Workers’ compensation and appealing denied claims in California

California workers who are injured and unable to work can seek workers’ compensation benefits to cover for lost wages and medical costs. A key to an approval is the claims administrator’s assessment of the injuries and whether workers’ compensation should cover it. If there is a denied claim, there are alternatives to try and reverse the decision.

Understanding the requirements to challenge the denial is key. The claims administrator could look at the case and dispute the treating physician’s assessment. A qualified medical evaluator (QME) will evaluate the case. In some cases, the claimant and the claims administrator can have an agreed medical evaluator (AME) look at the evidence and decide. Ongoing disputes will be resolved by an independent medical review (IMR).

To have a judge hear the case, there must be an Application for Adjudication of Claim. At a hearing, the claims adjuster and the claimant’s legal representative will appear. The judge will try to forge a reasonable settlement during the mandatory settlement conference (MSC). Without a settlement, the case will move to trial. A separate judge will oversee the trial. There will then be a written decision, generally, within 30 to 90 days. If there is, again, disagreement over the decision, a Petition for Reconsideration can be filed by either side.

A workers’ compensation claim could be denied for something as simple as a mistake when filling out forms, or it could be an outright dispute as to the extent of the injuries. Gathering all the necessary information and having witnesses can be essential to a successful appeal of denied claims. A denial does not automatically mean the case is over. To move forward with appealing a denied claim, a legal consultation can provide guidance and information on how to proceed.