Imagine your workers’ compensation claim was denied, but you’re down and out and unable to work due to a broken leg resulting from an employment-related accident. You’re convinced that you have the legal right to receive medical benefits and wage replacement benefits under the California workers’ compensation system, but the insurance company disagrees.
The first thing to do is this: Don’t panic. You might still have a chance to obtain the benefits you deserve.
When the claims administrator sends you a rejection letter
When the workers’ compensation claims administrator sends you a rejection letter and denies your claim for benefits, you can challenge the denial — as long as you do it within a certain amount of time.
Many individuals represent themselves when challenging a denial of benefits. Others obtain professional legal counsel to defend their legal rights as strategically as possible. Ultimately, a workers’ compensation administrative law judge will review an applicant’s appeal and make a decision regarding his or her eligibility.
When you receive benefits but you don’t agree with them
In other cases, you might receive an award of benefits but disagree with the extent and/or nature of benefits you receive. In these cases, you may want to receive an evaluation from a qualified medical evaluator (QME). The claims administrator might also approve of a medical provider that your attorney feels is appropriate to evaluate your case. Such an approved physician is referred to as an agreed medical evaluator (AME).
Fight for the benefits you have the legal right to receive
If you don’t agree with the decision of the claims administrator, it’s important to remember that this is not the end of the world. In many circumstances, injured workers submit successful workers’ compensation appeals so that they can get the benefits they need — not only to get better and heal from their injuries but also to support themselves and their families financially as they heal.
When you’re a sick or injured worker, there is no better lifeline of financial support than the California workers’ compensation system. Make sure you fight for the full amount of benefits you have a legal right to receive.
