5 Powerful Strategies to Overcome Workers’ Comp Treatment Denials in California
In California, workers’ compensation laws ensure that employees injured on the job receive the necessary medical treatment. However, treatment denials are common due to various reasons, including utilization review (UR), independent medical review (IMR), and disputes over medical necessity.
Here, we analyze five legal strategies to fight workers’ comp denials and California-specific laws and regulations governing the process.
1. Understand the Reason for the Denial
The first step is to request a detailed explanation from the insurance company. Under California workers’ compensation laws, they are required to provide a written explanation for the denial. Review this carefully to identify the specific reason and gather evidence to counter their claims.
Maintain Thorough Medical Records
Keep detailed records of all doctor's visits, diagnoses, and treatment plans. Also, emphasize the importance of seeing doctors who are familiar with the specific work-related injuries common in the area.
2. Appeal Through the Utilization Review (UR) and Independent Medical Review (IMR) Process
If you believe workers’ comp denials are unjust, you have the right to appeal. In California, you can request an IMR to have a neutral third-party doctor evaluate your case. If the IMR rules in your favor, the insurer must approve the treatment.
Legal Strategy
- Challenge Utilization Review (UR) Denials: Under California workers’ compensation laws, such as CA Labor Code § 4610, all treatment requests must go through a Utilization Review (UR), which determines whether the treatment is medically necessary.
- File an Independent Medical Review (IMR): If UR denies treatment, the worker has 30 days to appeal through Independent Medical Review (IMR) under Labor Code § 4610.5.
Key Regulations
- Timelines Matter: UR must decide within five business days, and an expedited review must be completed within 72 hours for urgent cases.
- Medical Evidence Required: The IMR process relies on medical records, expert opinions, and evidence from California Medical Treatment Utilization Schedule (MTUS).
Tactics
- Submit clear and thorough medical documentation proving necessity.
- Ensure doctors cite MTUS guidelines in their requests.
- If IMR upholds the denial, escalate it through WCAB.
3. File for a Workers’ Compensation Appeals Board (WCAB) Hearing
If the IMR doesn’t resolve the issue, you can take your case to the Workers’ Compensation Appeals Board (WCAB). An experienced workers’ comp attorney can help you navigate this process and present a convincing case.
The support you can get from the California workers’ compensation laws
- Petition for Hearing: If treatment is denied even after IMR and QME processes, the worker can file for a hearing with the WCAB under Labor Code § 5900.
- Request an Expedited Hearing for Medical Treatment: If the worker urgently needs care, they can request an expedited hearing under CCR § 10789.
Special recommendations
- Workers must file a Declaration of Readiness (DOR) to get a WCAB hearing.
- Employers and insurers must comply with the ruling or face penalties.
- Gather strong medical evidence (QME reports, expert testimony, MTUS compliance).
- Leverage employer violations (e.g., failure to conduct a proper UR).
4. Seek Legal Representation
Hire an experienced workers' compensation attorney who understands the complexities of California workers’ compensation laws.
Highlight that a local attorney will be familiar with the specific nuances of the Bay Area workers' compensation system.
Workers’ comp laws in California are complex, and insurance companies have teams of lawyers working to protect their interests. Hiring an experienced attorney in workers’ comp denials can:
- Help you gather evidence to support your claim.
- Represent you in hearings and appeals.
- Negotiate with the insurance company on your behalf.
- Ensure you receive all the benefits you’re entitled to.
If the insurer argues that your injury isn’t work-related or that you’ve reached Maximum Medical Improvement (MMI), they may refuse to authorize further medical care. That’s why several workers’ comp attorneys offer free consultations and work on a contingency basis, meaning you don’t pay unless they win your case.
Use the "Serious and Willful Misconduct" Exception
California workers’ compensation laws provide you with resources such as a Serious and Willful (S&W) Misconduct Claim. That’s to say, if the denial is linked to employer negligence, injured workers can seek additional compensation under California Labor Code § 4553.
Another relevant instance is the Employer Penalties for Bad Faith Denials. This means that if insurer or employer unreasonably denies medical treatment, they may be subject to penalties under Labor Code § 5814.
Key Regulations
- Penalty: Up to a 50% increase in benefits for employer misconduct.
- Claims must show evidence that the employer intentionally disregarded safety rules.
What to do
- Gather workplace safety violations to prove misconduct.
- Consult an attorney to assess viability.
- File a penalty petition if the insurer acted in bad faith.
5. Request a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME)
If the insurer disputes the medical necessity of your treatment, consider getting a Qualified Medical Evaluator (QME). A new medical report supporting your need for treatment can strengthen your case.
In connection with workers’ comp denials,it’s mandatory to get a strong treating physician. Find a doctor experienced in workers' compensation cases who can provide clear and comprehensive medical reports.
Recommend seeking doctors who are well known within the Bay Area medical community and have years of experience with workers compensation cases.
What California workers’ compensation laws offer
- Dispute the Denial with a QME: Under California Labor Code § 4062, if an injured worker disputes the denial, they can request a QME to provide an independent assessment.
- Agreed Medical Evaluator (AME) for Represented Employees: If the worker has an attorney, they can use an Agreed Medical Evaluator (AME) instead of a QME.
To Keep in Mind
- QME Panel Selection: Injured workers receive a panel of three QMEs from the Division of Workers’ Compensation (DWC) and must select one.
- 30-Day Window: The worker has 30 days to request a QME evaluation after receiving a denial.
Strategies
- Select a QME with expertise in the relevant medical field.
If a QME supports the treatment, use the report as evidence in WCAB hearings. - If unsatisfied with QME findings, request a replacement QME under specific legal grounds (e.g., bias, procedural errors).
Don’t Let a Denial Stop You—Take Action Today
If 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 California workers’ compensation laws 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.
Conclusion & Next Steps
Key Takeaways
✔ Act quickly – strict deadlines apply for UR, IMR, QME, and WCAB hearings.
✔ Strong medical evidence is critical for appeals.
✔ Legal assistance increases success rates in disputes.
✔ Employers and insurers can face penalties for bad faith denials.
Next Steps for Injured Workers
- If your treatment is denied, start by filing an IMR within 30 days.
- Consider hiring a workers’ comp attorney to navigate QMEs and WCAB hearings.
- Keep records of all denials, medical reports, and communications with your employer/insurer.
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 assist with empathy and world-class customer service. He fosters a supportive atmosphere, which is why each one of his team members 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.