Common Reasons Why Workers’ Comp Claims Are Denied In California
If your workers’ compensation claim has been denied, it’s not yet time to despair. In some cases, the denial is easy to reverse. In other cases, appealing a denial may involve filing complex forms on time and having your case heard before a judge.
Some Of The Most Common Workers’ Compensation Denial Reasons
The most frequent reasons that are used in denying a workers’ comp claim in California include:
- Unwitnessed injury
- Failing to meet reporting or filing deadlines
- Conflict between accident report and initial medical records
- Filing a claim after you were terminated
- Refusing to make a recorded statement
- Failing to seek proper medical treatment
- Refusing or failing the required alcohol and drug test
- Existing evidence of negligence or recklessness
- Inadequate or inaccurate paperwork
- Your injury or illness is from a pre-existing condition
- Suspected fraud
Failure To Report Your Injury Or Illness To Your Employer
In California, the first step in pursuing workers’ compensation benefits is to report your work-related injury or illness. You must do so within 30 days of being injured or becoming aware of an illness. If you didn’t report the incident, your claim will be denied.
Failure To File A Workers’ Compensation Claim Within A One-Year Deadline
California law requires injured workers to file a CCR §10840 within one year. Failure to file in time may disqualify you. However, exceptions to this may include the court‘s schedule or other extenuating circumstances that can extend beyond the one-year deadline.
Other extenuating circumstances may include an injured workers’ lack of knowledge of how to file a claim. Additionally, an employer may have misled an employee about workers’ compensation law.
Failure To Seek Proper Medical Treatment
If you didn’t receive medical treatment commensurate with what you reported, the insurance company may believe you’re falsifying your claim. To protect yourself, even if you didn’t believe your injury required medical care, you should still see a qualified workers’ compensation physician.
Accident Report And Initial Medical Report Conflict
If the injury or illness you reported isn’t consistent with the initial physician’s medical report, the insurance company will be suspicious. For instance, you may claim you had an on-the-job concussion. However, a specialist can find no brain injury or symptoms consistent with a concussion. Therefore, your accident report may be viewed as inconsistent with a medical evaluation, leading to a claim denial.
Injury Or Illness Is From A Preexisting Condition
If you had a pre-existing non-work-related injury or illness but claim your workplace is responsible, your claim will usually be denied. Even if a new injury exacerbated a pre-existing condition, your claim may still be denied.
Alcohol Or Drug Test Refused Or Failed
California’s workers’ compensation is technically a no-fault system. However, the no-fault clause does not apply to workers injured while under the influence of drugs or alcohol. If you either refused or failed a drug or alcohol test, your claim may be considered invalid and denied.
Willful Negligence Or Recklessness
Evidence may clearly suggest that you were engaging in reckless or careless conduct that resulted in an injury or illness. This will likely be a reason for a claim denial.
Undetermined Cause Of Injury
If the cause of an injury or illness cannot be identified, your employer’s workers’ compensation attorney may claim the incident was not work-related.
You Filed A Claim After You Were Terminated
If you only filed a claim after you were fired, an insurance company may consider your claim retaliation. Your claim may be viewed as irrelevant because if you didn’t report an incident while employed, it must not be serious. But if you believe you were fired in retaliation for filing a workers’ compensation claim, you may have legal recourse for damages.
Refusal To Make A Recorded Statement
An insurance company may have grounds to deny your complaint if you refuse to make a recorded statement. But complying with such a request could be detrimental to your case. When involved in an insurance investigation, you should never make a recorded statement without the advice of a qualified workers’ compensation attorney.
Not Completing Paperwork Properly, Fully And Accurately
It is imperative that you fill out all required forms in a complete and accurate manner, leaving no requested information or details out. All details, facts, and reports related to your injury or illness must be presented and clearly communicated to both your employer and their insurance company.
If you have not fully provided information, your claim will likely be denied. However, a denial on this basis can be corrected.
If your claim was filed only on the basis of your word, the insurance company may be suspicious and deny your claim. However, this depends on various factors. However, depending upon the circumstances, this may or may not disqualify your claim.
If your employer’s workers’ compensation carrier has reason to believe your work injury or illness claim is fraudulent, they will have grounds to deny it. You may have provided information inconsistent with your claim. You may have been observed engaging in an activity not possible if you were actually injured the way you reported. In such cases, your claim may be denied. When deemed necessary, your employer’s insurance company will use their resources to verify whether your claim is valid, honest, and accurate.
Contact Us For Help
Workers' Compensation Lawyer, Inc., is dedicated to fighting for the “Average Joe”® in California workers’ compensation claim denial cases. Contact us today for a free consultation. Call 800-496-0563 or send us a message online.