How to File a Worker’s Compensation Claim
If you have suffered a work-related injury, you will need the benefits that workers’ compensation insurance provides.
If your employer followed the law that requires them to purchase workers’ compensation insurance (they are subject to criminal penalties if they do not), you can receive the following if the insurance company grants your claim:
- Payment of medical costs for treatment that is related to your injury
- A portion of your lost income up to a statutory maximum
While you cannot sue your employer for a workplace injury or illness, the law makes it easier to receive workers’ compensation benefits, as you do not have to prove fault for your injuries. However, the claims process can still have its challenges and obstacles. Many injured workers greatly benefit from consulting with an experienced workers’ compensation attorney.
Not Every Workers’ Compensation Claim Is Straightforward and Easy
Not every workers’ compensation claim goes as smoothly as you expect when you file it. Some challenging claims include:
- Injuries that do not occur within the exact four corners of your job
- If you have a pre-existing condition that the insurance company may blame for your inability to work
- When you have suffered a cumulative injury, such as a repetitive motion injury
- When you have developed a work-related illness that may not be easily connected to your job
- When it is unclear which job at which you suffered an injury
Understand the Workers’ Compensation Process Before You File
Therefore, you should know as much as possible about the claims process before filing. There are strict timelines that you must follow to qualify for benefits. In addition, you should contact a workers’ compensation attorney in many cases at the outset of the process. While you need an attorney if you receive a claim denial, you should also consider getting help with your claim, especially when you anticipate a potential problem or have suffered an injury that can be permanent.
You Cannot File a Claim Unless You Give Timely Notice to Your Employer
You must do some things before you file a workers’ compensation claim. The most important thing you must do is notify your employer of the injury. This is a legal requirement under California law. You must notify your employer within 30 days of your injury. The notice to your employer must be in writing, and you should save a copy. Then, you have one year from the date of your injury to file an actual claim.
This requirement can be tricky when you have suffered a cumulative injury or a work-related illness. The employer may try to claim that you did not give notice of the injury in time.
Your employer may want to conduct an investigation of the accident or take other steps before you file the claim. They will certainly need to know about workplace accidents.
If you fail to give your employer the notice required by law, you can lose the ability to claim benefits entirely. Thus, it is crucial that you keep your eye on the calendar and not put off giving your employer notice.
You Need Evidence of an Injury to Qualify for Benefits
Before you file your claim, you will need evidence establishing that you suffered a work-related injury. This evidence is what the insurance company will consider in deciding whether to accept your claim.
One prerequisite is showing that you have suffered an injury. In California, the employer has the right to direct you to a physician from their network if you did not predesignate a physician with your employer before the injury. Your medical records must show evidence that you have an injury that will leave you unable to work.
Filling Out the DWC-1 Form for Compensation
In California, you will need to fill out your claim on Form DWC-1. First, you will complete the employee section of the claim form. You will return the form to your employer, who then fills out their part of the form. Once your employer completes the form, they will send it to the insurance company or their claims administrator.
The claim form itself only asks you brief questions about your injury. Whether your claim is successful depends on the investigation the claims adjuster performs. They will request access to your medical records. You will need to disclose each doctor you have seen, so they can obtain records from each one who provided appropriate treatment for your injury (the insurance company must restrict their inquiry to relevant medical records, and they cannot go on a fishing expedition).
Nonetheless, you must authorize the release of your medical records if you want your claim to be approved. In addition, you will need to cooperate with the investigation performed by the claims adjuster entirely.
The Claims Adjuster Will Conduct Their Investigation of Your Injury
The adjuster is trying to learn about the nature of your injury. First, they want to verify whether you have an injury preventing you from working. Second, they confirm that the illness or injury was related to your work. You must be careful when you are speaking with the claims adjuster. They can and will use what you say against you. Still, you must be truthful and honest with the claims adjuster.
One particular challenge is when you have some pre-existing condition. The adjuster may blame your inability to work on the pre-existing condition, which will relieve the insurance company from the obligation to pay your claim.
If you have any medical condition, the insurance company will look to make that the reason you cannot work. They will never hesitate to find a reason to make your life more difficult when you are at your worst.
Factually, the insurance adjuster may also try to question whether your injury stemmed from your job. If you suffered an injury in an on-the-job work accident, it will be much easier to prove that your injury was work-related. There may be more challenges when your injury happens off your employer’s premises or not during your regular work hours (such as on your lunch break). If there is any question about where, when, and how your injury occurred, the insurance adjuster may want to speak with witnesses.
The Insurance Company Has a Limited Amount of Time to Respond to Your Claim
Then, you will await the decision from the administrator or the insurance company. Whoever is handling your claim, whether the insurance company or your employer, has 14 days to notify you whether your claim is accepted. The insurance company may need more time to investigate and process the claim in certain cases. In those instances, they will notify you by that 14-day deadline that they will require an extension to investigate your claim further. If they do not deny the claim within a certain time from when you file, the law presumes the insurer approves your claim.
You Can Appeal if You Get a Claim Denial
If your claim resulted in a denial, you can appeal the decision. Your attorney can speak with the insurance company to clear up any misunderstandings that caused the denial. The insurance company may have noticed that some paperwork was missing or that you did not have essential information in your claim. Experienced workers’ compensation attorneys often resolve claims rather quickly in this manner.
The insurance company also does not want litigation. They must pay their own attorney to defend your case if you appeal the decision. However, it does not mean that they will approve any claim.
On the contrary, they may view your claim as an opportunity to try to save money at your expense. The insurance company often likes to deny your claim to force you to take the next legal step. Still, they may reverse themselves if you hire an attorney to push back. When you hire an attorney, the insurance company knows you mean business.
The California Workers’ Compensation Appeals Process
You have the right to appeal a denial of your claim. You will request a hearing before the Workers’ Comp Appeals Board. The administrative law judge will hold a hearing on the merits of your case. You can present evidence that shows that you have both suffered an injury and that it was work-related. You can call medical witnesses to explain your condition and fact witnesses who can testify about what happened. If you are not satisfied with the results of the medical examination from the employer’s doctor, you have the right to your medical examination.
You may seek an expedited hearing if the questions relate to whether your injury was work-related. The judge can issue a quicker ruling to decide this question.
The administrative law judge will consider the evidence and issue a ruling. Believe it or not, you have a decent chance of winning your appeal entirely, especially when you hire an attorney to help you argue your case. One survey found that roughly 70 percent of denied claims are converted to benefits through communication with the insurance company, settling your claim, or winning your appeal before a judge.
If you do not win your case, you must file a Petition for Reconsideration with the administrative law judge and point out how they made an error. You can take your case to the California court system if you are still unsuccessful.
Either way, the insurance company does not get the final say over your claim. They have financial interests, so you cannot trust them to make objective decisions.
You Should Hire an Attorney Whenever You Need Assistance
Depending on the complexity of your claim, you should consider hiring a workers’ compensation attorney to help with your claim. They can be available when the claims administrator questions your claim. You should particularly have an attorney if there are any issues regarding a pre-existing condition or a cumulative injury.
In addition, hire an attorney if you have a permanent injury because you will need a lot of money to cover your medical expenses. You may not even know about the potential problems until you receive the claim denial.
Your attorney can help you compile the necessary evidence and assist you in dealing with the requirements of the process. You may be unable to deal with any legal issues while getting medical treatment and trying to recover from your injuries.
The legal system understands that money is tight when you have suffered an injury and cannot work. The good news is that you do not need to pay a workers’ compensation attorney upfront to get them working for you. The attorney only receives fees if you win your case. Moreover, the attorney takes their fees from the proceeds of your benefits, and you never have to come up with the money to pay them from your own accounts.
The court will need to approve the percentage your attorney receives, depending on how much time they spent on your case. If you do not win your case, you do not owe your attorney any money for their time. Reach out to a personal injury lawyer.
If you have suffered a severe injury, the stakes are very high. You cannot afford to take any chances and leave your fate in the hands of the insurance company.