Receiving a denial letter after a workplace injury can be frustrating, especially when medical bills are accumulating or an injury prevents you from returning to work. A denial, however, does not necessarily end a California workers' compensation case.
California provides procedures for challenging disputed workers' compensation claims. The appropriate next step depends on where the claim is in the process and why benefits were denied. A worker challenging an insurance company's initial denial may need to bring the dispute before a workers' compensation judge, while someone challenging a final decision may need to pursue reconsideration before the Workers' Compensation Appeals Board.
For injured employees in Orange County, understanding these distinctions can help prevent missed deadlines and other mistakes that could affect a claim.
Why Are California Workers' Compensation Claims Denied?
A claims administrator may deny a claim because it believes the injury is not covered by California's workers' compensation system.
That conclusion can be based on many different issues.
Common disputes may involve allegations that:
- The injury did not arise out of employment
- The worker was not acting within the course of employment
- The condition was not caused by work
- The injury was reported too late
- The claim was filed outside an applicable deadline
- Medical evidence does not support the claimed injury
- The worker was an independent contractor rather than an employee
- The injury resulted from a non-work-related condition
- The employer disputes how the accident occurred
A denial reflects the claims administrator's position. It does not necessarily represent a final judicial determination that the employee is ineligible for benefits.
Our California workers' compensation attorneys can review the stated reason for a denial and determine what steps may be available to challenge it.
Can You Challenge an Insurance Company's Initial Denial?
Yes. California's Division of Workers' Compensation states that an employee has the right to challenge a claims administrator's decision denying a workers' compensation claim.
If the dispute is not resolved, the matter can be heard by a workers' compensation administrative law judge.
This is an important distinction from an "appeal" of a judge's final decision. When an insurance company initially rejects a claim, the worker generally needs to pursue the case through the workers' compensation adjudication process rather than immediately appealing to a higher court.
The worker may need to establish that the injury is compensable under California law.
That can require medical evidence, employment records, witness testimony, and other documentation supporting the relationship between the injury and the job.
What Happens After You Dispute the Denial?
A disputed California workers' compensation claim can proceed before the Workers' Compensation Appeals Board system.
The process may involve filing the necessary documents to establish the case, obtaining medical evidence, participating in conferences, and ultimately appearing before a workers' compensation judge if the parties cannot resolve the dispute.
The specific procedure depends on the issues involved.
Medical disagreements can be particularly important. The parties may disagree about:
- Whether employment caused the injury
- Whether work aggravated a prior condition
- The extent of permanent impairment
- Whether particular medical treatment is necessary
- Whether the employee can return to work
- The existence of temporary or permanent disability
Medical-legal evaluations can play an important role in resolving some of these disputes.
What Evidence Can Help Challenge a Denied Claim?
The evidence needed depends on the reason the claim was denied.
For an injury caused by a specific workplace accident, evidence may focus on establishing that the incident occurred and caused the employee's medical condition.
Potential evidence includes:
- Medical records
- Accident reports
- Witness statements
- Photographs or videos
- Employment records
- Communications with supervisors
- Time records
- Medical-legal evaluations
- Prior medical records
- Job descriptions
Cases involving cumulative trauma may require a different approach.
A worker who develops a repetitive stress injury over months or years may not be able to point to one accident. Medical evidence can instead become critical to establishing the relationship between the employee's work activities and the condition.
For an Orange County worker whose claim has been denied, identifying the insurer's actual reason for denial can help determine what evidence needs to be developed.
What if the Employer Says Your Injury Was Pre-Existing?
A prior medical condition does not automatically mean a workers' compensation claim is invalid.
Work can potentially cause a new injury or contribute to an existing medical problem. The relevant medical and legal questions can become complicated when both industrial and nonindustrial factors affect the same body part.
For example, an Orange County employee may already have degenerative changes in the spine but experience significantly worse symptoms after years of repetitive lifting at work.
The existence of degeneration does not, by itself, answer whether employment contributed to a compensable injury.
Medical evidence may be necessary to address causation and distinguish among the different factors affecting the worker's condition.
What if a Workers' Compensation Judge Rules Against You?
Once a workers' compensation judge issues a final decision, a different review process applies.
A party aggrieved by a final decision may seek reconsideration from the Workers' Compensation Appeals Board. The WCAB explains that reconsideration is generally available only from a final order and identifies specific statutory grounds for challenging the decision.
Those grounds can include claims that:
- The judge or Appeals Board acted beyond its authority
- The decision was obtained by fraud
- The evidence does not justify the decision
- Newly discovered evidence exists that could not previously have been produced
- The findings of fact do not support the decision
A petition for reconsideration is not simply an opportunity to restart the case because one party dislikes the result. The petition needs to identify a legally recognized basis for review.
How Long Do You Have to Seek Reconsideration?
Deadlines are particularly important in California workers' compensation cases.
The WCAB states that a party aggrieved by a final decision generally may petition for reconsideration within 20 days after service of the decision.
Rules governing service can affect the actual calculation in a particular case, so injured workers should not assume that they can simply count 20 calendar days and wait until the last moment.
The WCAB also requires petitions for reconsideration to be filed through the appropriate process, generally in the Electronic Adjudication Management System or with the district office having venue.
Missing a filing deadline can have serious consequences.
For that reason, an Orange County worker who receives an unfavorable final decision should have the document reviewed promptly.
What Can the Workers' Compensation Appeals Board Do?
The Workers' Compensation Appeals Board exercises judicial authority under California's workers' compensation laws and reviews petitions for reconsideration of decisions issued by workers' compensation judges.
Depending on the circumstances, the WCAB can deny reconsideration, grant reconsideration and issue a decision based on the existing record, or return a case for additional proceedings. Further proceedings can include additional evidence or other actions needed to complete the record.
This means a successful petition does not necessarily result in an immediate award of benefits.
The WCAB may instead determine that additional proceedings are necessary before the dispute can be resolved.
Can You Appeal Beyond the WCAB?
California law also provides a process for seeking judicial review of certain final WCAB decisions.
An aggrieved party may seek a writ of review in the appropriate California Court of Appeal after the administrative review process. The WCAB identifies Labor Code section 5950 and related provisions as governing writ proceedings.
Court of Appeal review is different from the initial process of challenging an insurer's denial and from seeking reconsideration of a workers' compensation judge's decision.
Each stage has its own requirements and deadlines.
For most injured employees, the immediate concern after receiving a denial letter is determining what stage the case is actually in and what procedure applies next.
What Should You Do After Your Claim Is Denied?
Read the denial letter carefully and keep a copy.
Pay attention to the reason given for denying the claim and any dates identified in the notice. Preserve medical records, communications with your employer, photographs, witness information, and other documents related to the injury.
Do not assume that the insurance company's denial is the final decision.
At the same time, do not ignore it. California workers' compensation proceedings involve deadlines, and waiting can make it more difficult to preserve evidence or pursue available remedies.
An Orange County workers' compensation attorney can review the denial, identify the disputed issues, and determine the next procedural step.
Talk With an Orange County Workers' Compensation Attorney
A denied workers' compensation claim does not necessarily mean you have reached the end of the process. California workers can challenge claim denials, bring disputed cases before a workers' compensation judge, and seek further review of certain final decisions.
If you are dealing with a denied workers' compensation claim in Orange County, our attorneys are here to help. Call us today or connect with us online to schedule a consultation.
