What to Do If Your Workers' Compensation Claim Is Denied in California

Learn how to appeal when your employer's insurance company has rejected your California workers' comp claim or denied you benefits.

California workers typically receive compensation when they are injured on the job. But employers’ insurance companies often deny workers’ comp claims or don’t award full benefits. You have the right to appeal if you don’t receive all the benefits that you’re entitled to under state law. Read on to learn more about some common reasons your claim might be denied and how to file an appeal with the California Division of Workers’ Compensation (DWC), which monitors the state’s workers’ comp system and helps resolve disputes.

Missed Deadlines May Lead to Lost Workers’ Comp Benefits

You could lose your right to workers’ comp benefits if you don’t report your injury to your employer within 30 days after the injury date. Generally the injury date is when the workplace accident happened or you were exposed to hazardous substances on the job. But sometimes, an injury or disease takes time to develop. In those cases, the 30-day deadline doesn’t begin until the date you knew or should have known that your medical condition was work related.

The notice must be in writing. Reporting promptly also helps avoid delays in receiving medical payments. For more details about the process, see our article on filing a workers' comp claim in California.

Denials for Injuries That Aren’t Work Related

California workers’ compensation covers only injuries and diseases “arising out of and in the course of the employment.” Essentially, that means that you were performing services for your employer when you were hurt or got sick, and that work activities or conditions were responsible for the injury or illness. This dual requirement is often the source of disputes over workers’ comp claims.

California law spells out some circumstances in which your injuries won’t be considered work related, including injuries that happen:

  • because you were drunk or using a controlled substance
  • because you started a fight or hurt yourself on purpose
  • as a result of a felony for which you were convicted
  • while you were voluntarily participating in an off-duty recreational activity (unless you were expected to participate as part of your job), or
  • while you were commuting to or from work, including a voluntary, government-sponsored alternate commute program (unless you were paid for the commute time).

To learn more, see our article on when your injury or illness is work related.

How to Appeal a Denied Workers’ Comp Claim

You have the right to appeal if your workers’ comp claim is denied, or if you have any disagreements with the insurance company about your case. The appeals process involves several steps and a lot of paperwork.

Application for Adjudication of Claim

The first step is filing an “application for adjudication of claim,” which officially opens your workers’ comp case with the California Workers’ Compensation Appeals Board (WCAB). Submit the completed form, along with the required documents, to the local WCAB district office. Generally, you must file the form within one year after:

  • your injury
  • the last day you received medical benefits, or
  • the day when your temporary disability benefits end.

It’s a good idea to file this application even when the insurance company has approved your claim. That way, you won’t risk missing the deadline if you have a dispute with the insurance company later on. (If the injury causes new or additional medical problems, you’ll have five years to request that your workers’ comp case be reopened.)

Declaration of Readiness to Proceed

When you’re ready to request a hearing with a workers’ comp judge, you’ll need to file a “declaration of readiness to proceed,” along with all relevant medical records and letters from the insurance company about your dispute.

Settlement Conference

Before you can get to a hearing, you’ll have to participate in a mandatory settlement conference, where you and the insurance company will discuss the dispute with a judge and try to reach a settlement agreement.

There is more paperwork to file if you don’t reach an agreement at the settlement conference. Your case will then be scheduled for a pretrial conference and a hearing.

Workers’ Comp Hearing

A workers’ comp hearing is similar to a trial (without a jury). Both sides will have the opportunity to present evidence, have witnesses testify, and make legal arguments about the case. Generally, you won’t be able to bring up any new evidence that you didn’t already share by the time of the mandatory settlement conference. (Learn more about what to expect at your workers' comp hearing.)

Petition for Reconsideration

Following the hearing, the judge will mail you a written decision. If you’re unhappy with the result, you can file a petition for reconsideration with the WCAB within 20 days after receiving the decision. A WCAB panel will decide whether to accept or deny reconsideration, based on the evidence. If the panel grants reconsideration, it will issue a decision that reverses, affirms, or alters the judge’s decision or award.

Judicial Appeals

If the WCAB decides against you, you may take your appeal to the courts by filing a petition with the California Court of Appeal for the district where you live. If the appeals court denies your claim, you can try again by petitioning the California Supreme Court.

How to Get Help With Your Workers’ Comp Appeal

The DWC’s Information and Assistance Unit offers workshops for injured employees, answers to questions, and general information about the process and workers’ rights. Be forewarned, however: Fighting a denied workers’ comp claim can be challenging and time consuming. An experienced workers’ comp lawyer can evaluate your chances of winning an appeal, help you gather the right kind of evidence to support your claim, and represent you at the settlement conference and hearing. (Learn more about what a good workers’ comp attorney can do for you.)

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