Being injured on the job in California is a stressful experience. You expect workers' compensation to cover your medical treatment, but what happens when your claim is denied? Workers’ comp denials are a frustrating reality for injured workers in cities like Sacramento, Oakland, Concord and all over Northern California.
Understanding why these denials occur and knowing how to fight them is the first crucial step to help you get the care you need. We wrote this article which breaks down the common reasons for treatment denials and provides you with actionable steps to challenge them.
Why Workers’ Comp Denies Treatment
Workers’ compensation is designed to provide medical care and financial support to employees injured on the job. However, we’ve mentioned in many of our blogs and Work Comp Talk Podcast Episodes that the insurance companies often prioritize their bottom line over your well-being, leading to denied treatments. Keep reading to learn some of the common reasons for claim denials:
Insufficient Medical Evidence
- Documentation is key! Workers’ comp denials are common when insurers discover that the medical reports lack detailed information connecting your injury to your work.
- Bay Area Specific: High-stress warehouse environments such as Tesla in the city of Fremont, CA., and the Amazon facilities in Oakley, Ca are where repetitive strain injuries are common, but often difficult to document.
Disputed Injury Causation
Insurance companies may argue that your injury is not work-related due to a pre-existing condition or an off-the-job incident.
With such diverse range of industries in Northern CA, such as construction in the East Bay to hospitality in the city of San Francisco, our law firm frequently learns about different interpretations of how an injury occurred. Some of our findings are honestly occurred.
Independent Medical Reviews (IMRs)
- California allows injured workers to request Independent Medical Review, IMRs, where a doctor, chosen by the state, reviews your medical records. These reviews can sometimes lead to denials if the IMR doctor disagrees with your treating physician.
- Bay Area Specific: Due to the high volume of cases, IMRs can create delays in receiving treatment. Available appointments are not always easy to find. For the city of Oakland, there are over 20,000 injury cases reported monthly.
Utilization Review (UR)
- Utilization Reviews URare used to determine if the requested medical treatment by your primary care physician is “medically necessary.” This makes the process longer for the injured worker, and sometimes they may deny treatments deemed unnecessary.
Cost-Cutting Measures
Unfortunately, the insurance companies may deny treatment simply to reduce costs, leaving injured workers like you without the care they need.
4 ways to Fight Workers’ Comp Denials
- Document Everything: Keep detailed records of your injury, medical treatments, and communications with your employer and the insurance company.
- Follow Your Doctor’s Advice: Stick to your treatment plan and attend all medical appointments.
- Know Your Rights: Familiarize yourself with California’s workers’ compensation laws to ensure you’re treated fairly.
- Act Quickly: Deadlines are critical in workers’ comp cases. Don’t delay in reporting your injury or appealing a denial.
Conclusion
If your workers’ comp has denied your treatment, you don’t have to accept it. The system is complex, but knowing your rights and seeking help can get you the care you deserve.
If you're an injured worker in the Bay Area facing a denial, contact our experienced team of workers' compensation attorneys for a free consultation. We can help you navigate the system and fight for your rights.
Remember, your health and well-being are worth fighting for.
About the author
Bilal Kassem President and Co-founder
Bilal Kassem, is the co-founder of Pacific Workers. Bilal has been nominated for Applicant Attorney of the Year. His passion for helping injured workers brings his leadership with his team to lead with empathy and world-class customer service. He fosters a supportive atmosphere, which is why each one of his team member feels empowered to excel. With a 98% success rate at Pacific Workers, Bilal is on a mission to continue to educate and serve any injured worker in CA.