Discovering that your employer’s workers’ compensation insurance will not cover the cost of your medical treatment can be financially devastating.
However, FindLaw explains that you do not have to give up after you receive the denial of benefits.
The denial letter
This document should provide the reasons that the insurance company denied your claim. You may find that your employer disputes your claim, saying that the accident happened because of horseplay, or that it is not a work-related injury.
Perhaps the accident was your fault, but you were negligent and not fooling around. Workers’ compensation is not a fault-based system, so your negligence would not disqualify you for benefits. Another aspect of the system is that even if you have a condition that your job did not cause, but it did exacerbate, workers’ compensation may still cover it.
Other common denial reasons include failing to seek medical treatment and missing a reporting or filing deadline. These claims may be more difficult to dispute, but that does not mean you should accept the denial.
The State of California Department of Industrial Relations explains how to challenge the insurance company’s decision. You have a limited window for the appeal, so you should file the necessary paperwork right away.
The paperwork includes an application for adjudication, which you file at your local Division of Workers’ Compensation office. The next document is the Declaration of Readiness to Proceed, which requests your hearing before a judge.
At the hearing, the judge tries to help you and the claims administrator to reach a settlement. If that does not work, then you must prepare evidence and witnesses for a trial before a different judge. Even if you still receive a denial, you have the option to request a reconsideration.
Adherence to the rules of the process, evidence and perseverance are all important keys to a successful challenge.