If your workers' compensation claim has been denied or rejected by your employer’s insurance company, you'll want to take steps to reverse that decision. In California, you can appeal a denial of claim by requesting a hearing in front of your local Workers' Compensation Appeals Board judge. At the hearing (which is like an informal trial), the judge can hear both sides of the case and make a decision on whether the insurance company must accept your workers' comp claim. (If you've already taken the matter to your local Workers' Comp Appeals Board (WCAB) and the judge didn't force the insurance company to accept your claim, you can appeal this decision -- for more information, see our article on appealing a WCAB decision.)
Workers' comp insurance companies deny claims for a number of reasons. Some insurance companies routinely deny initial workers' comp claims, betting that many injured workers will let the matter drop rather than pursue the claim. Other insurance companies accept valid claims but will deny claims it doesn't believe it should have to cover. Here are some legitimate reasons why a workers' comp clam can be denied:
To get the insurance company to accept your workers' comp claim, you'll need to request a hearing before the Workers' Comp Appeals Board (WCAB). Since your dispute with the insurance company is over whether your claim is "compensable" — that is, whether your injury is covered by worker’s comp and whether the insurance company has liability for the claim, yours will be a "trial on the preliminary issues."
In order to request this hearing before a WCAB judge, you (or your lawyer) will need to file a form called a Declaration of Readiness to Proceed (DOR). Before you file this form, however, you need to have filed an Application for Adjudication of Claim, which is part of fling your official claim and gives you a worker’s comp case number.
If the insurance company has denied your claim because it doesn't believe your injury "arose out of employment" (AOE, in workers’ comp terms — that is, your injury wasn't likely caused by your work activity) or that the injury did not happen "in the course of your employment" (COE — that is, the activity that caused your injury wasn't work-related), the WCAB judge will set an expedited conference date so that these AOE/COE issues can be resolved quickly and your claim can be accepted or denied. If the insurance company has told you that your claim was denied because of AOE/COE issues, on your Declaration of Readiness to Proceed form, you’ll check the boxes "Priority Conference" and "AOE/COE."
After you submit the Declaration of Readiness to Proceed form, a pre-trial conference may be scheduled (if your denial wasn’t based on AOE/COE issues—for instance, if the insurance company doesn’t believe you need medical treatment or are entitled to temporary disability payments for time off work). You should receive a notice of hearing that will tell you the date, time, and location of the conference. At the conference, the workers' comp judge will help you try to resolve the issue over whether the claim should be accepted or denied.
If the dispute can't be settled, the judge will then set the matter for trial — or, if the judge feels more information is needed before a trial can go forward, the judge will set up a "discovery plan" to come up with evidence to help determine the issues in your case. (In that case, the judge may also schedule a status conference to check on the sufficiency of the evidence discovered.)
Many disputes over whether a claim should be accepted or denied are settled at the pre-trial conference, and indeed most cases that get to this stage are accepted by the insurance company.
Before a hearing on compensability, if the insurance company is denying your claim based on medical issues, you'll need to see a doctor to have your injury or illness evaluated. If you are unhappy with the evaluation of your treating physician, you can request a medical-legal evaluation by another doctor. If the insurance company is unhappy with the evaluation of your treating doctor, the insurance company can request that you submit to a medical-legal evaluation by another doctor.
If you're not represented by an attorney, you'll choose from a panel of qualified medical evaluators (QMEs). If you do have a workers' comp attorney, your attorney and the insurance company will jointly choose an agreed upon medical examiner (AME).
If the insurance company has denied your claim (that is, disputes the compensability of your claim), and your injury was more than slight, you should hire a worker's compensation attorney if possible. If you lose on the compensability issue, you won't get any workers' comp benefits, including reimbursement for medical treatment, time off work, or a cash award for a permanent impairment that harms your ability to compete in the job market.
In California, workers' comp attorneys are compensated on a contingency basis from any workers' compensation award you receive (that is, if you don't get an award, the lawyer doesn't get paid). Judges will usually approve an attorney fee of 12-15% of your disability award, depending on the number of hours your attorney spends on your case.