Workers’ Compensation Claim Denial: What You Need to Know

Dealing with a Workers’ Compensation claim denial can be a huge problem. When you suffer a work injury or get sick because of your job, you are not generally allowed to sue your employer. As a result, a work injury claim may be the only way you can get compensation for the medical bills and other financial losses you’ve experienced due to your health issues.

The good news is, you do have options when your claim is denied. You can appeal and fight for your right to benefits, but you must understand how the process works and will often need legal help from an experienced work injury attorney to maximize your chances of success.

Read on for information on how to respond to a denial of your claim.

Understanding the Denial

Workers’ Compensation claim denials are far too common. Unfortunately, claims are denied for many reasons, often because of mistakes. Here are some common reasons for denials, as well as some insight into why it’s so important to act swiftly if this happens to you.

Reasons for Workers’ Compensation Claim Denials

Here are some of the most common reasons claims are denied:

• The insurer believes the injury isn’t work-related or was a pre-existing condition. If a Workers’ Compensation insurer doesn’t believe the job was the direct cause of the harm or they believe you were already injured, they’ll deny your claim. Sometimes, it can be complicated to determine if an injury was work-related, such as if it happened while driving somewhere for your job or at a workplace event. In general, if you were performing job duties, then the injuries you incurred should be covered.
• You failed to provide a timely notice. You have a limited amount of time to alert your employer when a work-related injury happens. If you didn’t submit notice of the injury on time or in accordance with your employer’s process, this could result in a claim denial.
• You didn’t get medical treatment or weren’t treated by an approved doctor. California generally requires you to see a doctor on an approved list provided by your company to get treatment. There may be exceptions for dire emergencies, but seeing the wrong doctor could adversely impact your claim. If you don’t get treatment at all, you also typically won’t be able to get benefits because there won’t be documented evidence of the injury.
• You were intoxicated or engaged in horseplay at the time of the injury. Generally, your own negligence is not a factor that results in your claim being denied. However, if you were intoxicated at work at the time of the injury or were playing around and engaged in behaviors that were not work-related or against company policy at the time of the incident, this can give your employer grounds to deny your claim if those factors contributed to the cause of the injury.
• Your employer doesn’t believe your claim was legitimate. If the company has other reasons to believe your claim is illegitimate, such as a suspicion you are lying about the cause of the injury or its severity, they may deny your work injury claim.

These are some of the most common reasons why employers and Workers’ Compensation insurers may refuse to pay benefits on a claim that you make.

Common Mistakes Leading to Denials

Unfortunately, sometimes mistakes that you make will result in your claim being denied. Here are some common errors you’ll want to avoid:

• Not reporting your claim quickly. Failing to report your injury in a timely manner within any deadlines required could result in a claim denial.
• Not getting prompt medical treatment. You should always see a doctor as soon as you are hurt or made ill by the performance of your work duties. Be sure the doctor documents all your symptoms.
• Not seeing the right doctor. If your employer requires you to see an approved doctor, there should be a list of physicians at work. Pick from the list to avoid problems with your claim. If you cannot find a list, ask your employer to send you to a doctor. If they do not do so, you can go to any doctor, preferably your normal primary care doctor.
• Not disclosing all your symptoms. Downplaying the severity of your injury could result in your claim being denied or may reduce the value of your claim. Don’t be a whiner, but don’t be tough. Tell the doctor about all the symptoms you are experiencing. Even if some of the symptoms are minor, still advise the doctor, but tell the doctor the truth about the severity of the symptoms. You may not be able to add symptoms later if you experience them from the beginning, but do not advise the doctor.
• Not getting legal help. Workers’ Compensation claims can be complicated. It’s often best to talk with a lawyer right away when you’re hurt at work, so you don’t make mistakes that could cost you. The initial consultation is free, and there is no obligation to retain the attorney. The employer and the insurance company have lawyers advising them. You should have the same access.

Importance of Knowing Your Rights

You have rights if your claim is denied. You can appeal the decision and fight for the compensation that the law entitles you to receive.

However, you have a limited period of time to act. If you do not file your appeal within the allowable time, you may be unable to move forward with your claim.

You don’t want to lose the chance to recover your benefits, as Workers’ Compensation is generally your only option for getting paid by your employer after a work-related injury. California Workers’ Compensation laws generally prohibit you from filing a personal injury lawsuit against your employer in court.

A Workers’ Compensation lawyer will take swift action on your behalf, so your appeal is submitted correctly and by the required deadline, and you don’t lose your access to benefits.

Contact Our Victorville Workers’ Compensation Lawyers at Lerner, Moore, Silva, Cunningham & Rubel

If your claim has been denied, don’t wait—contact an experienced Victorville Workers’ Compensation lawyer at Lerner, Moore, Silva, Cunningham & Rubel today to understand your rights and protect your benefits. Call 909-889-1131 or contact us online for a free consultation. Located in Ontario and Victorville, California, we serve clients in San Bernardino County, Ontario, Victorville, Hesperia, Apple Valley, Fontana, Rancho Cucamonga, Colton, and Riverside County.