You could file a workers' compensation claim if you sustained work-related injuries in Los Angeles. Workers' compensation covers damages like lost income, lost earning capacity, and medical costs. However, you should meet specific requirements before receiving compensation. In most cases, claims fail to meet these requirements, resulting in denial. If your employer or insurer has turned down your claim, contact The Workers Compensation Lawyer Law Firm immediately. We can help you identify and meet the requirements you did not satisfy. If your case proceeds to appeal, we can work with you to collect evidence and prepare your case, increasing the chances of obtaining a favorable outcome. This article discusses different options you can take after the denial.

Reasons Insurance Companies Deny Workers’ Compensation Cases

The first step is to determine why your claim was denied. Employers and their insurance providers often look for possible reasons to deny a workers’ comp claim. The reason should be valid under the law. Once you know the reason, you can find out how to fix the issue.

Common reasons for claim denials include:

You Refused to Give the Insurer Recorded Statements or Sign a Medical Authorization

Workers’ compensation insurance companies typically ask injured workers to provide recorded statements describing their accidents and injuries. However, that can put the employee in a difficult position. Providing the statement will not help you if you do not have legal representation. You are also not lawfully required to give the insurance firm your recorded statement.

If the company asks for the statement, it could mean the insurance provider has a problem with your case. If you give the statement, the insurance company is still probably not going to award you workers’ comp benefits. If you refuse to provide the statement, the insurance adjuster has grounds for denying your claim.

Also, the insurer can ask you to sign a medical authorization that allows the insurance provider to write to your doctors to obtain your medical bills and records. You are not medically required to sign the medical authorization.

You are responsible for issuing the insurer medical bills and records related to your accident. You can satisfy this obligation by obtaining your records and sending them to the insurance firm.

Nevertheless, insurance companies do not like when injured workers offer their records. They do not trust employees and want to be sure they obtain a complete file. The challenge with medical authorization is that sometimes the company can invade your privacy and acquire medical records unrelated to your workplace accident.

If the insurance firm pushes you to sign a medical authorization, consult a skilled workers’ comp attorney and allow the legal expert to handle the insurance adjuster.

You Filed Your Workers’ Comp Claim After You Were Laid Off or Fired

Sometimes, employees who were lawfully injured at work delay bringing their workers’ comp claim, and when they do, they are terminated.

If you are fired before filing your claim, you will have challenges convincing the insurance provider and the judge that you have work-related injuries. They will assume that your move has nothing more than a revenge claim or an attempt to collect your weekly paycheck.

To support the claim, you will require evidence that the injuries occurred at work before your termination. It could be a statement from your colleague or eyewitness, video footage from work surveillance cameras, or medical records.

Your Medical Records Show Presence of Illegal Controlled Substance in Your Bloodstream

Workers’ comp law does not cover an injury caused by alcohol or drugs. If you go to an emergency room following your accident, and your medical records show controlled substances in your system, the insurance company will not compensate you.

There exists a Discrepancy Between Your Medical Records and Accident Records

Generally, insurers will deny your claim if your statements about how your accident occurred are inconsistent. Suppose you tell your boss that the accident happened one way but tell the medical expert a different account. In this case, your statements could negatively affect your case. Ensure what you tell everyone is consistent.

Missed Deadlines

To recover workers’ compensation benefits, you should immediately report your workplace illness or injuries to your employer. In California, you should report your workplace injuries within 30 days of the incident and file a workers’ comp claim within a year. Otherwise, your claim will be denied.

You Did Not Report the Work-Related Injuries Immediately

Most insurance companies do not like cases where plaintiffs fail to report accidents immediately. They believe you did report immediately because you were not hurt.

Workplace injuries should be reported within 30 days of the accident. However, the sooner, the better. If you believe your injuries can result in missing work, report immediately to your supervisor by filling out an accident report and increase the chances of recovering compensation.

No Witnesses

Injuries without witnesses or video footage supporting them are more likely to raise suspicion, mainly if you delay reporting your accident. However, you can ensure you report your injuries to your supervisor and colleagues immediately and tell them the same account regarding your accident and injuries.

Disputes About Whether Your Injuries Were Work-Related

The insurance company can claim that:

  • You were not working when you were hurt
  • You were involved in misconduct during your accident
  • Your health condition is not a result of your workplace exposure or accident

Whatever the reason for the dispute, you should collect evidence to support the claim. You can use witnesses or medical proof. If the treating physician has attributed your disease to your work, but the insurer disagrees, you could require undergoing an independent medical examination (IME) to receive a second opinion.

Out-of-Network Medical Attention

Your workers’ compensation insurance provider could require you to consult with a specific medical expert after sustaining workplace injuries through your boss' policy. A denial can happen after visiting a physician of your choice when you should see a doctor within the insurer’s network. Even though your physician understands you better, you should abide by the workers’ compensation policy requirements. You can then change doctors after the initial treatments and discuss your concerns and worries about the previous treatment plan.

A Preexisting Medical Health Condition

If, for instance, you fell off a ladder while at work and injured your back, do not be surprised if the insurance carrier argues that the backache was from your motorcycle accident three years ago.

The insurance company should not use your preexisting condition as a disqualifier. You should hire an attorney to ensure the condition is not blown out of proportion and used to deny your workers’ comp benefits. The lawyer knows how to use medical records to prove the degree of your work-related injuries. Additionally, the attorney can argue that your worsened preexisting condition is a valid injury to consider for your case.

Fighting the Denial of the Workers’ Compensation Case

To have the insurer accept the workers’ compensation claim, you should request a hearing before the Worker’s Comp Appeals Board. Because the disagreement with the insurer is over whether the case is compensable, your claim will proceed to trial.

To request a hearing before the Worker’s Comp Appeals Board judge, you should file a Declaration of Readiness to Proceed (DOR) form. Before filing your DOR form, you should file an Application for Adjudication of Claim.

Priority Conference

If the insurer denied the claim because the firm does not believe the injuries:

  • Did not occur in the course of the employment (COE) — The cause of your injuries was not work-related
  • Arose out of employment (AOE) — Your work activity did not cause the injuries,

The judge will schedule a conference date, allowing AOE/COE disputes to be resolved and the claim denied or accepted.

If the insurer denied your claim due to AOE/COE matters, check the boxes AOE/COE and “Priority Conference” on the Declaration of Readiness to Proceed form.

Pre-Trial Conference

Once you submit your Declaration of Readiness to Proceed form, your pre-trial conference will be scheduled. You will receive a notice of your hearing telling you the location, date, and time of your conference. At your conference, the judge will assist you in determining whether your claim ought to be denied or accepted.

The judge should set the case for trial if you and the insurance firm cannot resolve your dispute. Alternatively, if the judge believes more details are required before trial, they should develop a discovery plan and proof to assist in determining issues in the case. Additionally, the judge can plan a status conference to determine the adequacy of the discovered evidence.

Most disagreements over whether your claim must be denied or accepted are resolved at the pre-trial conference, and insurance companies issue compensation during this phase.

Appealing Denial of Your Workers’ Comp Claim Proceedings

It is essential to understand how workers’ comp cases end to better understand the process of appealing denials of workers’ compensation claims. If you agree with the employer and their insurer, you do not require the judge to decide. It is called settlement (an agreement on your benefits, including medical attention, permanent disability, lost income, and temporary disability). You can settle by a Compromise and Release or a Stipulation With Request for Award.

If you cannot agree with the insurer on an issue in your case, the judge will decide during your trial. Their decision is final. You cannot raise it again unless you file an appeal with the 7-member Workers’ Comp Appeals Board (WCAB).

There are two options if you believe the judge made the wrong decision, namely:

  • Petition for Removal
  • Petition for Reconsideration

The type of petition you file depends on the decision the judge makes.

Petition for Reconsideration

Bringing your Petition for Reconsideration to the Worker’s Comp Appeals Board initiates your appeal process. Per California Labor Code Section 5903, you have twenty days from the date you received the judge’s award or decision to file the appeal. If the judge mailed their decision to you, you have twenty-five days from your claim decision’s date.

You can only file this petition if the judge’s verdict is wrong and falls into either of the categories below:

  • The judge acted without power
  • The proof does not support the findings of fact
  • The findings of fact do not support the award, decision, or order
  • The decision, order, or award is fraudulent
  • There exists new proof that you could not have discovered before

If the matter is the proof as in 1, 2, or 3, your petition should state comprehensively how the proof fails to explain the judge’s findings.

If the bone of contention is new evidence or fraud, your petition should highlight:

  • Your witnesses’ names
  • A summary of your witnesses’ testimony
  • An account of your documentary evidence
  • The impact that the proof will have on the record and the previous decision

Regarding newly discovered proof, you should provide an accurate and complete statement of why you could not produce or discover the testimony or evidence before your case submission.

A Petition for Reconsideration should use details that were part of your trial to argue that the judge’s decision was mistaken. It should also indicate the laws that the judge applied wrongly. Your petition will be denied if you fail to abide by these steps.

When filling out this petition, you will see a list of reasons for filing your petition. Check what does not apply to you. In your statement of facts space, ensure to include all issues you want WCAB to consider, like:

  • reasons you contend with the judge’s verdict, and
  • reasons the board should change the decision

After filing your petition, the judge who made the original decision has fifteen days to change their decision. In this case, the judge might want to look at your case and schedule another hearing.

Once you file your petition, the board has sixty days to deny or accept it. If it fails to act within sixty days, consider your petition denied.

If the WCAB reviews the petition, it will next amend, reject, or affirm the previous award or decision.

The board will decide on your appeal without another hearing. However, the board will schedule a hearing if you have more evidence.

Finally, the board will mail you a notice of the decision.

Petition for Removal

You can file a petition for removal if the judge’s decision is not made at trial. It can affect:

  • Whether you should attend medical appointments
  • Who should attend the hearing and when it occurs
  • Whether you should provide precise medical records to the insurer

To file your petition for removal, you must prove:

  • The previous decision was biased
  • Reconsideration is not the right move
  • The original decision can lead to significant harm

A Writ of Review

If you or the insurance firm are unsatisfied with the WCAB’s decision following the appeal, you can appeal this decision to the state appellate court for a writ of review. You should file your petition for writ of review with the court of appeal in the appellate district where you reside.

However, the appellate court only considers whether the WCAB’s decision was rational. The appellate court neither overturns the board’s decision nor reverses the findings of fact the board makes. Therefore, you should consider whether it is worthwhile to bring your appeal.

You should file your writ for review petition within forty-five days of a new award or decision or your Petition for Reconsideration denial.

All issues in your Writ should be in your Petition for Reconsideration.

Medical Evaluation After Your Workers’ Comp Claim Denial

A claim administrator determines your workers’ comp claim denial. The bureaucratic administrator works for the insurance carrier and should make money for the company and deny as many claims as possible.

On the other hand, your primary care physician (PCP) has your best interests in mind and can help you secure your workplace injury benefits. The legal team at The Workers Compensation Lawyer Law Firm can work closely with your PCP to obtain a favorable case outcome.

If your claim was denied, it could mean the claim administrator disagreed with your primary care physician’s medical opinion about the illness or injury and their recommended treatment plan. In this case, you could be required to consult with:

  • A qualified medical evaluator (QME) — A medical expert who has undergone additional education or training to secure their QME license. The state of California grants them the license to practice as a medical physician, dentist, psychologist, acupuncturist, podiatrist, chiropractor, osteopath, or optometrist. Additionally, they are certified by the Division of Workers’ Compensation (DWC) to conduct medical or legal evaluations.
  • An agreed medical evaluator (AME) — A clinician mutually selected by the attorneys of the employee and their employer tasked to conduct medical or legal analysis in the disputed workers’ compensation claim.

Sometimes it is preferable to have your AME consider the medical claim. Unlike QMEs, the DWC does not provide AMEs.

Both AMEs and QMEs determine the following parameters of a workplace illness or injury:

  • If the work caused the disease or injury
  • If you require medical treatment for the injury
  • If you should take time off your work to recover
  • If the illness or injury has a permanent and stationary date (the date when the condition has stabilized and is unlikely to improve)
  • If you have a pre-existing condition and if the workplace disease or injury exacerbated the condition
  • If you have a further or new disability
  • Your permanent disability rating

QME Selection Process

If you decide to work with a QWE, the claim administrator will send you a panel request form. You should fill out and submit the form within ten days. Otherwise, the claim administrator will do it on your behalf, making you lose the right to select your preferable QME.

After submitting the request form, the DWC will issue three QMEs for the case. You have ten days from the issuance date to choose a QME. If you miss the deadline, the claims administrator will select the physician.

The QME you select makes essential medical decisions concerning your health. While you can dispute some decisions or defer them to a judge, their original decision can influence your outcome.

One mistake most plaintiffs make is selecting a medical expert based on their immediate availability or a QME they believe will speed up their case. While an expert with an open calendar can see you sooner, if you want someone good, find a busy person. Typically, reliable QMEs are busy. Waiting longer for your initial appointment with an experienced, renowned, and skilled QME is worth the wait.

Additionally, please do not choose a physician because their office offers you good customer service. Friendly customer care services do not necessarily mean they are competent QMEs. Select a professional who spends quality time with you and your medical records and analyzes the records to understand the case better.

Finally, select a QME with previous experience with the California workers’ comp system. They know how to write a convincing report to the judge.

Please note that you can replace a QME due to procedural violations like:

  • The expert is unable to complete their medical report timely
  • Two QMEs practice within the same medical group or office
  • Experts highlighted on the second QME list are the same as on the initial QME list

If a procedural violation exists, you can request a new list of QMEs.

What Occurs After the QME Report is Completed?

Your QME should send copies of their report to your lawyer, claim administrator, you, and the Division of Workers’ Compensation Disability Evaluation Unit (DEU). The DEU should then issue your injury rating within twenty days. The rating affects your settlement amount.

Find a Skilled Workers’ Comp Attorney Near Me

If you suffered work-related injuries, you might have expected the benefits under California workers’ compensation laws and counted on them for financial support through recovery. A claim denial can be devastating. Luckily, with the assistance of The Workers Compensation Lawyer Law Firm, an experienced Los Angeles lawyer, the denial does not have to be permanent. We know how vulnerable you feel and can work aggressively to reverse the decision. Let us handle the legal side of the case as you focus on your emotional and physical healing by contacting us at 424-501-9228.