It’s a nightmare scenario for an injured worker. You get hurt on the job; you make your report, file your DWC-1 form, and start treating your injury. Then, after the delay period, the insurance company sends you the notice: your claim is denied. How can they do this to you? The injury happened at work, and you know it’s real – maybe you can’t even work. What are you supposed to do?
Some injured workers give up and go back to work, which can make injuries even worse. The good news is that a denied Workers’ Compensation claim doesn’t have to be a nightmare. While it’s true that denied claims make for a more complex Workers’ Compensation process, a denial is not the end of the process – it’s just the beginning. There are many reasons claims get denied. Insurance companies deny valid Workers’ Compensation claims all the time, and you’re far from alone.
Get a Lawyer on your side
While some simple, straightforward claims can be handled without a lawyer, that is not the situation you’re in. Forcing an insurance company to accept your denied claim is a complex legal process that requires expertise. Bring in a Workers’ Compensation lawyer to do the heavy lifting.
Apply for State Disability
While your claim is denied, the insurance company doesn’t have to pay you anything. That means no wage replacement, no medical treatment, and no benefits of any kind. If you cannot work, SDI may be an option for you.
Get medical treatment
Even though the insurance company is not obligated to pay for your medical treatment while the case is denied, you still have to treat. Medical treatment is the most important part of your Workers’ Compensation claim. It’s crucial for your health, and it’s crucial because it makes up the legal evidence for your case. Unfortunately, your personal doctor might not be able to treat you for your workplace injury. In California, it’s illegal to charge injured workers for treatment for their work-related injury. Some doctors will provide treatment despite of this, but otherwise, you’ll need to receive treatment on a lien. A lien means that your doctor gets paid for your care after the case is accepted. Your Workers’ Compensation attorney will be able to find a doctor who will treat you on a lien basis – this can be very challenging to do on your own.
Have a Hearing at the WCAB (Workers’ Compensation Appeals Board) if there’s a factual dispute
The next step varies depending on why the insurance company is denying your claim. Sometimes, the insurance company will try and deny the fact that you’re an employee, or deny your case based on another factual dispute. In this situation, your Workers’ Compensation attorney will compile evidence and request a priority conference with the WCAB. At your hearing, which is like a less formal version of a trial, your attorney or a representative of your Workers’ Compensation law firm will present the evidence to a Workers’ Compensation judge. The judge then makes a ruling on whether the insurance company must accept your claim. If all goes well, your denied claim turns into an accepted Workers’ Compensation claim after your WCAB hearing.
See a QME/AME if you need to prove that your injury was work-related
If the insurance company is denying your claim based on causation, you need to see a QME/AME. A QME (qualified medical evaluator) or an AME (agreed medical examiner) determines whether your injury is work-related during an appointment known as a medical-legal evaluation. A QME is a special pre-approved doctor from a list managed by the state. An injured worker with a denied Workers’ Compensation claim is given three doctors to choose from. This is known as a panel. If you have an attorney, your attorney and the insurance company each strike a name from the panel, and the remaining doctor performs your evaluation. If you are unrepresented, you pick one of the three doctors yourself. The process for selecting an AME is a little different. An AME is a respected doctor agreed upon by the insurance company and your Workers’ Compensation attorney.
If the QME/AME rules that your injury is industrial in nature, the insurance company will (likely) have no choice but to accept your claim, though these reports can also be brought into question. Your medical-legal evaluation is also a crucial part of getting good results for your claim, as the QME/AME determines your level of impairment. It’s important to have a Workers’ Compensation lawyer by your side for this process. Workers’ Compensation attorneys know which medical-legal evaluators are trustworthy, and which medical-legal evaluators are to be avoided at all costs. Getting in to see a QME/AME can take a long time, so call an attorney right away to start this process.
The process of dealing with a denied Workers’ Compensation claim is challenging, but it isn’t impossible. If your claim has been denied, don’t give up. Call the best workers' comp attorneys and fight for your rights today. Pacific Workers', The Lawyers for Injured Workers has free consultations and you can do them from the comfort of your home. Call now for a free consultation 800 606-6999.