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How to Appeal a Denied Workers’ Comp Claim

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Posted By DAM Firm | January 27 2021 | Workers' Comp

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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