Delayed and Denied Claims

Was your claim delayed or denied? Have you received a “Notice of Delay in Determining Liability for Workers’ Compensation” or a denial of benefits in the mail? This either means your employer or the insurance company needs more time to investigate or it has outright denied your claims. You may be confused. The last thing you need after your injury is to learn your workers’ compensation benefits are delayed or denied. A Sacramento Workers’ Compensation Attorney can help. Contact us today to learn more about your options.

    Why was my claim delayed?

    There are many reasons why your claim was delayed including:

    • The claim administrator needs more information from your doctor.
    • The claim administrator has not sent 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 filed a claim for workers’ compensation 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.

    How long will my claim be delayed?

    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 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).

    Why was my claim denied?

    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.
    What do I do if my claim was denied?

    If your claim was denied, you still have the right to appeal the decision. In order to appeal a denied workers’ compensation claim, you need to have a hearing before the Workers’ Compensation Appeals Board. First, you need to fill out an Application for Adjudication of Claim and a Declaration Pursuant to 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 reach a settlement with the claims administrator. If nothing comes of the settlement conference, a trial will be set. The judge will issue a written decision and it 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.

    What can Sacramento Workers’ Compensation Attorneys do?

    Our Sacramento Workers’ Compensation Attorneys understand the pain and anguish you’re experiencing because of your workplace injury. We are prepared to do whatever it takes to help you get the compensation you deserve. We can help you determine why your claim was delayed or how long your claim will be delayed. We can also explain why your claim was denied and help you determine the next step. If you have any questions, don’t hesitate to reach out to a Sacramento Workers’ Compensation Attorney.