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

Workers’ Compensation in California: A Guidebook for Injured Workers

Workers’ Compensation in California: A Guidebook for Injured Workers

This guidebook gives an overview of the California workers’ compensation system. It is meant to help workers with job injuries understand their basic legal rights, the steps to take to request workers’ compensation benefits, and where to seek further information and help if necessary.

Introduction How to Use This Guidebook

Chapter 1 The Basics of Workers’ Compensation
Chapter 2 After You Get Hurt on the Job
Chapter 3 Medical Care
Chapter 4 Resolving Problems with Medical Care and Medical Reports
Chapter 5 Temporary Disability Benefits
Chapter 6 Working for Your Employer after Injury
Chapter 7 Permanent Disability Benefits
Chapter 8 Supplemental Job Displacement Benefits
Chapter 9 Return-to-Work Supplement Program
Chapter 10 For More Information and Help
Questions & Answers about State Information & Assistance Services
Questions & Answers about Attorneys
Appendix A Important Laws and Regulations
Appendix B Glossary


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