Managing a Denied Claim

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CHALLENGING A DENIED WORKERS COMPENSATION CLAIM

Work Injury Lawyer Los Angeles

There are multiple ways that you may be injured at work, whether it’s through sustaining a direct injury, a compensable consequence injury, a psychiatric injury, or cumulative trauma injury. Generally, employers are insured as per the legal requirement in the State of California, and workers’ compensation benefits are paid out by the relevant insurer. However, it is widely known that insurers will look for ways to avoid liability and deny payment of claims.

If you have sustained an injury while at work and your claim has been denied, it is very important to know what steps to take. If you have not already found a lawyer to assist you with your case, this would be the time where you’d need to seriously consider that. You may contact our Los Angeles Workers Compensation Attorneys anytime.

In order to provide you with a general overview of the topic, and to help you make the right decision on the steps following a denied workers’ compensation claim, we have provided below an outline of the most important information relating to a denied workers’ compensation claim.

What does it mean for my claim to be denied?

If your claim was denied, this effectively means that the claims administrator does not believe that your claim is covered by workers’ compensation benefits. The denial of the claim happens through a letter which the claim administrator sends to you.

What can I do if I receive a letter denying my claim?

If you receive such a letter by the claim’s administrator, do not despair. You have a right to challenge the decision. It is important, however, that you act promptly and avoid any delays because filing the necessary paperwork is connected to particular deadlines which you should not miss.

In order to contest the denial of the claim, a case can be filed and may be heard by a workers’ compensation administrative law judge. You may represent yourself, or you may wish to appoint an attorney, which is the option that we would recommend. Contacting one of our experienced Workers Comp Attorney Los Angeles is always a good idea when faced with a hearing before a judge in respect of contesting a denied claim.

Where can I file my objection to the denial of my claim?

If you wish to contest a denial, then you would need to file a case, as said above. This can happen at one of the DWC offices, which total at 24 and are located around the State of California. Each office is also the trial court where the cases with respect to the denied workers’ compensation claims are adjudicated and decided upon. Please note that there is no jury involved in this process, only a worker’s compensation judge.

How do I file my case?

What you would need to do is file an Application for Adjudication of Claim. As said in the point above, this application needs to be filed at a DWC office – particularly the one in the county where you live, or where the injury occurred.

Subsequently, you must properly serve the claims administrator (or any other relevant party, such as your employer, depending on the case) with the application.

After filing the application, the following needs to happen:

  • You will receive a notice by the DWC office where you filed your claim that contains confirmation that the case has indeed been filed;
  • The notice you receive shall include your assigned case number, which needs to begin with “ADJ”, and a sequence of numbers will follow;
  • You need to keep this notice, and the relevant case number will need to be used going forward on all documents and correspondence which relate to your case in any way;
  • You then must file a Declaration of Readiness to Proceed, with which declaration you effectively request a hearing before a judge;
  • Your case will be scheduled for a hearing, which hearing is called a mandatory settlement conference (MSC). You must appear at the scheduled hearing in person or your attorney may appear on your behalf if you are represented by counsel.

What can I expect of the hearing?

You and your claims administrator, or your attorneys if such have been appointed, shall need to appear before a judge. Please note that at this stage, if you decide to represent yourself you might put yourself in a disadvantageous position if you do not have sufficient knowledge of the requirements of the law.

The judge’s primary goal will be to attempt to aid the Parties (meaning you and your claims administrator) in reaching a settlement, and thus finding a somewhat amicable solution which would satisfy both Parties to some extent. If no settlement is reached, then further documentation and preparation shall be needed. This would include on your part, the following:

  • Documents that outline the dispute;
  • Identifying the items that you will present at trial, and all relevant information pertaining to the case (medical reports/records, other pertaining documents, etc.);
  • Identify the names of any witnesses that may be relevant to the dispute, which you shall ask to testify for your benefit;

After the aforementioned has been fulfilled by both Parties, the judge will schedule a trial date. However, the trial itself may be held and adjudicated by a different judge. It is important that you personally attend the trial.

When can I expect a decision?

The judge will usually aim at delivering a decision within a period ranging from 30 to 90 days after the date of the trial. After issuing the written decision, the judge will then send it to you via email and mail.

What if I do not agree with the judge’s decision?

The judge’s decision on the case is not final. If either you or the claims adjudicator disagree with the judge’s decision, the next possible step to be undertaken is filing a Petition for Reconsideration.

The Petition for Reconsideration is effectively what allows you to appeal the decision made by the workers’ compensation judge. Filing such an appeal through a Petition for Reconsideration must be done within a specific time period. The local district office of the Workers’ Compensation Appeals Board (WCAB), which issued the decision, must receive the document for appeal (the Petition for Reconsideration) within 20 days of issuing the decision.

Please note timing is not when you have filed the Petition, but when the WCAB has received it – so timing is of the essence, as is often the case when dealing with issues of legal nature. If the decision has been sent to your house via post, then the period would be 25 days after receiving the decision.

The Petition for Reconsideration includes a list of reasons that you may have for appealing the decision by the judge. Prior to filing, you would need to remove by striking out the items which are inapplicable to your particular case. All of the items which you have left as relevant to your decision for appeal must be supported by extensive and thorough legal argumentation and full explanation. If you are represented by an experienced workers compensation attorney, he or she can properly draft and timely file the Petition for Reconsideration on your behalf.

What if the amount of my benefits is the issue which causes disagreement?

In many instances, the claims administrator does not want to pay and thus disagrees with the estimate given by your doctor with respect to the treatment necessary for your injury. Where there is such a disagreement on whether or not your claim is actually covered by workers’ compensation benefits, this is decided in most cases through an evaluation conducted by a qualified medical evaluator (QME).

QMEs are generally physicians, who also satisfy additional requirements with respect to both education and licensing, and they also take part in educational sessions which provide them with knowledge on the specifics of the workers’ compensation evaluation process. An alternative of the QME is an AME – an agreed medical evaluator, which your attorney (if you have one) and your claims administrator have agreed upon.

Please note that for all injuries sustained on or after Jan. 1, 2013, any disagreement with respect to a specific type of treatment that has been recommended by the treating physician is resolved through an independent medical review (IMR).

Conclusion

It is very important for employees whose claims have been denied to be aware that their rights do not stop there and that they are entitled to dispute the denial, as well as appeal the decision of the judge should he or she not rule in their favor. Claims administrators often take advantage of the scarce knowledge that workers have with respect to their rights, as well as the fact that the legislation is complicated and confusing, which may lead to people being unaware or unwilling to continue fighting for what are essentially benefits that they are entitled to.

Claims adjusters are experienced in dealing with workers compensation claims on a daily basis. They have a clear advantage of using this professional knowledge and experience against you, that it why we highly recommended that you hire an experienced workers comp attorney to fight on your behalf and obtain the maximum benefits that you are entitled to.

If you have a workers’ compensation claim which has been denied, you are free to pursue the matter further on your own and to represent yourself. However, hiring an experienced professional in the field will allow you to avoid any mistakes caused by lack of experience and knowledge on your part. Our Los Angeles Workers Compensation Lawyers remain available to be contacted by any potential clients who feel like they are entitled to receive workers’ compensation benefits, but their claim has been denied.

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