Was Your Claim Denied in California?

Workplace injuries or illnesses should be covered by your employer’s workers’ compensation insurance. The majority of employers in California are required to have insurance cover in case of an accident at work or industrial illness. Workers’ compensation can help to pay for a worker’s medical treatment and a portion of lost earnings.

Although workers' comp is a no-fault type of insurance, there is no guarantee that it will be honored. A denial of compensation or an award that is much less than you expected can be worrying and may force you to make an appeal the decision. Compensation may still be awarded even after an initial denial with the help of an experienced attorney.

Workers Compensation Law in California

Workers’ compensation in California is overseen by the Division of Workers’ Compensation (DWC). The DWC ensures that employers have insurance and pay what is entitled. This includes adjudicating disputes when employers’ insurance companies refuse to pay compensation or only agree to pay smaller than claimed amounts.

Generally, workers’ compensation insurance in California ensures that injured workers or those who suffer from an industrial illness are able to pay medical expenses and receive compensation for lost earnings. In the first instance, an employee who suffers an injury or becomes ill should notify their employer as soon as possible. The employee should complete the relevant claim form provided by their employer who will then pass on the form to the insurer.

California Worker's Comp Case Lawyer

The employer is bound by law to provide immediate medical cover up to $10,000 irrespective of any decision about the claim by the insurer, who should notify the employee in any case within 90 days whether the claim is to be honored or denied.

Why Your Claim Could be Denied

There are strict time limits imposed if you are injured or become ill at work. You must advise your employer of your condition in time and commonly a denial of a claim happens because the claim has been submitted too late. Because the insurer depends on your employer to provide information about the incident that caused the injury or illness sometimes there are incidences of information being submitted incorrectly. The reasons for a denial may be because the insurer alleges that you:

  • were not at work when the injury or illness developed;
  • that the injury or illness was not sufficiently serious to warrant medical treatment or paid time off work;
  • deliberately caused an injury in order to obtain compensation;
  • were intoxicated at the time of the injury;
  • did not obey safety precautions or deliberately refused to use safety equipment.

Workers’ compensation is a no-fault insurance so the insurer cannot deny you compensation just because it has been alleged that an accident was your fault. A denial does not mean you cannot obtain compensate, but you will have to submit an appeal.

The California Workers' Compensation Appeals Process

If your claim is denied or the amount awarded is too little, you should submit an appeal to the nearest state Division of Workers’ Compensation. The office will appoint a workers’ compensation administrative law judge (WCJ) to hear your case and make a decision based on evidence that you have available to support your claim as well as evidence from the insurer to counter it. You will be notified of a hearing where you can either represent yourself or have an attorney. The claims administrator or an attorney representing the claims administrator will also be present. If no amicable agreement can be made at the hearing, a trial will be arranged to be heard by another judge.

Why a Workers' Comp Attorney May be of Help

It’s bad enough having an accident or suffering an illness at work, but it’s even worse if you cannot obtain compensation to cover medical costs and lost wages. The appeal process can seem quite confusing and there are demands n you t have sufficient documentation too back up your initial claim for compensation. The insurance company that is supposed to provide your employer with workers’ comp. insurance will no doubt have legal assistance to help them present their case in the event that you challenge a denied claim. It may be sensible on your part to use a workers’ comp. attorney to help you make a case for a review of the decision when you go to a hearing or, if necessary, to a trial.

Additional Resources