The Workers’ Compensation Insurance Rating Bureau of California reported in 2015 that the state had higher premium rates than any other state in the country. Additionally, the state is near the top of the list when it comes to the average cost of medical benefits on every claim.
Unfortunately, that could be part of the reason companies or insurance providers are motivated to deny someone’s claim. There are a number of other reasons that someone’s request for benefits could be denied as well. It is important to know what could nullify a claim and what to do in the event this occurs.
Why are claims denied?
A claim for workers’ compensation benefits will have to entail an illness or injury that is work-related, such as falling on the job or developing a condition due to toxic substances at work. If the injury is not deemed to have been the result of employment, the claim will be rejected.
The State of California Department of Industrial Relations also notes that workers are required to report the injury to their employers within 30 days of the incident or learning about the illness. Failing to do so could likely mean losing the right to benefits.
Claims could also be denied due to the following:
A worker’s alleged role in the injury, such as being intoxicated at work
A claims adjuster believing the injury is not severe enough to warrant benefits
When a claim is denied, the worker will receive a letter that states the reason for the denial. This is essential to know when appealing the rejection.
What do I do if my claim has been denied?
People in California are entitled to challenge the decision regarding a denied workers’ compensation claim. The first step is to complete an application for an adjudication of a claim with the workers’ compensation office in either the county where the person was injured or the county where the person lives. Once the application has been processed, the worker can request a hearing with a judge by filing a form known as a Declaration of Readiness to Proceed.
During the initial hearing, both sides will present their case. If the parties cannot reach a settlement, the case may go to trial. The judge from that trial will make a decision, though it is possible to disagree with the decision and file a petition for a reconsideration of the claim.
In addition to filing a case, the worker may have to take additional steps. For example, if the claims administrator disagrees with a physician’s report, the injured worker can undergo an assessment from a qualified medical evaluator.
A denial of benefits can be detrimental not only to a worker, but also to his or her family. People who have concerns about this topic should speak to a workers’ compensation attorney in California.