Why Was My CA Workers’ Comp Claim Denied?

Learning that your workers' compensation claim has been denied will only add to the frustration and stress you are already dealing with in the wake of a work-related injury. This added burden can make the road to recovery feel even more challenging, especially when you are counting on workers’ compensation benefits to cover your medical treatment and some of your lost wages. Fortunately, you typically have the right to appeal a rejection in California.

Successfully challenging a CA workers’ comp denial requires understanding why your claim was rejected in the first place. Below, we review some of the most common reasons workers' compensation claims get denied in California.

Late Reporting

Late reporting of workplace injuries is one of the primary reasons that workers' compensation claims are denied in California. State law stipulates a strict timeline for reporting work-related injuries to employers. Under these laws, injured workers are required to notify their employers of their injury within 30 days. The clock starts ticking the day an employee is injured, becomes aware of the injury, or reasonably should have become aware of the injury.

This 30-day window is critical to the outcome of a workers' compensation claim. If you fail to adhere to this timeline, your employer or the insurance company might use this delay as a reason to deny your claim. The rationale behind this is that late reporting may cast doubt on the legitimacy of the claim. For example, it could be argued that the injury was not severe enough to warrant immediate reporting, or even worse, that the injury was not work-related at all.

In some cases, you may be tempted not to report a work-related injury immediately because you underestimate its severity, believe it will heal on its own, and do not want to deal with the fuss of paperwork. However, this can be a costly mistake. If the injury worsens over time and you then realize you need to file a workers’ compensation claim, the delay in reporting could be used against you even if you are acting in good faith. To avoid having a workers' compensation claim denied due to late reporting, you should always report a workplace injury of any severity to your employer immediately.

Medical Evidence Does Not Support the Claim of a Work-Related Injury

For a claim to be successful, the medical documentation provided must clearly link the injury sustained to the workplace. If the medical evidence does not support the claim, the workers' compensation claim may be denied.

To illustrate this point, consider a scenario where a worker injures their back while lifting a heavy box at work. If the worker visits their doctor and only complains about back pain without explaining that it occurred at work, the medical report may miss the crucial detail of the injury being work-related. Consequently, this lack of a clear link between the injury and the workplace in the medical report may lead to the denial of the workers' compensation claim. In other words, you need to unambiguously communicate to your doctor how you sustained your injury and how it was work-related.

Medical Evidence Suggests that the Injury Is Not Severe Enough

A workers' compensation claim can also be denied if the evidence suggests that the injury is not severe enough to warrant benefits. Despite the injury having occurred at the workplace, if the medical documentation does not adequately demonstrate the severity of the injury, the claim could be denied. The underlying assumption is that workers' compensation is meant for injuries that are significant enough to warrant medical treatment and impair an individual's ability to work, either temporarily or permanently.

For example, if an employee suffers a minor cut or bruise at work that can be treated with basic first aid and does not impede their ability to work, a claim for workers' compensation benefits may be seen as unnecessary. On the other hand, injuries that require extensive medical treatment, result in an inability to continue work, or lead to permanent impairment would generally be considered severe enough for workers' compensation claims.

In cases where the severity of the injury is in question, medical evidence becomes crucial. You must work with your doctor to ensure all symptoms and impacts on your work capabilities are accurately recorded. You can then demonstrate the extent of your injury by submitting detailed medical records with your claim, including the attending physician's notes, diagnostic tests, treatment plans, and prognosis. The more evidence documenting the severity of your injury, the better.

Failure to Seek Immediate Medical Attention

When a worker gets injured on the job but decides not to seek immediate medical care, it can create the impression that the injury is not serious enough to warrant a workers' compensation claim. For instance, if an employee twists their ankle at work but does not seek medical attention, the insurance company might argue that the injury was not severe enough to necessitate medical treatment, and therefore, does not qualify for workers' compensation benefits. Similarly, if the injured worker delays seeking medical attention, it may cast doubts about the severity and the timing of the injury, creating room for the insurance company to question whether the injury occurred at the workplace at all.

You should always seek immediate medical attention following a workplace injury, no matter how minor the injury may initially appear. Remember, the injury may be worse than you realize. Prompt medical attention not only ensures appropriate treatment but also supports the legitimacy of your workers' compensation claim, consequently increasing the likelihood of its approval.

Injury Not Covered Due to Disqualifying Behavior

Not all injuries sustained at work qualify for coverage under California’s workers' compensation laws. Work-related injuries caused by misconduct are generally excluded from workers' compensation coverage. For example, self-inflicted injuries are typically not covered. If an investigation reveals that the injury was intentionally self-inflicted or occurred as a result of horseplay or reckless behavior, the claim will likely be denied. Similarly, injuries sustained while an employee was under the influence of drugs or alcohol usually do not qualify for workers' compensation.

Injuries that occur while an employee is violating company policy can also lead to claim denial. For instance, if an employee is injured while not using the safety equipment required by their employer, the claim may be denied.

You need to anticipate and be prepared to refute any claims that you were acting recklessly, violating company policy, or attempting to hurt yourself (or someone else) at the time you suffered your work-related injury. Employers and insurance companies will sometimes look for any reason to deny a claim, and they could try to do so on these grounds if any evidence suggests you were doing something improper when the incident occurred.

Discrepancies in Your Statement

This scenario typically occurs when there's an inconsistency between what the worker reported about the incident and what's documented in the accident report or medical records. The insurance company may question the validity of the claim if the details provided by the employee do not correlate with other evidence or reports.

For example, suppose a worker tells their employer that they slipped on a wet floor at work, but the accident report indicates that the floor was dry at the time of the incident. This discrepancy could be used as a reason to deny the claim. Similarly, if a worker claims to have sustained a severe back injury from lifting a heavy object but their medical records show only minor strain, the claim may be denied due to this inconsistency.

You must provide accurate, consistent, and detailed information when reporting a workplace injury. Any alteration in the story or contradiction between different sources of information may cast doubt on the legitimacy of your claim and could be used by the insurance company to deny it.

Was Your CA Workers’ Comp Claim Denied? We Can Help.

If your claim was denied due to any of the reasons outlined above or for any other reason, do not lose hope. Our team of experienced workers' compensation attorneys at the Law Offices of Wax & Wax can help you explore your options and determine the best way to secure the benefits you deserve. We conduct thorough reviews of denied claims, identifying any issues or discrepancies and working diligently to address them. Our team understands how to effectively appeal rejections related to late reporting, lack of medical evidence, the nature of the injury, the severity of the injury, discrepancies in statements, failure to seek immediate medical attention, and more. Our primary objective is to ensure your rights are protected and that you receive the compensation you are entitled to under the law.

An initial denial does not mark the end of your workers' compensation claim – you have options, and we are here to help. Schedule a free initial consultation today by calling (818) 946-0608 or contacting us online!