Workers’ compensation claims are an incredibly important part of the legal system, providing financial help to those injured on the job. That’s why the help of a worker’s compensation attorney can go a long way in getting the compensation you need.
Unfortunately, these claims don’t always get accepted. While it’s important to understand the reasons why a claim might be rejected, it’s just as important to know how to appeal a denied workers’ compensation claim.
By understanding the potential pitfalls associated with filing a claim, you’ll have the best chance of success when it comes time to file for workers’ compensation.
Indeed, workers’ compensation is a critical safety net for workers injured on the job, allowing them to receive the money they need for medical bills and lost wages. Claims may be denied for one of several reasons so you need to know where you stand with respect to your rights and the laws that define these filings.
An overview of worker’s compensation
Worker’s compensation is insurance related to injuries suffered on the job. Essentially, an employee has a duty to report work-related injuries to their employer who then has an obligation, by law, to report the injuries to an insurance company.
Your employer’s insurance company then pays benefits for medical expenses and lost wages. Workers’ compensation laws vary from state to state which impacts the way the benefits are paid.
California’s obligations under the state’s workers’ compensation law
If you get injured on the job in California, your employer’s insurance company is legally obligated to pay up to $10,000 of medical expenses while your claim is considered. This is true even if the claim is eventually denied.
In addition, if the claim is not rejected within a specific time period, California law assumes that the claimant is entitled to benefits.
When benefits are generally paid and what they cover
California law allows workers comp payments for medical treatments that it deems reasonably needed to relieve or cure a patient with no out-of-pocket expense to the employee.
Therefore, your benefits should cover the bills from the doctor and hospital and the costs associated with medical supplies, equipment, and prescriptions. Costs may extend to acupuncture therapy or may cover up to 24 treatments with an occupational therapist, physical therapist, or chiropractor.
Medical Provider Networks
Some employers are part of a medical provider network (MPN). If that is the case for you, you may have to see a doctor in the MPN. Some exceptions are made to this rule. If you require emergency care or if you already have a primary care doctor who regularly treats you, you usually can bypass seeing an MPN doctor.
Determining the medical necessity of a treatment
Before you receive any care that is doctor-recommended, you may have to receive authorization through a utilization review. This process is designed to see if a treatment is medically needed.
The rules for this type of pre-authorization are less stringent if you follow up shortly after you’re injured. Therefore, it is in your best interest to seek treatment as soon as possible. (Cal. Labor Code §§ 4600(d)(5), 4610 (2020).)
Seeking emergency treatment or a doctor’s care
If you need emergency treatment, you want to call 911 or go to an emergency room the day you get injured.
Tell the medical personnel that your illness or injury is employment-related. You may also contact your employer for further instructions if you can safely communicate.
If you don’t require emergency treatment, you should still seek a doctor’s care so you can show proof that you were injured at work.
Reasons why worker’s comp claims get denied
If you don’t obtain legal assistance when filling out a claim, you may have difficulties with “claim issues.” This catch-all term may cover issues such as the medical necessity for filing a claim, the claim’s validity, the amount of the claim, or the period for filing.
The following list gives more in-depth reasons why claims may be turned down.
1. The injury is not considered work-related
If you were involved in horseplay at work and got injured, you were not working, so in all likelihood, you won’t receive benefits.
2. Employee negligence
Also, if you were intoxicated on the job, it’s highly unlikely you’ll receive compensation if you get injured.
3. A pre-existing medical condition
Maybe you had a pre-existing medical condition before you got employed. Workers comp generally will not pay for a claim you make if it involves this type of condition. If the tasks you do did not make the ailment worse, there’s a good possibility you won’t receive benefits.
However, some grey areas do exist in this regard legally. So, you should discuss your case with a worker’s compensation attorney.
4. The claim is not reported within the legal time frame
In California, if you don’t report your worker’s comp claim within 30 days, your claim may be denied. It’s best to tell your supervisor about your injury ASAP. If the injury or illness developed slowly, report the finding as soon as you believe it is job-related.
In this case, it’s best to notify your employer early as doing so avoids problems with denials, delays, or the receipt of benefits.
5. The employer makes errors when reporting a claim or when entering data
Sometimes a problem happens with unreported or denied workers’ compensation claims if the employer does not enter the data correctly.
Claims may also go unreported if the employer does not comply with OSHA recordkeeping guidelines or Survey of Occupational Illnesses and Injuries (SOII) reporting instructions.
Strategies to prevent a denied worker’s comp claim
To avoid problems with denial, workers’ compensation claims should be submitted correctly via the employee and employer. Claims should be reported within 30 days and submitted with all the paperwork completely filled out and corrected.
Contact a Worker’s Compensation Lawyer to Avoid Delays or Denials
If you need help with a denied claim form or you wish to file for workers’ compensation, it’s best to use the services of an experienced workers’ compensation lawyer. In California, call (213) 263-6131 today. Contact Workers Comp Attorney LA, Bela Hamideh, PC now.
