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When You Get Denied for Workers’ Compensation

When You Get Denied for Workers’ Compensation

Getting a worker’s compensation claim approved is not always cut and dry. Many Californians hit bumps in their road to compensation, like getting denied. However, rest assured that there are steps to appeal or reverse such crucial decisions. You may have asked yourself why your case and so many others get denied in the first place.

What Causes a Workers’ Compensation Denial?

Workers’ compensation insurers deny claims for a variety of reasons. Frequently, insurance companies deny initial workers’ compensation claims because they assume most injured employees will drop the matter rather than continue pursuing it. In other instances, insurers accept valid claims but refuse to pay claims they feel are not legitimate.

Let’s look at the most common and valid reasons claims get denied:

  • A work-related activity neither caused your injury nor did it happen while performing your duties at work.
  • No medical treatment is necessary for you to recover from this injury.
  • Your injury does not require you to miss any time from work.
  • The injury happened while you were working for a different job or company.

Denied Workers’ Compensation Claim? Here’s what you need to do NOW

denied stampAs frustrating as denials are, if you believe you have been unjustly denied, you or your experienced workers’ compensation attorney must begin the process of appeals.

You’ll need a hearing before the Workers’ Compensation Appeals Board (WCAB) to pursue approval of your claim. Because your conflict with the insurance company is over whether your claim is “compensable” – or, more specifically, whether work comp will cover your injury, and whether the insurance company is responsible for the claim, you will have a “trial on the preliminary issue.”

You (or your lawyer) must file a Declaration of Readiness (DOR) to proceed to request a hearing before a WCAB judge. To file the DOR form, however, prior, you will need to file a form of “Adjudication of Claim”. The form is part of the official workers’ compensation claim and issues a case number.

Why did I get a Notice of Priority Conference?

A priority conference is filed whenever a disagreement occurs over whether your claim is compensable. In this case, the defense argues that the alleged injury did not arise from an employment-related activity. Consult with an attorney immediately if you do not already have one.

A settlement can be reached in a Priority Conference, but you should consult an attorney before signing anything. There will be an attorney representing the defense there and attempting to go through the process without one is not recommended.

The leading reason insurers deny workers’ compensation claims is that they don’t think the injury arose out of employment duties (AOE) or occurred during the course of employment (COE).

  • AOE is when the insurer believes that you were not injured on the job at all.
  • COE is when the insurer believes that the claimant was injured but in a way separate from their work duties.

Mandatory Settlement Conference

The law requires a mandatory settlement conference (MSC) with all parties in attendance and held before trial. Both parties must make a settlement attempt. Otherwise, they must agree on what issues exist. For instance, an agreement may be made over you being injured, but a disagreement may exist over the extent of your disability.

There is no requirement to settle at the conference, but an effort must be made by coming to the MSC. Participation in the conference is mandatory, as the name insinuates. There are times when the insurer will be taking their first look at the case in terms of settlement. It’s not uncommon for insurance adjusters to see hundreds of cases and not have the opportunity to go over them in detail until a conference.

Your attorney will have the opportunity to get you a settlement at this conference; however, more complex cases may require additional time.

Documented and Professional Medical Evidence

Before a hearing on compensability, the insurance company must evaluate your injury or illness to consider the medical issues. Therefore, you will need to have a doctor evaluate your injuries or related illnesses and have proper documentation to provide to your attorney for the insurers or for you to present. You can have a medical-legal evaluation done by another doctor if you are unhappy with what your treating physician says. Your attorney may request a medical-legal evaluation for you.

Note: The insurance company can also request a medical-legal evaluation by another doctor if it is unhappy with the assessment of your treating physician.

You can choose from a list of qualified medical evaluators (QMEs) if a lawyer does not represent you; otherwise, the insurance company and your workers’ comp attorney will jointly select a medical examiner (AME).

The complexities of a workers’ compensation case and denials

As expressed in this article, there are many details, forms, meetings, conferences, and a structured order to file for workers’ comp, specifically when appealing a denial. If the compensability issue is finally lost, you will not be entitled to any workers’ compensation benefits. This will look like losing reimbursement for medical treatment, lost wages, or a cash payment in the event of permanent impairment.

All the above reasons and more are why you should consult with a skilled California workers’ compensation attorney immediately. Your attorney will work vigorously on your behalf and fight aggressively, by the law, to get you complete compensation. Our experienced attorneys at Castillo & Associates can help you gather any evidence you may need to get the maximum benefits for your injury. Contact us today at 1-800-497-9774.

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