What Happens if My Employer Denies My Workers’ Compensation Claim?

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If you or somebody you love has sustained a workplace injury but received a claim denial from the employer or an insurance carrier, you may need to go through the official appeals process in order to recover the benefits you are entitled to. However, appealing a workers’ compensation decision can be challenging, and we encourage you to reach out to an attorney with experience handling these matters.

Filing an Appeal of a Denied Workers’ Compensation Claim

An employer will typically not be the entity denying workers’ comp benefits. That responsibility typically falls to a workers’ compensation claims administrator. 

Information directly from the California Department of Industrial Relations indicates that a claimed denial means that the claims administrator believed the injury was not or should not be covered by workers’ compensation insurance benefits. If a person wishes to appeal the denial of their claim, they will have to file the case with one of the 24 Division of Workers’ Compensation offices located within the state.

Each DWC branch is essentially a mini-trial court where disputes arising from workers’ compensation claims are heard by a judge. In order to have your case heard by a judge, you and your attorney must first file an Application for Adjudication of Claim.  The application must be filed in the county where the individual lives or where the individual sustained the injury, and the application must be served on all parties involved, including the claims administrator.

The office where the claim was filed will send a notice confirming they have received the filing. The notice will include a case number, which must be included with all documents and correspondence related to the case. In order to have the hearing heard before a judge, you and your attorney must file a Declaration of Readiness to Proceed.

At the hearing, the claims administrator or their lawyer will appear before the judge, and the judge will discuss the case with all parties involved and try to assist in reaching a settlement. If the case does not get settled, it will move forward to a trial where it will be heard by another judge. This judge will ultimately issue a written decision within 30 to 90 days after the trial.

In the event the claim is denied, you will receive a denial of benefits letter.

After receiving a denial of benefits letter, the next step in the appeals process is to file a motion for reconsideration. After this is filed, the California Workers’ Compensation Appeals Board will respond with its decision. Some of the possible outcomes of this decision include:

  • Denying the petition. The WCAB could either adopt the report and recommendation from the workers’ compensation judge or issue their own opinion about why the claim should be denied.
  • Granting the reconsideration and a decision. The Board could give its own decision after reconsidering the earlier findings, and this decision could be an order that the case returns to the workers’ compensation judge to continue the proceedings and a new decision.
  • Granting reconsideration for further proceedings. The Board could call for further proceedings that consist of rehearing the case to hear additional evidence or call for a new medical examination. A reconsideration could also occur to obtain a recommendation for a permanent disability rating or reassign the case to the full Board for reconsideration. 
  • Dismissing the petition. A dismissal may be issued for various reasons, and we recommend you speak to your attorney if this occurs.

Working With an Attorney

We strongly encourage you to reach out to a skilled Long Beach workers’ compensation attorney who can help you through this process. Appealing these denials is a challenging process, but an attorney can help you handle every aspect of the process, including filing the appeals and appearing before the judge.