Workers’ compensation provides vital benefits to injured employees and their families. When a workers’ comp claim is denied, employees may be able to request a reevaluation by another doctor or file an appeal or Petition for Reconsideration. Diefer Law Group advocates for workers throughout Southern California. If you believe you may have the right to receive workers’ compensation and your claim was denied, contact our compassionate and dedicated workers compensation attorneys at (888) 301-7795 to ensure your legal rights are protected.
What Are Common Reasons for the Denial of a Workers Comp Claim in California?
Workers compensation insurance companies deny claims for any number of reasons. Common explanations for denials include:
- The injury does not qualify the worker as disabled or unable to work
- The worker did not file the claim on time
- The worker filed the incorrect paperwork
- The worker did not see the correct physician or saw a physician that does not fall under their employer’s workers comp insurance policy
- The employee did not follow the recommendations of the workers comp doctor
- The reason that the worker is unable to work is related to a preexisting injury rather than the work injury
- There is an insufficient connection between the work and the resulting injury (i.e., the insurance company does not believe it is a work-related injury)
- The employee was not on-the-job when the accident occurred
- The worker was acting outside the scope of employment at the time of the accident
Receiving a denial notice can be difficult because a worker may depend on those benefits to support themselves and their family. When insurance companies deny a workers comp claim, the injured employee may have options available to them.
What Are Your Options if Your Workers Comp Claim Is Denied?
If the insurance company sends a notice denying a workers comp claim, this may mark the beginning of a new process rather than the end. Workers can request a reevaluation, either by a qualified medical examiner (QME) or if they have an attorney, an agreed medical examiner (AME). Additionally, they can file an appeal or Petition for Reconsideration with the California Workers’ Compensation Appeal Board (WCAB).
An appeal starts an official case with the California WCAB, a body of administrative law judges who oversee disputes between employers and injured workers. The WCAB investigates the claim, hears testimony and arguments, and reviews submitted paperwork, such as medical records and forms, to determine the appropriate outcome. If a party disagrees with the WCAB’s final decision, they may file a Petition for Reconsideration.
How Do I Request to be Reevaluated by Another Doctor When My Workers Comp Claim Is Denied?
Sometimes, one or more parties disagree with the recommendation and assessment provided by the worker’s treating physician. In this case, either party can request a reevaluation by another authorized medical examiner. Typically, this is either a qualified medical examiner (QME) or an agreed medical examiner (AME).
If your workers comp claim is denied or you disagree with the doctor’s recommendations, consider contacting an attorney at Diefer Law Group to learn more about your options.
What Is a Qualified Medical Examiner (QME)?
A qualified medical examiner is a licensed medical provider who performs reevaluations in workers comp cases. They are responsible for evaluating the injured worker and determining the injury’s severity and cause and its impact on the worker’s ability to do their job.
QMEs are typically called in when the worker or employer disagrees with the findings of the treating physician. As the California Division of Workers’ Compensation reports, whoever files the form to request a reevaluation chooses the specialty of the QME.
What Is an Agreed Medical Examiner (AME)?
An agreed medical examiner is a QME that a worker’s attorney, the employer, and the insurance company decide to hire to perform the reevaluation. Typically, if the injured worker has an attorney, the parties negotiate about what doctor should carry out the reexamination and for what purpose.
How Do I Request a Reevaluation by a QME?
Parties can request a reevaluation by filing a “Request for QME Panel” with the appropriate Division of Workers’ Compensation Medical Unit. The party submitting the request can choose the specialty of the doctors on the panel. In many cases, the DWC will then send the parties a list of three doctors from which the parties agree on one to perform the reevaluation.
What Happens at a QME Appointment?
At the appointment with the QME appointment, the doctor and staff typically perform an evaluation and run tests to determine the nature, cause, and outlook of the injury. The doctor may also review the findings of the treating physician and interview the worker to understand what happened and how the injury impacts their life.
What Happens After a Qualified Medical Examination?
At the end of the assessment, the doctor prepares a final report and submits it to the parties. If a party disagrees with the QME report, they can file a formal disagreement with the Division of Workers’ Compensation or ask for further investigation of the injury.
How Do I Appeal the Decision in a Workers’ Comp Case?
Another option available to injured workers whose claim is denied is to file a formal appeal with the Workers’ Compensation Appeals Board. The WCAB oversees disputes regarding workers’ compensation and, much like a court of law, conducts hearings and hears testimony to fully understand the controversy. At the end of the hearing, they issue a final decision about the underlying workers’ compensation claim.
File the Application for Adjudication of Claim
Workers begin the appeals process by filing an Application for Adjudication of Claim with the WCAB in the county where they live or were injured. The form requests a host of information about the worker, their employer, the injury, and other critical matters. Injured employees might consider meeting with an attorney to help them gather the appropriate information for the form.
File a Declaration of Readiness to Proceed
After opening up the appeal with the WCAB by filing the form, workers must file a Declaration of Readiness to Proceed with the appropriate claims office. This sets a hearing date on which the parties will appear before the court to argue the case or participate in a status hearing.
Prepare for and Attend the Hearing
The parties prepare for the hearing by conducting discovery and legal research and putting together a case strategy. The discovery process is where the parties gather information about the injury and the case. It usually involves requesting and reviewing medical records and procuring witness statements.
Once the discovery process is over, the parties can either engage in settlement negotiations or proceed to a hearing. The hearing is similar to a courtroom trial where witnesses give testimony, the parties present evidence, and the WCAB hears arguments from each side. After the hearing, the judges thoroughly review the case and issue a decision.
What Happens If I Disagree with the Workers’ Compensation Appeals Board’s Decision?
If a party disagrees with the Workers’ Compensation Appeals Board’s decision, they can file a Petition for Reconsideration. As per the Division of Workers’ Compensation, reasons to file a Petition for Reconsideration include the following:
- The underlying facts of the case do not support the WCAB’s decision
- Someone committed fraud, and it impacted the evidence supporting the decision
- The party discovered new evidence that may have a significant impact on the WCAB’s decision
Consider meeting with a workers’ compensation attorney to understand your right to file an appeal or Petition for Reconsideration and what that entails in your case.
Contact a Workers Compensation Attorney for Help
When a workers comp claim is denied, injured employees may be able to request a reevaluation by a different doctor, file an appeal with the California Workers’ Compensation Appeals Board, or further challenge the decision by filing a Petition for Reconsideration. Consider setting up a consultation with Diefer Law Group to learn about your options by calling (888) 301-7795.