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How to Appeal a Denied Workers’ Comp Claim

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Posted By DAM Firm | February 17 2021 | Workers' Compensation

Workers’ compensation claims can be complex. While the system is generally supposed to operate smoothly so that work injury victims can recover compensation for their medical bills and lost income, there are times when insurance carriers or employers push back. In fact, there are times when an insurance carrier or an employer could deny your workers’ compensation claim. There are various reasons a denial may occur. Here, we want to discuss how you can appeal a denied workers’ comp claim in Riverside.

Why would a Riverside workers’ comp claim be denied?

There is no denying that employers and insurance carriers have the ability and the right to deny certain claims. Often, a denial is legitimate. Some of the most common legitimate reasons that employers and insurance carriers deny a Riverside workers’ compensation claim include the following:

  • The injury occurred during non-work-related hours (activities outside of the workplace or during break periods).
  • The injury was caused by a third party within the workplace.
  • The injury victim refused to seek medical care.
  • The injury victim did not need any time off.
  • The injury victim was impaired by alcohol or drugs at the time the incident occurred.
  • The injury was caused by the worker horse playing on-the-job

While there may be many legitimate reasons why a workers’ compensation claim is denied, employers and insurance carriers often stretch the truth or rewrite reality in order to suit their reason for the denial.

Appealing a Riverside workers’ compensation claim

If your workers’ compensation claim has been denied, you need to begin the appeals process as soon as possible. We strongly suggest working with a skilled Riverside workers’ compensation attorney who has experience handling these appeals. The first step in these cases is filing an Application for Adjudication of Claim, which is part of the process of filing the official workers’ compensation claim and gaining a case number.

After your claim has been denied, you need to request a hearing in front of the Workers’ Comp Appeals Board (WCAB). In order to request this hearing, you and your attorney need to fill out a form called a Declaration of Readiness to Proceed (DOR).

Will a priority conference be set?

There are some situations where a WCAB judge will set a priority conference so that the claim can be resolved quickly. This will occur if the claim was denied because the employer or the carrier does not believe that the injury arose out of employment (AOE) or that the injury did not happen within the course of the employment (COE).

Pre-trial conference

If an insurance carrier or employer denies a claim for a reason not based on COE or AOC, then a pre-trial conference will be set for the claim. An example of when a pre-trial conference would be appropriate would include the insurance carrier not believing that you need the medical treatment that you are requesting or that you are not entitled to temporary disability benefits. You will receive a notice of the hearing time, date, and location. During a workers’ compensation pre-trial conference, the judge will attempt to resolve the issues between the two parties. If the issues cannot be resolved at this conference, the judge will set a future trial date and establish a discovery plan so that both sides will produce evidence for the case.

Gathering medical evidence

The injured worker will need to be evaluated by a doctor before any hearing and if the insurance carrier is denying the claim based on medical issues. Workers who are unhappy with the evaluation of the treating physician are allowed to request an evaluation from another doctor. If the insurance carrier is unhappy with the evaluation of the treating doctor, they are also allowed to request that another doctor conduct an evaluation.

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