If you were hurt on the job, you probably know your employer is required to carry workers’ compensation insurance, which provides payments for your medical treatment and lost wages. The system may even offer to retrain if you cannot return to your old job or provide you with permanent disability payments if your injuries are severe. However, there are cases where insurance denies your claim for compensation.
Thankfully, if you find yourself in this situation, you can usually file a claim to appeal the decision. An administrator usually denies a claim because they believe your injury or illness is not covered. Call a workers’ compensation attorney immediately if you receive a denial letter. A Fresno workers’ compensation appeals lawyer could help you resolve medical disputes and represent you in the trial court before the administrative judge.
When a claims administrator denies your request for benefits, the system provides avenues to settle the disagreement. First, an employee must determine why an administrator rejected a claim. Some common reasons are:
Some denials are easy to resolve, but others require more effort. For example, if a claims administrator believes an injury might not qualify for workers’ compensation benefits, a physician could serve as an agreed medical evaluator (AME) and work to settle the dispute if you have an attorney.
An administrator could also request a qualified medical evaluator (QME) to assess an injured employee. A QME is a physician with special training and credentialing who is assigned the Division of Workers’ Compensation (DWC).
Employees appealing a denial of workers’ compensation benefits must file an Application for Adjudication of Claim at a DWC office near where an injury occurred or where an employee lives. DWC offices and satellites are trial courts where a judge will first hear a case with no jury. A claims administrator must serve all parties involved in an appeal with the adjudication paperwork.
After an individual files adjudication paperwork, the DWC office will notify an injured employee of its receipt and the assigned case number, which an individual should include in all correspondence concerning the case.
An employee or their attorney could schedule a mandatory settlement conference (MSC) by filing a Declaration of Readiness to Proceed. The parties can attempt to settle at this conference, however if it is not settled the case can be set for trial
The defendant, injured employee, and Fresno attorneys make their cases to appeal a worker’s comp decision at trial. The workers compensation administrative law judge will take testimony, admit evidence and eventually issue a decision. An employee or administrator could file a petition for reconsideration if they still object to the judge’s ruling.
If you were injured or became ill because of your job, the State of California backs an insurance program that pays you temporary and permanent disability benefits and provides medical care, so you do not have to file a personal injury lawsuit against your employer. In fact, in California workers compensation is the exclusive remedy for almost all work related injuries. Sometimes, people reviewing these claims deny them, and you have the right to appeal that rejection.
Appealing a denied benefits claim includes extensive paperwork and strict deadlines. We could help guide you through this process. Our experienced team of attorneys and support staff is well versed in negotiations and trial work. A Fresno workers’ compensation appeals lawyer could help turn your claim denial into an approval. Contact us to start.