Dealing with workers’ comp claim denials

Not all workers’ compensation claims are approved when they have been successfully challenged by the employer or its insurer or the California Division of Workers’ Compensation determines the injury does not qualify for coverage. Claims can also be denied when the medical evaluation by the primary caregiver is not accepted by the agency. This happens for a variety of reasons, but most typically the claims are questionable enough that they must be proven. There are unusual circumstances where injury claims can still be approved, but only after reevaluation through the appeals process.

QME evaluation

Many times when the California Division of Workers’ Compensation denies a claim the applicant will be scheduled for an appointment with a qualified medical examiner. This doctor will evaluate the claimed workers’ compensation injury compared to the diagnosis by the initial treatment professional and issue a second opinion. The question is often whether or not the injured employee can still work in any capacity in a different position.

Filing the Application for Adjudication of Claim

The next step following a claim denial from the QME evaluation is filing an application for a claim case number with the claims administrator office closest to where the claimant is employed. The state maintains 23 local offices plus satellite locations. The agency will then acknowledge receipt and issue a claim number.

Filing the Declaration of Readiness to Proceed

The next necessary documentation to request an ALJ hearing is filing the Declaration of Readiness to Proceed. The administrator will then assign a hearing date where the claimant can present any evidence in support of their claim for workers comp benefits.

While it is not necessary to retain legal counsel in filing a workers’ compensation claim appeal, the process of proving that the injury is work-related can be tedious. Administrative law judges can easily uphold a denial based on any technicality.