What to do if Your California Workers Compensation Claim is Denied

What to do if Your California Workers Compensation Claim is Denied

When you file a workers’ compensation claim in California, you usually receive a decision about whether your claim was accepted within 90 days. Lack of response within 90 days counts as the claim being accepted. If your claim is denied, the Division of Workers’ Compensation will notify you of this decision no more than 90 days after you file form DWC-1. As disappointing as it may be to see your claim denied, it does not automatically mean that your only options for paying your medical bills are to borrow money or try your hand at crowdfunding. A workers’ compensation judge (WCJ) will re-examine your claim and may decide to have workers’ compensation cover your medical expenses. Some injured people represent themselves when getting their workers’ compensation claims adjudicated, but others choose to hire a workers’ compensation lawyer.

How to Have a California Judge Adjudicate Your Denied Workers' Comp Claim

When you find out that your claim was denied, the first step is to see a Qualified Medical Evaluator, a physician who has not been involved in your treatment but who is certified in reviewing workers’ compensation claims. The QME can give you a second opinion and advise you on how to present your case when applying for adjudication. You must them file an application for adjudication of claim. The information on this form is similar to that on the DWC-1 form, but more detailed. File one copy of the application for adjudication of claim with the court in your county and give another copy to your employer.

When the court receives your application for adjudication of claim, they will assign you a case number and give you instructions on how to prepare for your hearing. It is a good idea to hire a lawyer to help you prepare. When you are ready for a hearing, file a Declaration of Readiness to Proceed. The court will schedule a hearing called a Mandatory Settlement Conference. If you and your claims administrator do not reach an agreement during this hearing, your case will go to trial. It is almost always necessary to hire a lawyer to represent you at the trial and during the time leading up to it, even if you have been representing yourself until the Mandatory Settlement Conference.

How to Resolve Disagreements About the Amount Covered

Dealing with denied claims is not the QME’s only task. A QME can also help you if the Division of Workers’ Compensation has accepted your claim, but there is a dispute about which treatments they will cover or how much money they will allocate for your medical care.

When to Hire a Workers’ Compensation Lawyer

The safest choice is to consult a workers’ compensation lawyer as soon as you receive notice that your claim has been denied, even before the QME reviews your claim. Your lawyer can help you understand the legal implications of details that others involved in the process. They might even advise you about other ways of recovering compensation for your medical expenses, besides workers’ compensation.

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