Like any other type of insurance payment, you must file a claim for workers’ compensation benefits. The insurance company will review your filing and make a decision about whether you qualify for the benefits that you need to pay your medical bills and support your family. For some injured workers, the unfortunate reality is that the insurance company may deny your application. However, you have the right to appeal a denial, and the insurer does not have the final word.
The law entitles you to workers’ compensation benefits, so long as you:
- Prove that you suffered an injury
- Show that your injury was work-related
- Comply with the time deadlines, and technical requirements of the application process
However, not every injury is compensable. While most initial claims result in benefits, some of them are rejected at the insurance claim stage.
The most common reason why your claim may be denied is that the insurance company is questioning whether you have been injured and can still work. They may think that the medical diagnosis and information that you provided are insufficient to justify your claim of a debilitating injury that would keep you from working.
The insurance company may also claim that your injury had nothing to do with work. They may argue that it happened during your off-duty time and away from work premises. Alternatively, they may claim that your injury happened some other way than a work accident or condition. These denials are more common when you are claiming an injury that does not happen as a result of a specific accident, but because of:
- Exposure to toxic substances on the job
- Repetitive motion and the physical stress of the job
- Aggravation of pre-existing conditions (you can be paid benefits for this)
Because of the tight time constraints and the detailed procedural requirements, you must remain aware of deadlines and application procedures. The insurance company will insist on strict compliance, and if you miss a deadline, it could be the end of your efforts to obtain compensation.
The good news for you is that California law establishes a robust appeals process to challenge any denial of benefits. The first thing to do when you have been denied benefits is to contact an experienced workers’ compensation attorney to help with your appeal.
If the denial was the result of some missing information in your claim, you may have an easier time resolving it. Sometimes, an attorney can clear up problems by having a conversation with the insurance company.
You have the ability to provide additional information as part of the appeals process. You also have the right to have an administrative law judge review the insurance company’s denial of your claim. Many denials are overturned and converted to benefits through the appeals process. First, you must stand up for your own legal rights and fight an unfair and incorrect denial.