Denied Claims

Santa Clarita Denied Workers' Compensation Claims

What Do I Do If My Workers’ Comp Claim is Denied?

Workers’ compensation is a great system to get injured workers back on their feet when they are ready – but only when the system itself works. The chances of your workers’ compensation claim being denied are fairly high. Some estimates from insurance groups note that upwards of 20% of workers’ comp claims will be denied or delayed initially. Denial is not the end of a case, though, and you will have some options to explore to get the benefits that you need and deserve.

Just because your claim has been denied does not mean that you can't still receive compensation. Contact our firm today to discuss what your next step should be.

What Disqualifies You from Workers’ Comp Benefits?

Why do workers’ comp claims get denied, or what is a disqualifier for workers’ compensation benefits? Every case is unique, so there could be unique reasons for a denial. However, there are some reasons that appear far more often than others.

Four of the most common reasons for a workers’ comp claim denial are:

  • Injury happened while they were not working or while they were performing an action unrelated to their job.
  • Injury or illness is preexisting, or a preexisting condition exacerbated the new injury, so only a portion of the medical treatments should be covered.
  • Extent of the injuries or the medical treatments are disputed, such as an insurer argues some medical care is elective, not required.
  • Incomplete or inaccurate workers’ compensation form is submitted, or the form is submitted too late.

Workers’ Comp Appeals Process

If your workers’ comp claim has been denied for any reason, then the next step is to talk to our Santa Clarita workers’ compensation attorneys about appealing that decision. We can walk you through the entire workers’ comp appeals process or act on your behalf if you require representation.

The workers’ comp appeals process in California usually includes:

  • Inquiry: The appellate process usually begins with speaking with the insurer to figure out exactly why the denial happened. We might uncover a technical error that the insurer reverses without needing to become invested in the entire appeals process.
  • Petition for Reconsideration: We can submit a Petition for Reconsideration, which formally requests the insurer review the case and reconsider the validity of its denial.
  • Second medical examination: If the insurer still does not want to approve your workers’ compensation claim after a reconsideration, then we can work with you to find a qualified medical examiner (QME) or agreed medical examiner (AME) to complete a secondary evaluation of your injuries.
  • WCAB decision: Using the information from this secondary evaluation, we can prepare an appellate case to bring before the appropriate review board or administrative judge with the California Workers’ Compensation Appeals Board (WCAB). The WCAB will decide if your case was wrongfully denied, and how to correct the situation if it was. Further appeals are possible if the WCAB sides with the insurer.

Can You Sue Your Employer for Denying Workers’ Comp?

The appeals process will not always end in the appellant’s favor, of course. There are times when courts and workers’ compensation boards agree that a worker’s injuries or treatments do not technically fall under the umbrella of workers’ comp. If this happens in your case and workers’ comp won’t pay, then you are still not out of options.

Depending on why your accident happened, you might be able to sue your employer as you would any other liable party in a personal injury claim brought to a civil court. Workers’ comp bars you from holding an employer personally liable for your injuries, but only if workers’ comp benefits are approved. In their absence, an employer can be sued, which is why the typical employer actually wants workers’ comp claims to be approved at least to a minimal extent. Suing an employer is as rare as it is complicated, though, so it is advised you only proceed with this legal course with an attorney leading the way.

If your claim has been denied, contact the Law Offices of Wax & Wax today to find out how our attorneys can help.

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