Santa Clarita Denied Workers' Compensation Claims
What Do I Do If My Workers’ Comp Claim is Denied?
Workers’ compensation is a great system to get injured workers back on their feet when they are ready – but only when the system itself works. The chances of your workers’ compensation claim being denied are fairly high. Some estimates from insurance groups note that upwards of 20% of workers’ comp claims will be denied or delayed initially. Denial is not the end of a case, though, and you will have some options to explore to get the benefits that you need and deserve.
Just because your claim has been denied does not mean that you can't still receive compensation. Contact our firm today to discuss what your next step should be.
What Disqualifies You from Workers’ Comp Benefits?
Why do workers’ comp claims get denied, or what is a disqualifier for workers’ compensation benefits? Every case is unique, so there could be unique reasons for a denial. However, there are some reasons that appear far more often than others.
Four of the most common reasons for a workers’ comp claim denial are:
- Injury happened while they were not working or while they were performing an action unrelated to their job.
- Injury or illness is preexisting, or a preexisting condition exacerbated the new injury, so only a portion of the medical treatments should be covered.
- Extent of the injuries or the medical treatments are disputed, such as an insurer argues some medical care is elective, not required.
- Incomplete or inaccurate workers’ compensation form is submitted, or the form is submitted too late.
Workers’ Comp Appeals Process
If your workers’ comp claim has been denied for any reason, then the next step is to talk to our Santa Clarita workers’ compensation attorneys about appealing that decision. We can walk you through the entire workers’ comp appeals process or act on your behalf if you require representation.
The workers’ comp appeals process in California usually includes:
- Inquiry: The appellate process usually begins with speaking with the insurer to figure out exactly why the denial happened. We might uncover a technical error that the insurer reverses without needing to become invested in the entire appeals process.
- Petition for Reconsideration: We can submit a Petition for Reconsideration, which formally requests the insurer review the case and reconsider the validity of its denial.
- Second medical examination: If the insurer still does not want to approve your workers’ compensation claim after a reconsideration, then we can work with you to find a qualified medical examiner (QME) or agreed medical examiner (AME) to complete a secondary evaluation of your injuries.
- WCAB decision: Using the information from this secondary evaluation, we can prepare an appellate case to bring before the appropriate review board or administrative judge with the California Workers’ Compensation Appeals Board (WCAB). The WCAB will decide if your case was wrongfully denied, and how to correct the situation if it was. Further appeals are possible if the WCAB sides with the insurer.
Can You Sue Your Employer for Denying Workers’ Comp?
The appeals process will not always end in the appellant’s favor, of course. There are times when courts and workers’ compensation boards agree that a worker’s injuries or treatments do not technically fall under the umbrella of workers’ comp. If this happens in your case and workers’ comp won’t pay, then you are still not out of options.
Depending on why your accident happened, you might be able to sue your employer as you would any other liable party in a personal injury claim brought to a civil court. Workers’ comp bars you from holding an employer personally liable for your injuries, but only if workers’ comp benefits are approved. In their absence, an employer can be sued, which is why the typical employer actually wants workers’ comp claims to be approved at least to a minimal extent. Suing an employer is as rare as it is complicated, though, so it is advised you only proceed with this legal course with an attorney leading the way.
If your claim has been denied, contact the Law Offices of Wax & Wax today to find out how our attorneys can help.
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"The attention to detail meant so much!"I wanted to thank you and your staff for helping me in a very difficult time.- Former Client
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"You’re a rare breed!"A lawyer with a heart who seemingly can awaken a similar characteristic in the insurance company.- Jeff
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"Highly recommend Robert for your future cases."I worked with Robert Castillo on my case. He is knowledgeable and patient; Allows time and space for you to ask questions. The office staff is organized and responsive. They send regular correspondence to home and set up a phone appointment if necessary. I enjoyed working with this law firm. Reasonable price, friendly staff, and professional. Highly recommend Robert for your future cases.- Azin G.
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"Highly recommend!"An honest firm with integrity.- Kevin K
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"Wax and Wax are true professionals!"They helped me make the right decision.- Jonathan
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"Highly recommend for worker’s compensation!"They always filled me in on the details and explanations of everything I needed to know.- Former Client
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"I was extremely satisfied with the entire process."
I was referred to this law office by a friend of mine and I was very pleased with the results of my case due to the amazing service and advisement by my lawyer Robert Castillo. I highly recommend this law firm for any worker's compensation-related cases. I was extremely satisfied with the entire process.
- Selin M. -
"Going to speak to Mr. Wax was calming and informative."After working 4 decades at one grocery chain I became badly injured. Filing a WC claim was easy but after 4 major surgeries, one to remove 3 discs from the lumbar region, 1 disc removed from the cervical region, surgery to repair 3 torn rotator tendons, and have an electronic lumbar stimulator the bureacracy of WC insurance and the mounds of paperwork and approvals required for all tests and procedures would have stressed me out to a point of severe anxiety. Going to speak to Mr. Wax was calming and informative. His representatives who accompanied me to depositions and the courthouse was such a relief. I could not have done this myself. Thank you to the lawyers who helped me, Mireya who was my contact in the office for immediate feedback to my concerns. I highly recommend this firm for dealing with insurance companies and the SS office. Thank you- DV Hig
