Are You a Worker in California Who Has Had Their Workers’ Compensation Claim Denied?
Educating yourself regarding the common reasons for denial can help you take steps to ensure your claim is successful.
Top Reasons Workers' Compensation Claims are Denied
1. Failure to report the injury on time
3. Failure to file claims within the time limit
4. Pre-existing medical conditions
5. Failure to link work duties to injury
6. Challenges in determining the cause of injury
7. Injury caused by intoxication or drug use
8. Lack of proper legal support
Delay in Reporting the Injury to the Employer
One common reason for denied workers’ comp claims in California is the failure to report the injury to the employer on time. California’s workers’ compensation laws mandate that employees report an injury to their employer within 30 days of its occurrence or within 30 days of when the injury becomes known or reasonably should have been known to be related to the occupation. [1]
Failing to report a workplace injury in a timely manner can jeopardize your ability to receive workers’ compensation benefits. Prompt reporting that complies with state regulations can help facilitate a smoother claims process and mitigate potential challenges in receiving the benefits entitled to injured workers.
Absence of Medical Proof
Delaying or avoiding seeking medical treatment after a workplace injury can result in claim denial. Prompt medical evaluation not only ensures proper care for you but also provides essential documentation supporting the validity of your claim.
Insufficient or inconsistent medical documentation can also lead to claim denial. Medical records must clearly outline the injury’s diagnosis, treatment plan, and causation, establishing a direct link between the workplace incident and the medical treatment sought.
Failure to Submit Claims Within the Specified Timeframe
In California, the Statute of Limitations for filing a workers’ compensation claim form with the California Division of Workers’ Compensation (DWC) is one year from the date of injury or the date they knew or should have known their injury was work-related. [3]
Missing this deadline can lead to the denial of your workers’ compensation claim. Employers and their insurance companies often use missed Statute of Limitations as grounds for compensation denials, arguing that the claim is untimely and does not comply with the legal requirements. Consequently, you may lose access to compensation payments, such as medical expenses, disability payments, and other forms of assistance.
Pre-Existing Conditions Present Prior to the Incident
In California, the presence of pre-existing injury can complicate the process of obtaining workers’ compensation benefits. When you sustain an injury on the job and have a pre-existing medical condition, it can lead to disputes over whether the injury is solely work-related or if the pre-existing condition contributed to the injury.
Employers and their insurance carriers may deny compensation claims for workers in California based on the argument that the injury was caused, wholly or partially, by a preexisting condition. Providing thorough medical documentation and evidence to demonstrate that the work-related incident exacerbated or directly caused the injury, separate from the pre-existing condition, is vital to prove your claim.
Inability to Establish Connection between Work Duties and Injury
In California, one of the common reasons workers’ compensation claims are denied is a failure to establish a direct link between the injury and the duties performed in the workplace. When you file a workers’ compensation claim, demonstrate that the injury arose directly from work-related activities or conditions.
Employers and their insurance carriers often scrutinize the circumstances surrounding an injury to determine whether it occurred due to work duties. If the connection between the injury and the workplace is not established, the claim may be denied. Provide thorough documentation and evidence supporting your claim, including eyewitness testimonies, medical reports, and other relevant evidence to establish the connection between the injury and workplace activities.
Challenges in Identifying the Source of Injury
Workers’ compensation claims can be denied when there are challenges in determining the cause of the injury. When the cause of an injury is not immediately clear or is subject to dispute, it can complicate the claims process and potentially lead to the denial of comp benefits.
The claim may be denied if there are conflicting accounts of how the injury occurred or if there is insufficient evidence to determine definitively that the injury arose from a work-related illness.
Substance Abuse Results in Injuries
Substance abuse can have significant implications on workers’ compensation claims. In many cases, employers have the right to require alcohol and drug testing after a work injury. If an employee tests positive for drugs or alcohol, it can affect their eligibility for benefits.
Being intoxicated or under the influence of drugs or alcohol at the time of a workplace accident can also impact eligibility for benefits, as it may be considered a contributing factor to the accident. Workers’ compensation is generally not available for injuries caused by substance abuse. If it can be proven that your intoxication directly contributed to the injury, you may be ineligible to receive workers’ comp benefits.
Insufficient Legal Support
One primary reason for denying workers’ compensation claims is the absence of proper legal representation. When you lack the guidance and support of an experienced California workers’ compensation attorney, you may struggle to navigate the complex legal procedures and requirements.
Without proper legal support, you may make errors in your comp claims, fail to gather necessary evidence, or miss critical deadlines, all of which can lead to compensation claim denial.
Employer Controversies Over Claims
Employer disputes over workers’ compensation claims in California can lead to delays or denials of benefits for work-related injuries. Employers or their insurance providers may challenge the validity of your claim, arguing that the injury or illness is not work-related or that it falls outside the scope of workers’ compensation coverage.
An employer may do this to avoid paying for medical costs, lost wages, or disability benefits. They may also dispute a claim to maintain a favorable insurance record, which can impact their future premiums.
Company Policy Violations
Employer allegations of policy violations can significantly impact your ability to receive financial assistance and medical care. Insurance companies may use these allegations to challenge the legitimacy of the claim, leading to delays or denials of benefits for your injuries.
Seeking legal representation from a qualified compensation lawyer is vital to challenge these allegations and ensure that you receive the maximum compensation and medical care to which you are entitled, regardless of any disputed company policies.
Contact Goldberg & Loren’s California workers’ compensations lawyers today for expert advice and assistance with your work injury claim.
FAQs
If your employer disputes the work-relatedness of your injury or illness, your claim may be denied. However, you have the right to provide evidence supporting your claim, such as witness statements, medical records, or documentation of job duties. Consult with our workers' compensation attorney to strengthen your case and challenge the denial.
Yes, California has strict deadlines for filing workers' compensation claims. If you miss to file the claim within one year time period, your claim may be denied. [2] However, there are exceptions to the deadline, such as delayed onset of symptoms or newly discovered injuries, which may allow you to file a claim later.
Having a pre-existing condition does not automatically disqualify you from receiving workers' compensation benefits in California. However, if your employer or their insurance company believes your injury or illness is primarily attributable to the pre-existing condition rather than work-related factors, they may deny your claim. Seeking legal advice from our attorney can help you navigate this situation effectively.
Sources:
[1] Information, D. O. W. C. I. W., & California, S. O. (n.d.). DWC – I was injured at work. https://www.dir.ca.gov/dwc/injuredworker.htm
[2] Statutes of Limitation in Workers Compensation Cases. (n.d.). https://www.irmi.com/articles/expert-commentary/statutes-of-limitation-in-workers-compensation-cases
