What Is a Denied Claim in a California Workers’ Compensation Case?

In a California workers’ compensation case, a denied claim means the insurance company or self-insured employer has decided that it is not legally responsible for providing benefits for your injury or illness. This may apply to the entire claim or only certain parts of it, such as medical treatment or disability payments.

A denial does not end the case. Injured workers have the right to challenge the decision through the workers’ compensation system.

When Are Workers’ Compensation Claims Denied?

Common reasons for claim denials include:

• The injury is not work-related
• The injury was not reported on time
• There is not enough medical evidence
• The condition is pre-existing and unrelated to job duties
• The worker is classified as an independent contractor
• The claim appears to be exaggerated or fraudulent

The insurance company has 90 days from the date the claim form (DWC-1) is filed to accept or deny the claim. If no denial is issued within that time, the claim is presumed accepted under Labor Code section 5402.

How Will You Know if Your Claim Is Denied?

If your claim is denied, the insurance company must send you a written notice. This denial letter should include:

• A clear statement that the claim is being denied
• The reasons for the denial
• Information about your right to dispute the decision
• Contact information for the adjuster
• Instructions on how to request a Qualified Medical Evaluator (QME) if the dispute involves medical issues

What to Do After a Claim Denial

If your claim is denied, you can:

• Request a medical evaluation by a QME or an Agreed Medical Evaluator (AME)
• File an Application for Adjudication of Claim with the Workers’ Compensation Appeals Board (WCAB)
• Participate in a Mandatory Settlement Conference (MSC)
• Proceed to trial before a workers’ compensation judge if the dispute cannot be resolved

There are strict deadlines in the appeals process, so it is important to take action promptly.

Partial vs. Full Denial

Not all denials apply to the entire claim. A partial denial means that some benefits are approved while others are not. For example:

• Medical treatment may be approved, but disability payments are denied
• One body part is accepted, while another is denied

You can continue receiving any accepted benefits while disputing the denied portions of your claim.

Get Help With a Denied Workers’ Compensation Claim

If your workers’ compensation claim has been denied, legal guidance can help you navigate the process and protect your rights. The Law Offices of Norman J. Homen represents injured workers throughout California and works to secure the benefits they may be entitled to under the law.