Delayed and Denied Claims

There are many reasons why your claim was delayed, including:

• The claim administrator needs more information from your doctor.
• The claim administrator needs to send adequate information to the physician reviewer.
• The injured worker did not seek timely medical care or file a claim on time.
• The doctor’s diagnosis was wrong or inadequate.
• The injury was not reported on time.

What happens if you file a worker’ compensation claim and your employer’s insurance ultimately denies your claim? Our Sacramento Worker’s Compensation Attorneys can tell you why your claim was denied and what you should do. Contact Sacramento Workers’ Compensation Attorneys, P.C. today to learn more about your options.

After filing a claim for workers’ compensation, your employer and their insurance have up to 14 days to decide whether to accept, deny, or delay a claim. During this time, your employer generally has to pay up to $10,000 for medical expenses. If your claim is delayed, the claims administrator has up to 90 days to decide whether to accept or deny your claim. If your claim is delayed for a medical issue, the claims administrator may tell you to complete a new evaluation from a Qualified Medical Evaluator (QME).

There are many reasons your claim could be denied. Here are the most common reasons workers’ compensation claims are denied:

• You missed deadlines.
  • If you don’t report your injury to your employer after 30 days, you may lose your rights to workers’ compensation.

• Your employer disputes the claim.

• The circumstances surrounding your injuries are not considered work-related.
  • You were drunk or using an illegal/controlled substance.
  • You started a fight.
  • You got hurt on purpose.
  • You were hurt during your lunch break and not on company grounds.
  • You were hurt while commuting to or from work.
• The injury is not severe enough to receive workers’ compensation benefits.
  • You don’t need time off or medical care to recover from the injury.
• The claim was filed after you left your job.

You still have the right to appeal the decision if your claim is denied. To appeal a denied workers’ compensation claim, you must have a hearing before the Workers’ Compensation Appeals Board. First, you must fill out an Application for Adjudication of Claim and a Declaration under the Labor Code with the Workers’ Compensation Appeals Board. This form should be filed within one year of your accident. Next, you or your lawyer will file a Declaration of Readiness to Proceed to request a hearing before a judge. This is known as a mandatory settlement conference. A Workers’ Compensation Appeals judge will review your case and hopefully settle it with the claims administrator. If nothing comes of the settlement conference, a trial will be set. The judge will issue a written decision, which will be sent to you in the mail. Depending on the outcome of the hearing, you can file a Petition for Reconsideration and, eventually, a petition with the California Court of Appeal.