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Reasons Your Workers’ Compensation Claim May Be Denied

This blog discusses ten reasons your workers’ compensation claim might be denied in California. If you filed for workers’ compensation benefits and your workers’ compensation claim got denied, you need to know why your employer or their workers’ comp insurance carrier made that decision and what you can do about it.

According to the California Department of Industrial Relations (DIR), a claims administrator may deny a claim if they believe your injury does not qualify for workers’ compensation. You can challenge the decision, but there are deadlines to do so. 

Why Are Workers’ Compensation Claims Denied in California?

Let’s jump right into ten reasons claims administrators may deny workers’ comp claims.

The Worker Did Not Report Their Illness or Injury to their Employer by the Deadline

Injured workers in California have only 30 days to give written notice to their employers of a work-related illness or injury, per the DIR. When you are sick or injured, you understandably want to focus on your health and recovery, but you must still meet this deadline to prevent the denial of your workers’ comp claim.

The Claims Administrator Suspects the Workers’ Comp Claim Is Fraudulent

Many factors could be “red flags” to your boss or the workers’ compensation insurance carrier that a comp claim is suspicious. For example, a worker who has filed multiple claims in recent years could receive heightened scrutiny and investigation on subsequent claims.

If the employer or a healthcare professional thinks the wound might be self-inflicted, they might suspect fraud. Additionally, a worker with multiple claims who always has the same friends serve as witnesses might not appear to be an honest claimant.

The Claimant Did Not File by the Deadline

In addition to notifying your boss within 30 days, you must file your formal workers’ compensation claim within one year of the illness or injury, according to the California Department of Social Services. Missing this deadline can be grounds for claim denial.

The Medical Exam and Accident Report Conflict with Each Other

Let’s say the accident report said the worker injured their right leg. The medical exam revealed an injury on the left arm, but nothing was wrong with the worker’s right leg. When the medical exam results are inconsistent with the accident report, the claims administrator might deny the claim.

The Worker Did Not Disclose All of Their Injuries Initially

After an accident, people often tell the doctor about their most significant wounds, but fail to mention their minor aches and pains. They might hope the smaller injuries will improve on their own, or they do not want to complain.

Unfortunately, if you later seek treatment for an injury you thought was minor after it does not resolve on its own or gets worse, the claims administrator may deny that portion of your claim because you did not disclose it during the first medical examination. In this case, the administrator must assume the injuries you did not report initially are from a different event instead of the initial work-related accident. 

The Prescribed Medical Treatment Does Not Match the Injury Disclosed in the Workers’ Compensation Claim

When the workers’ compensation claim is for a back injury caused by lifting heavy objects, but the worker received treatment for a head injury, the claims administrator will likely deny the claim. The treatment must match and make sense with the workers’ compensation claim.

The Worker Had a Pre-Existing Injury or Illness Similar or Identical to the Current Claim

If you already had a similar injury to the same body part or a similar illness, you might face an uphill battle to prevent a denial of your claim. Sometimes, a claim can address the situation if an accident at work worsened a pre-existing condition, but winning a claim like that can be challenging.

You will need strong evidence of the severity of your previous condition and precisely how your work exacerbated it.

The Worker’s Recklessness or Intoxication Caused the Injury

Workers’ compensation insurance does not cover injuries resulting from horseplay at work. As such, the claims administrator will usually deny a claim in which a worker engaged in recklessness or willful negligence.

The Worker Was Intoxicated or Refused Drug or Alcohol Testing

Your employer has the right to demand you undergo drug or alcohol testing because the workers’ comp program does not cover injuries that happen when the worker is under the influence of alcohol or other drugs. Failing or refusing to take a drug or alcohol test can be grounds for denial of your claim.

The Worker Filed a Claim After Their Employment Was Terminated

While filing a claim after your employer terminates your employment is allowed, and many such claims are valid, the claims administrator could deny the claim if they believe you only filed it to retaliate against your employer and do not actually have a valid claim. 

On the other hand, if an employee gets injured and their boss immediately fires them to prevent the worker from filing a workers’ comp claim, the fired employee has legal options they can pursue against the employer. Firing a worker for filing a workers’ compensation claim is illegal.

How to Challenge a Denial of Your Workers’ Compensation Claim

The California Division of Workers’ Compensation (DWC) has several offices across the state. Judges hold trials about workers’ compensation claim disputes at these offices. These trials have only judges, not juries. 

To start the dispute process, you must file an Application for Adjudication of Claim in the correct DWC office. The correct office will be either in the county where the injury happened or where you live. 

Get Help From a Workers’ Comp Lawyer Today

We understand that the many rules and procedures involved in challenging a workers’ compensation claim denial can be confusing and overwhelming. Please do not give up on your claim before talking to a workers’ compensation lawyer at KJT Law Group. Call us today for a free consultation at (818) 507-8525.

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