Workers’ compensation is the country’s oldest social insurance program to reimburse employees injured on the job without regard to fault. In exchange for timely medical benefits and a portion of lost wages, workers cannot sue employers in Civil Court for workplace injuries. California businesses, under most circumstances, must carry this insurance. However, some companies may be eligible to self-insure if they can have sufficient funds to qualify.
If you are injured at work or become ill because of your job, it is important to know that this system is here to help you. However, if your worker’s compensation claim is not filed correctly, it may be denied. Denials usually occur when a claims administrator doubts an injury is work-related, or if the claim is incomplete.
If this is your experience, there is a process in place to appeal a denial. If you have received a denial letter from a workers’ compensation adjuster or your employer Visalia workers’ compensation appeals lawyer could help. A dedicated workers’ compensation attorney could guide you through this complex process and ensure that the legal requirements of your appeal are met. Call today to get started.
Claim denials are not the final word. If someone is denied benefits, the system allows an applicant to provide more evidence or clarify information in an appeals process. An adjuster has the power to grant or deny benefits and may reject a claim for reasons such as:
If an adjuster does not believe that the injury was work-related, a Visalia workers’ compensation appeals attorney could negotiate with the adjuster or their attorney. During negotiations, they could agree on a suitable physician, called an Agreed Medical Evaluator (AME), who can render an opinion about the applicant’s medical condition.
Qualified Medical Evaluators (QMEs) are licensed physicians explicitly trained to resolve applicants’ issues when there is a dispute with the treating physician’s opinion. The adjuster often requests this independent medical review, although the applicant and attorney are also able to make such a request. Employees who are refused benefits after suffering an injury at work should contact a Visalia workers’ compensation attorney for help proceeding with an appeal.
The process to appeal a workers’ compensation claim denial begins with filing an Application for Adjudication of Claim at the closest DWC site, which will also be the location of the trial court in which a judge will hear the case. After the adjudication paperwork is filed and a copy is supplied to the claim’s administrator, the DWC will assign a case number which, like any court filing, should appear on subsequent filings and correspondence. A Visalia attorney could guide an applicant from start to finish of this complex worker’s compensation appeals process.
Once a case has issues that the parties are unable to resolve and at least one of the parties feels the case is ready to proceed to trial, an attorney or a party will file a Declaration of Readiness to Proceed. This signals to a judge that the appellant and their lawyer are ready to schedule the mandatory settlement conference (MSC). The assigned judge functions similarly to a mediator, encouraging the appellant, the attorney, and the claims administrator to agree on an outcome satisfactory to both sides. If the Visalia worker’s compensation appeals attorney and the defendant disagree, additional paperwork is submitted, and a trial date is set. Details about the dispute, including a list of witnesses, why the parties disagree, and what evidence will be presented, are shared with all parties.
A different judge is assigned to preside over the trial, much like a civil trial with both sides presenting their cases. Usually, within 90 days of the case being submitted, the judge will issue an opinion, and if either side still objects, a Petition for Reconsideration can be filed.
It is stressful enough to be injured or fall ill on the job. When your workers’ compensation claim is denied, matters become even more overwhelming.
The appeals process is a flurry of paperwork, negotiations, settlement conferences, and possibly a trial. If your claim reaches this stage, you may not want to take the system on yourself, especially when you are injured or unwell. Our seasoned attorneys understand what the DWC is looking for, and we have experience providing the necessary forms, evidence, and skill for an appeal. A Visalia workers’ compensation appeals lawyer could work tenaciously to turn your denial into an approval. Contact our firm today to learn more.
