What if my workers’ compensation claim is denied?
There are many steps you can take to appeal a denial of your claim and get benefits for your work injury.
Workers’ compensation insurers use a shockingly high number of excuses to turn down a workers’ compensation claim, saying the injury wasn’t work-related, the person wasn’t injured enough to need medical care or time off from work, the person isn’t covered by workers’ comp or didn’t report the injury correctly, the injury is due to a pre-existing condition… and on and on.
If your claim has been denied by your employer or their insurance carrier, don’t get too discouraged. There are steps you can take to appeal a denial, and a recent study found that 67% of denied claims end up getting paid, and the amount awarded ends up 55% higher than the original claim on average! Get a workers’ compensation attorney on board to review your claim and prepare a strong case for your appeal.
Workers’ compensation hearing
If your claim is denied, you can request a hearing with the Workers’ Compensation Appeals Board (WCAB). The WCAB is part of the Division of Workers’ Compensation (DWC) and maintains offices throughout California. To get started, file an Application for Adjudication of Claim to open a case get a case number. You will also need to file a Declaration of Readiness to Proceed to request a hearing before your local WCAB judge.
In preparing for the hearing, your attorney will conduct discovery by collecting documents and records, taking depositions, etc. Depending on the issues, your case could get resolved at a priority conference or pretrial conference before a hearing is ever held. If not, the case will be set for trial before the judge at your local WCAB office. This hearing is structured like a courtroom trial, but it is less formal; it does not take place in a courtroom, and the strict rules of evidence do not apply. An attorney familiar with workers’ compensation hearings will know how to prepare you for the hearing and present your strongest case.
Petition for reconsideration
The WCAB hearing is your best chance to get the judge to rule in your favor and turn a denied claim into a paid claim. If the hearing doesn’t go your way, however, you have a limited right to appeal that decision to a panel of judges at the WCAB office in San Francisco. You request this hearing by filing a Petition for Reconsideration at your local WCAB office within 20 days from when the judge’s decision was handed to you or 25 days from the date of the decision if it was mailed to you.
A petition for reconsideration should argue either that the judge’s decision was unsupported by the evidence or you have new evidence to present that wasn’t available at the time of the hearing. The WCAB in San Francisco might decide your appeal based on the documents you submit, or they might schedule a hearing if there is new evidence to present.
Appellate Court
If the WCAB decision was unfavorable, you can appeal to state court by filing a Writ of Review with the California Court of Appeal. To be successful here, you would have to prove that the WCAB acted arbitrarily or unreasonably and against the weight of the evidence, which is a difficult burden to meet. You have 45 days to file an appeal in state court.
The final step if the appellate court rules against you would be an appeal to the California Supreme Court. The state’s highest court is only likely to consider your appeal if it presents a new issue that has not been decided before, a constitutional question, or an issue that is considered of high importance for all employees statewide.
As you can see, although there are many steps available to appeal a denial of your claim, the further you go, the harder it gets to be successful. Resolving your case at an earlier stage is more likely to be successful and will also help you get your benefits sooner rather than later. Getting an attorney on board as soon as your claim is denied or delayed will help. If you wait to call a lawyer until you’ve already tried and lost a WCAB hearing, it can be much harder to get the benefits you need to deal with your work injury.
