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What Are My Options if I Was Denied Workers’ Compensation?

Dangerous accident during work
If you are injured on the job, you should always work in a timely manner when it comes to making your claim for workers’ compensation. Workers’ compensation benefits are meant to cover things like medical costs and lost wages when you are unable to work due to an illness or injury caused by work. There are several reasons why a workers’ compensation claim may be denied – however, just because you received a denial, this doesn’t mean it’s the end of the road for you.

Why Was My Claim Denied?

  • Failure to Notify Employer of Injury:There is a statute of limitations on when you should notify your injury to an employer. The claim doesn’t actually begin until you report your injury to your employer. Each state has its own limitations, but it is typically around 30 days.
  • Failure to File Claim Within Time Period: Missing the filing period for your claim is grounds to have your claim denied. The State of California has a filing period of one year since the discovery of your injury.
  • Injury Occurred Outside of Employment: Were you on-site while performing work duties when the injury occurred, or off-site while pursuing duties your employer assigned to you? Then you will probably qualify. However, if your injury occurs before or after normal work hours, you may not be covered.
  • Injury Occurred While Under the Influence: If you are under the influence of illegal narcotics or alcohol when injured, then you should expect your claim to be denied. This could even include medications under certain circumstances.
  • Employer Disputes Injury Claim: Your employer may fight that your injury is pre-existing. They could also claim that the injury occurred outside the scope of your employment or that the injury is faked. You must prove the legitimacy of your injury.
  • Your Medical Condition Isn’t Covered: Mental health issue claims are typically denied, so you must be able to link the mental issues to a specific event such as trauma. This will require clear medical evidence from a licensed psychiatrist or other doctor in the field.
  • Injuries Aren’t Serious Enough For Coverage: Your injury must limit or prohibit you from completing the job duties assigned to you. You must have a doctor’s opinion stating that your injury is debilitating, and you must be able to convince the insurance company of this.

How Do I Appeal a Workers’ Compensation Claim Denial?
You may receive a letter in the mail saying your claim was denied for any of the above reasons. That same letter may contain information about how you can go about appealing the denial of your claim. You should always note deadlines for the appeal. You should always call your employer or workers’ compensation insurance to discuss why the denial occurred and if there was a mistake.

If there was no mistake, then you want to go about appealing the denial. Appeals processes will vary from state to state, the first level of appealing typically being an issue seen before an administrative law judge. When your appeal hearing takes place, you will be required to present all of your medical and factual evidence to support the existence of your claim. Always make sure that the appeal is filed within the specified time limits and that you have plenty of evidence.

In the State of California, you will want to file an Application for Adjudication of Claim, which must be filed at a DWC office in the county where you live or were injured. The DWC office will then send you a notice confirming that it has been filed, which will include your assigned case number. The process continues from there.

How Do I Reopen a Claim if the Statute of Limitations Has Expired?
Judges may be able to define the statutory periods even when they have technically expired, but this depends solely on the situation at hand. However, even though this is legally possible, reopening a closed workers’ compensation claim can be an extremely tiring and difficult process. Insurance companies will usually oppose the reopening of old claims, especially when there’s a chance that they will have to pay that claim when all is said and done.

If you believe you have a case, you may want to consult an attorney who specializes in the complex law of workers’ compensation. Call RAWA Law Group today to get a free case evaluation at a consultation. The moment you believe you have a claim, it is best to have an attorney on your side to ensure a better outcome. Enlist in an attorney you trust and get the compensation you deserve today!

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