What Should I Do If My Workers’ Comp Claim Is Denied?

A denial is not the end of your claim. When a California workers’ compensation carrier denies a legitimate work injury, you still have the right to have a qualified physician evaluate your injuries at no charge to you, and that medical opinion is usually what turns the case around. This article explains what a denial actually means, what your right to a medical evaluation covers, why pre-existing conditions do not automatically disqualify you, and when to bring in an attorney. It does not walk through the hearing and appeals paperwork itself.

WHAT DOES A DENIED CLAIM ACTUALLY MEAN?

I get a lot of calls from workers who were injured on the job, went through the investigation with a workers’ compensation adjuster, and then received a denial. A denial means the carrier is refusing to take responsibility for your workers’ compensation benefits at all. No medical treatment, no wage replacement, nothing.

What it does not mean is that a judge has looked at your case, or that a doctor has examined you and decided your injury is unrelated to work. A denial is the insurance company’s position, not a final ruling. If you suffered a legitimate injury while working and the employer or its insurance company has decided not to honor its responsibility under California law, that is the point to have the file evaluated by someone on your side.

CAN YOU STILL SEE A DOCTOR AFTER A DENIAL?

Yes, and this is the part most injured workers do not know. When your claim is denied, you have the right to have a qualified physician evaluate your work injuries at the employer’s expense, meaning at no charge to you.

That physician’s job is to make a determination on the medical question the carrier is disputing: were your conditions caused by your work, or aggravated by your work? Either answer can support benefits. This is why a denial so often comes down to medical reporting rather than argument. The adjuster made a decision based on a paper investigation. A doctor who actually examines you and reviews your records is working from something better.

WHAT IF YOU ALREADY HAD THE PROBLEM BEFORE?

A pre-existing condition does not disqualify you, and carriers count on people believing that it does. If you had prior back problems, for example, and the work made them worse, you may still be entitled to workers’ compensation benefits.

The same is true for conditions like high blood pressure and diabetes. California workers’ compensation covers work that aggravates an existing condition, not only work that creates a new one from nothing. There may be a dispute about how much of the disability belongs to the work as opposed to the underlying condition, but that is a question for the medical reporting to sort out, not a reason to walk away from the claim.

WHEN SHOULD YOU CALL AN ATTORNEY AFTER A DENIAL?

Not every claim needs an attorney. If your employer accepted the injury, arranged treatment, and is paying benefits while you treat, you may be fine on your own.

A denial is different. Once the carrier has taken the position that it owes you nothing, you are on a track with deadlines, and letting a denied file sit is how people lose claims they should have won. In my practice out of Santa Ana, the workers who do best after a denial are the ones who move quickly to get the right medical evaluation in place rather than waiting to see if the carrier changes its mind.

I have spent over 30 years handling California workers’ compensation cases, including a great many that started with a denial letter. If you have a legitimate work injury and the insurance company has told you no, it is worth finding out what a qualified physician says before you accept that answer. This article is general information about California workers’ compensation and is not legal advice for any individual case.

Thomas F. Martin, PLC offers a free 30-minute case evaluation. Call (714) 547-5025.