When a San Jose worker suffers workplace injuries or another issue related to the job that leaves them unable to work, there is an automatic belief that they will be free to use workers’ compensation benefits as they are treated. However, there are times when a claim is denied. If there is a denial, it is due to the workers’ compensation claims administrator believing that the injury is not covered. A worker can challenge the decision. It is important to note that there are deadlines for the challenge.
While the claim is underway, the administrator might also disagree with the reports from the treating physician regarding the injury itself or the treatment that is being provided. If that is the case, there can be an evaluation by a qualified medical evaluator (QME). A separate doctor called an agreed medical evaluator (AME) can resolve any dispute. If there is a disagreement regarding the medical treatment the treating physician recommends, it must be resolved by an independent medical review (IMR).
To object to the claim denial, a case must be filed with the Division of Workers’ Compensation (DWC). The case is decided without a judge or jury at a DWC office. To file the case, there must be an Application for Adjudication of Claim. It must be filed either in the county where the injury occurred or where the claimant lives. It is possible to have a hearing before a judge by filing a Declaration of Readiness to Proceed. This will be a mandatory settlement conference (MSC).
The claimant and the claims administrator or their legal representation will appear in front of a judge. An attempt will be made to settle the matter. If this cannot be done, the dispute must be argued with documents and witnesses. There will then be a trial date set. Another judge will oversee the actual trial. The decision usually comes one to three months after the trial. If it is still denied, it is possible to request a reconsideration via petition.
For injured workers who are expecting to receive workers’ compensation, one of the most stressful issues they can face is if they are told that their injuries do not meet the criteria for benefits. This does not necessarily mean the case is over. Having legal assistance from an attorney who is experienced with workers’ compensation and denied claims is essential when trying to get benefits.
Source: dir.ca.gov, “If my claim was denied,” accessed on July 25, 2017