Work Injury Claim Was Denied

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My Work Injury Claim Was Denied

My Work Injury Claim Was Denied.  Now What?  When a claim is denied, it means the claims administrator believes your injury is not covered by workers’ compensation. If the claims administrator sends you a letter denying your claim, you have a right to challenge the decision. Don’t delay, because there are deadlines for filing the necessary papers. If you need help with your workers’ compensation claim, you can contact the Information and Assistance Unit. You may represent yourself or hire an attorney. If you contest the denial of your claim, your case will be heard by a workers’ compensation administrative law judge (WCJ) at one of the division’s 23 local offices plus satellites.

What if I have a disagreement about my benefits?

At some point during your claim, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. When there is a disagreement about whether your claim is covered by workers’ compensation, you may be evaluated by a qualified medical evaluator (QME). To qualify as a QME, a physician must meet additional educational and licensing requirements. They must also pass a test and participate in ongoing education on the workers’ compensation evaluation process. If you have an attorney, your attorney and your claims administrator might agree on a doctor to resolve medical disputes. This doctor is called an agreed medical evaluator (AME).

For injuries on or after Jan. 1, 2013, and as of July 1, 2013 for all dates of injury, disagreements about a specific course of medical treatment recommended by the treating physician can only be resolved through a process called independent medical review (IMR).

My Work Injury Claim Was Denied – I want to object to the denial of my claim

If you want to object to the denial of your claim, you will need to file a case at one the division’s 24 offices located around the state. Each DWC office is a trial court where disputes that arise from workers’ compensation claims are decided by a judge without a jury.

How do I file a case?

In order to have your case heard by a judge, you must first file an Application for Adjudication of Claim. The application must be filed at the DWC office in the county where you live or in the county where you were injured. You must serve the application on all other parties, which is generally the claims administrator.

What happens next?

The DWC office where you filed the application will send you a notice confirming that it has been filed. The notice will include your assigned case number, which will begin with the letters “ADJ” followed by a sequence of numbers. Keep the notice and use the assigned case number on all documents and correspondence relating to your case.

How do I get a hearing before a judge?

You must file a Declaration of Readiness to Proceed to request a hearing. Your case will be scheduled for a hearing called a mandatory settlement conference (MSC).

What happens at the hearing?

You and your claims administrator or their attorney will appear before a judge. The judge will discuss the case with both of you and try to assist in reaching a settlement. If your case is not settled at the MSC, you will need to prepare documents that outline the dispute, identify the items each party will present at trial and the names of the witnesses that each party will ask to testify. The judge will then schedule a date for trial.

The trial will be held before another judge. You must attend the trial. The judge will issue a written decision after the trial and send it to you by mail, which usually occurs between 30 and 90 days after the trial. If either you or the claims adjustor disagrees with the judge’s decision, you can file a Petition for Reconsideration.

Want to learn more? Find it in the guidebook

My Work Injury Claim Was Denied:  #AskNikkiNow

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Nikki Mehrpoo Jacobson, Certified Specialists in Workers’ Compensation Law
by the State Bar of California Board of Legal Specialization
Professor of Law
Legal Analyst

How To File A Workers’ Compensation Claim?


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File a claim form (DWC-1)

File a claim form (DWC-1) to protect your rights and start the workers’ compensation process. Your employer must give or mail you a claim form within one working day after learning about your injury or illness. If your employer doesn’t give you the claim form you can download it from the forms page of the DWC website.

How to fill out a claim form

Complete only the “employee” section of the form and send it to your employer right away. Be sure to sign and date the claim form and keep a copy for your records. Return the claim form to your employer in person or by mail. If you mail the claim form, use certified mail — return receipt requested — so you have a record of the date it was mailed and the date it was received. If you don’t return the completed form to your employer you may risk your right to benefits.

What happens next?

Your employer should fill out the “employer” section and forward the completed claim form to the insurance company. You should receive a copy of the completed claim form from your employer. If you don’t, request a copy and keep it for your records.

Generally, the insurance company has 14 days to mail you a letter telling you the status of your claim. If you don’t receive this letter, call the insurance company to find out the status of your claim.

Want to learn more? Find it in the guidebook



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