How to Appeal a Denial of Workers’ Compensation Benefits in California

Receiving a denial of your workers’ compensation claim can be overwhelming, especially when you are dealing with a work-related injury or illness. In California, injured workers have the right to appeal if their workers’ compensation benefits are denied. Understanding the appeals process and the steps you can take to challenge the decision is essential to protect your rights and pursue the benefits you may be entitled to receive.

Common Reasons for Workers’ Compensation Denials

Before starting the appeals process, it is helpful to understand why your workers’ compensation claim may have been denied. Common reasons for denial include:

• Disputes about the cause of the injury: The insurance company might argue that your injury is not work-related, particularly in cases of repetitive strain injuries.
• Lack of medical evidence: Insufficient medical documentation can lead the insurance company to deny your claim.
• Late reporting: Failing to report your injury within the required timeframe can result in a denial.
• Pre-existing conditions: The insurer may argue that your injury was caused by a pre-existing condition and not related to your job.
• Failure to follow medical advice: Not adhering to the treatment plan prescribed by your doctor may also be a reason for denial.

Step One: Request a Qualified Medical Examiner (QME) Evaluation

In most cases, proving that your injury is work-related begins with an evaluation by a State Qualified Medical Examiner (QME). A QME is a neutral, state-appointed medical professional who assesses whether your injury or illness is related to your job. This evaluation is often the first and only step needed to establish your claim. If the QME determines that the injury is work-related, insurance companies generally accept the case.

However, there are circumstances where the insurance company may still choose to dispute or bypass the QME’s findings. These include situations where the statute of limitations has passed, or if an employee claims an injury after being terminated. In such cases, the insurer may reject the findings, regardless of the QME’s determination. It is important to be aware of these exceptions as you proceed.

What to Do If the Insurance Company Does Not Accept the QME’s Findings

If the insurance company continues to deny your claim despite the QME’s findings, or if you encounter one of the exceptions mentioned above, additional steps may be necessary to appeal the decision:

1. File an Appeal with the Workers’ Compensation Appeals Board (WCAB)
   Should the QME process not resolve the dispute, you can file an appeal with the Workers’ Compensation Appeals Board (WCAB). This involves submitting an “Application for Adjudication of Claim” in the county where you live or where the injury occurred. Along with this application, you must file a “Declaration of Readiness to Proceed” to request a hearing.
2. Attend a Mandatory Settlement Conference (MSC)
   After filing the necessary paperwork, you will attend a Mandatory Settlement Conference (MSC). This is an informal meeting aimed at settling the dispute without a formal hearing. If a resolution cannot be reached, the case will proceed to a formal hearing before a workers’ compensation judge.
3. Prepare for a Workers’ Compensation Hearing
   If the MSC does not result in a settlement, the case will move forward to a hearing. During the hearing, both parties will present their evidence, which may include medical reports, witness testimony, and employment records.
4. Await the Judge’s Decision
   Following the hearing, the judge will review the evidence and issue a decision. Depending on the outcome, you may choose to appeal further if necessary.

Tips for Strengthening Your Workers’ Compensation Appeal

• Consult with an attorney: An experienced attorney can help gather evidence, present your case effectively, and guide you through the entire process.
• Follow your doctor’s recommendations: Compliance with medical advice is critical to demonstrate the severity of your injury.
• File all paperwork on time: Missing deadlines can lead to further complications in your appeal.

Request a Free Consultation

If your workers’ compensation claim has been denied, do not hesitate to reach out. At the Law Offices of Norman J. Homen, we have extensive experience helping injured workers appeal their claims and navigate the legal process. Contact us today for a free consultation.