pay?

If the insurance carrier refuses to pay a fair amount or even denies a claim after the demand letter is sent, then it may be necessary for the injury victim to file a personal injury lawsuit against the alleged negligent party. This will push the case into the civil court system and will inevitably extend the total amount of time it takes to receive a settlement or be awarded compensation through a favorable jury verdict.

It is strongly recommended that you work with a skilled Orange County personal injury lawyer for help with your case, especially if you receive any pushback or trouble from the insurance carrier.

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