Reasons Your California Workers’ Compensation Claim May Have Been Denied

If your claim has been denied, it’s not yet time to despair. In some cases, the denial is easy to repair. In other cases, appealing a denial may involve filing complex forms on time and having your case heard before a judge.

▪Failure to Report Your Injury or Illness to Your Employer In California, the first step in pursuing workers’ compensation benefits is to report your work-related injury or illness within 30 days of being injured or becoming aware of an illness. If you didn’t report the incident or illness, your claim will be denied.

▪Failure to Meet the 30-day Deadline If you do not report your injury or illness to your employer within 30 days, your claim will probably be denied.

▪Failure to File A Workers’ Compensation Claim Within A One-Year Deadline California law requires injured workers to file a CCR §10840 within one year. Failure to file in time, may disqualify you. However, exceptions to this may include the court‘s schedule or other extenuating circumstances that can extend beyond the one-year deadline. Other extenuating circumstances may include an injured workers’ lack of knowledge of how to file a claim or when an employer has misled an employee about workers’ compensation law.

▪Failure to Seek Proper Medical Treatment If you didn’t receive medical treatment commensurate with what you reported as your harm or didn’t seek any medical care, the workers’ compensation insurance company may believe you’re falsifying your claim and deny it. To protect yourself, even if you didn’t believe your injury required medical care, you should still see a qualified workers’ compensation physician.

▪Accident Report and Initial Medical Report Conflict If the injury or illness you reported to your employer isn’t consistent with the initial physician’s medical report, the insurance company will be suspicious of your claim.

For instance, if you claim you had an on-the-job concussion, but a specialist can find no brain injury or symptoms consistent with a concussion, your accident report may be viewed as inconsistent with a medical evaluation and, therefore, deny your claim.

▪Injury or Illness is from A Pre-existing Condition If you had a pre-existing non-work-related injury or illness but claim your workplace is responsible, your claim will usually be denied. Even if a new injury exacerbated a pre-existing condition, your claim may still be denied.

▪Alcohol or Drug Test Refused or Failed

If you either refused or failed a drug or alcohol test, your claim may be considered invalid and denied. While California’s workers’ compensation is technically a no-fault system, the no-fault clause does not apply to workers’ who were injured while under the influence of drugs or alcohol.

▪Willful Negligence or RecklessnessIf evidence clearly suggests that you were engaging in reckless or carless conduct that resulted in an injury or illness, this will likely to be a reason for a claim denial.

▪Undetermined Cause of Injury If the cause of an injury or illness cannot be identified, your employer’s workers’ compensation attorney may claim the incident was not work related.

▪You Filed A Claim After You Were Terminated If you only filed a claim after you were fired, an insurance company may consider your claim retaliation. Your claim may be viewed as irrelevant because if you didn’t report an incident while employed, it must not be serious. But if you believe you were fired in retaliation for filing a workers’ compensation claim, you may have legal recourse for damages and/or your job back.

▪Refusal to Make A Recorded Statement An insurance company may have grounds to deny your complaint if you refuse to make a recorded statement. But complying with such a request could be detrimental to your case. When involved in an insurance investigation, you should never make a recorded statement without the advice of a qualified workers’ compensation attorney.

▪Refusal to Sign Medical Release Forms If your employer’s workers’ compensation company can’t review your medical records about your reported injury or illness, they can’t properly assess and evaluate your claim. So, a denial is highly probable.

▪Not Completing Paperwork Properly, Fully and Accurately It is imperative that you fill out all required forms in a complete and accurate manner, leaving no requested information or details out. While a denial on this basis can be corrected, it is likely to be considered grounds for a denial.

▪No Witnesses If your claim was filed only on the basis of your word, the insurance company may be suspicious and deny your claim, but it depends on various factors. However, depending upon the circumstances, this may or may not disqualify your claim.

▪Fraud If your employer’s workers’ compensation carrier has reason to believe your work injury or illness claim is fraudulent, they will have grounds to deny it. If you’ve provided information inconsistent with your injury or illness claim or you’ve been observed engaging in an activity not possible if you were actually injured the way you reported, your claim will be denied. When deemed necessary, your employer’s insurance company will use their resources to verify whether your claim is valid, honest and accurate.

▪Inadequate Documentation All details, facts, and reports related to your injury or illness must be presented and clearly communicated to both your employer and their insurance company. If you have not fully provided information, your claim will likely be denied.

Appealing A Workers’ Compensation Claim Denial is A Complicated Legal Process

When you receive your disqualification notice, CCR §10840 will be included. To appeal a benefits disqualification, you must complete and return the form within 30 days of the date on the notice. When a workers’ comp claim is denied, it means the claims administrator believes your injury is not covered by workers’ compensation. In this case, you have a right to challenge the decision but must follow stringent, inflexible established deadlines. If you appeal a denial of your claim, your case will be heard by a workers’ compensation administrative law judge (WCJ) at one of California’s 23 local offices or by satellite.

There are specific ways to file an appeal including:

Petition for Reconsideration & Petition for Removal (CCR §10840). Petitions for reconsideration, removal, or disqualification and answers must be filed with a Workers’ Compensation Appeals Board district office or with the office of the CCR §10840.

or

CCR §10840 (Labor Code §5950, et seq.)  A claimant who has been denied a workers’ compensation claim by a final decision of the Appeals Board CCR §10840 district in which the party resides for review.