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What to Do If You Must Appeal Your Workers’ Comp Claim in California

  • Published: September 23, 2021

Do you know what to do if you must appeal your workers’ comp claim in California? Employers must carry workers’ compensation insurance to cover employees injured on the job. However, employers or their insurance companies have the right to deny a claim. If your claim is denied, you have several options, such as discussing your claim with the claims adjuster, mediation, or appealing the claim denial.

Reasons Your Workers’ Compensation Claim Could Be Denied

Just because you have a work-related injury, do not assume your claim will automatically be approved. Insurers would rather not pay out benefits, and employers do not want to see their premiums rise. Disputing and denying claims save them money.

Missed Notification or Filing Deadline

Missing workers’ comp deadlines raises questions that could result in claim denial. California’s deadline for notifying your employer is 30 days. California’s deadline for filing for benefits is within one year of the date of the accident or injury.

Employer or Insurer Disputes Your Claim

Employers might argue that the details of your report are inaccurate or that you were not at work when you were injured.

Inconsistent Accident and Medical Reports

If your injury seems more severe than would ordinarily result from the work or accident you reported, this opens the door for a challenge of inconsistent facts. If you tell your employer the accident happened one way but describe a different set of circumstances to the doctor, you have created a red flag.

Your Injury Is Not Work-Related

An injury must have occurred while you were acting within the “course and scope” of your employment.

Your Injury Is Not Compensable

A compensable injury is a condition covered by workers’ compensation insurance. For example, some states allow claims for incapacity linked to psychological stress, but others do not.

You Did Not Receive Medical Care for Your Injury

If your injury was not severe enough to require medical care, you likely will not be able to recover financial compensation.

You Were Treated by a Doctor Not Approved by Your Employer

Most employers require you to receive treatment for your injury from a doctor approved by the employer and insurance company. Going outside the approved provider network could get your claim denied. A worker’s compensation attorney in Glendale, California can help make sure you get the necessary treatment for your injury and the benefits due to you.

You Have a Pre-existing Condition

In California, employers are liable only for the degree to which a work injury worsened your pre-existing condition. Suppose you injure your knee at work, but your past medical records show you suffered a football injury in college. The insurance company could claim that your knee was already weak from a previous injury and reduce the amount of compensation you receive.

You Were Fired, Laid Off, or Quit before Filing the Claim

Generally, unless you notified your employer of your work-related injury while you were still employed or within the notification deadlines of California, you are not eligible for workers’ compensation benefits from your employer once you have left your job. 

Refusing to Give a Recorded Statement

Workers’ compensation insurers frequently ask claimants to provide a recorded statement detailing the accident and injuries because there is some doubt about the claim. Providing a recorded statement probably will not help your claim; however, refusing to give a recorded statement could be used as a reason to deny or delay benefits. If asked to give a recorded statement, you should ask to speak to your lawyer and consult a California workers’ compensation lawyer about how to proceed.

No One Witnessed Your Work Injury

If a tree falls in a forest and no one sees it, did it happen? The insurance company can make the same argument regarding your injury. Make sure you dot all your “i’s” and cross all your “t’s.”  Make sure you take pictures of the scene of the accident and your injury. Report your injury to your supervisor immediately. Tell your co-workers about your work injury. Be sure to tell everyone the same circumstances involving your injury.

You Were Under the Influence of Alcohol or Drugs

Most states’ workers’ compensation laws disallow claims for injuries that result from employees injured while under the influence of drugs or alcohol. The prosecutor must prove that you were using a substance at the time the accident occurred. Additionally, your injury must have occurred within the course and scope of your job.

Your Injury Was the Result of Horseplay or a Fight

If your workplace injury was the direct result of horseplay or a fight that you initiated or willingly participated in, your claim likely will be denied.

You Can Appeal

You do not have to give up your right to workers’ compensation if your claim is denied. You can file an appeal. Workers’ compensation law is complex and filing an appeal for a denied claim is no simple matter. The appeal will require hearings to review the evidence to support your appeal. You will not want to file an appeal without an experienced workers’ compensation attorney to help you prepare a strong case.

The Appeals Process Involves Mediation or an Administrative Hearing

Some people may be comfortable with trying mediation before going to a full-blown hearing. A hearing is a formal meeting with a judge presiding and making a final ruling. Mediation is more informal, and there is no final ruling. More detailed descriptions of mediation and administrative hearings are listed below:

  • Mediation: Mediation, or a settlement conference, consists of an informal negotiation in which you and the insurance company discuss your claim with the assistance of a trained, neutral third party and attempt to come to an agreement. The mediator will try to get the parties to reach an agreement. Mediation is not a trial, and the mediator cannot make a ruling.
  • Administrative Hearing: If mediation fails, the next step in an appeal is an administrative hearing. The hearing can be through a state labor department or a state board of workers’ compensation. The hearing will be run by an administrative judge. You and the insurance company must be ready to defend your case by presenting evidence, witnesses, medical records, and accurately citing relevant employment laws. The burden of proof is on you. After hearing the evidence, the administrative judge will make a ruling, but it could be weeks before a ruling is made.

Appeals are complicated legal processes involving rules of evidence and civil procedure that the judge will expect you to know. More than likely, the insurance company will be represented by its lawyers. You would be wise to hire the experienced workers’ compensation attorneys at KCNS Law Group.

Further Administrative Appeals

If your appeal is denied by the administrative hearing, you have the right to a board appeal. If you believe that the administrative hearing officer made errors in the appeal hearing, the board can review your argument and make a ruling. The hearing is not a trial with evidence and witnesses. It is an administrative hearing where a workers’ compensation appeals board or a panel of workers comp judges evaluate your argument.

When all appeals have been denied, you can advance your appeal through the state court system. Assuming no acceptable settlement is made, the appeal is treated like any lawsuit with a trial, presentation of evidence, witnesses, and a decision rendered by a judge or jury.

Talk to an Experienced Southern California Workers’ Compensation Lawyer at KCNS Law Group Today

Recovering from an on-the-job injury is hard enough without battling your employer and insurance company to recover your losses. Appealing a denied claim is a complicated process that can take months. Without a clear understanding of the relevant California workers’ comp laws, you may not win your appeal. KCNS Law Group has 40+ years of combined experience successfully handling workers’ compensation cases in Southern California.

KCNS Law Group will handle your workers’ compensation appeal by filing for you, advising you of progress, helping you make informed decisions, and protecting your rights. We are prepared to negotiate a fair settlement or take your appeals case to trial, and we may be able to obtain the maximum compensation you deserve. Contact us at (877) 513-9007 or go online for a free consultation.

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