Workers’ Compensation Appeals
Workers’ compensation claims seem like they should be pretty straightforward: after a work injury occurs, the injured worker receives necessary medical treatment and compensation for missed work. Unfortunately, it’s not always that simple. Insurance companies routinely deny claims for a variety of reasons, but a workers’ compensation claim denial does not mean the end of your case. Our work injury law firm helps its clients pursue workers’ compensation appeals.
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Common Reasons Workers’ Compensation Claims are Denied
Workers’ compensation claims can be denied for a variety of reasons, but mostly occur due to a lack of proper injury documentation. Some common reasons insurance companies will deny a claim include:
- Failure to report the injury in a timely manner
- Lack of medical evidence documenting the injury
- Lack of proof showing the injury occurred while working
- Suspicion that the work injury occurred while under the influence
- Suspicion that the work injury was the result of a pre-existing condition
- Suspicion that the work injury happened because of a non-covered situation, such as fighting
- Claim is contested by your employer
- Claim was filed after the worker quit, was laid off, or fired
- Any number of small mistakes that crop up during the claims process
For any one of these reasons, a workers’ compensation insurance company could deny your claim, leaving you responsible for your own medical care and unable to collect disability benefits. Fortunately, if your claim is denied by the insurance company, you have the right to appeal the decision, and it is often worth the effort: a majority of denied workers’ compensation cases result in a settlement or judgment in favor of the injured worker. Retaining an experienced workers’ compensation attorney can increase your chances of a successful appeal.
The Workers’ Compensation Appeals Process
After their workers’ compensation claim is denied, injured workers have 20 days to appeal (25 days if the denial is received by mail) the decision. In order to pursue an appeal, injured workers must request a hearing from the Workers’ Compensation Appeals Board (WCAB). This is done by filing a Petition for Reconsideration with the Board. A Petition for Reconsideration is a legal document where injured workers can allege fraud, argue against the findings, argue that the findings do not justify a denial, and/or provide new evidence in support of their case.
Upon receipt of the petition, WCAB will have 60 days to approve or deny it. If the board approves your petition, it will review your workers’ compensation claim in light of the evidence provided in the Petition for Reconsideration. Depending on the circumstances of your original workers’ compensation claim denial and the information in your petition, WCAB will affirm, reject, or amend your claim. When WCAB makes its decision regarding your workers’ compensation appeal, it will mail you the decision. In some cases, the board will schedule a hearing to examine your denial and appeal before making a decision.
What to Expect at a Workers’ Compensation Hearing
Injured workers will receive advance notice of when and where their WCAB hearing will be. Usually, WCAB hearings will take place at the WCAB office location that has jurisdiction over your claim. Hearings heard before a WCAB judge are not like what you would see on TV. The hearings themselves are much more casual than TV dramas. The room where your hearing takes place will probably be smaller than you expect, and there is no jury or gallery present; the only people that will be in the hearing room are the judge, courtroom staff, and the parties involved in your claim.
Preparing for Your Hearing
Your workers’ compensation attorney will advise you of everything you need to know and do before your hearing. You may need to collect certain documents and/or medical records to bring to the hearing. Though hearings are typically less formal than one would expect, applicants are still expected to dress appropriately for the venue. Suits or other business attire are not necessary, but clothing should be clean, comfortable, and inoffensive. Hearings can last all day, so it’s recommended to bring all necessary medications and medical devices with you. It’s also recommended that you bring a fully-charged cell phone to communicate with your attorney if necessary. There is typically a lot of waiting involved, so you may want to also bring a book. It’s also not uncommon for applicants to wait at the board all day, never to have their hearing. Do not be alarmed if your hearing is rescheduled; it likely means other cases on the docket are running long.
During Your Hearing
As your hearing begins, it’s important to remember to treat everyone present in the hearing with respect, especially anyone who seems to be disrespecting you. The judge will take notice of anyone in the hearing behaving poorly and it may factor in to the outcome of your claim. When the hearing is underway, your attorney and the insurance company’s attorney will present the judge with all of the evidence relevant to your case. This evidence could include medical records, employment records, deposition notes, and anything else that is relevant to your injury claim. When presenting the evidence, each party will be arguing its case while simultaneously negotiating a possible settlement. In some circumstances, you will be required to testify before the room.
You won’t have to take the stand to testify, but you will need to swear to tell the truth under penalty of law. After being sworn in, your attorney, the insurance company’s attorney, and the judge may ask you questions. Regardless of the nature of the questions, you should answer them truthfully and concisely the best you can. If you’re unsure of the answer to any question, say so. “I do not remember” or “I do not know” are valid answers if they are truthful. Even if a particular question posed to you by the insurance company seems like it would hurt your case to answer truthfully, you should still answer truthfully. If you are perceived as lying by the judge it can severely damage your case.
It’s very possible that your case does not conclude in one day. If that happens, the judge will set another day in the future to continue your hearing, which will likely be several days, if not weeks, away. The case will be picked up where it left off on the new trial date.
After the Hearing
If your claim is not settled by the end of the hearing, you can expect to wait even more. You will not receive a decision from the judge at the end of the hearing. The judge will take all of the evidence and testimony into consideration before making a decision, which can take up to several months. A normal, uneventful hearing, you can expect a ruling from the judge in about 30 to 90 days. You will receive the decision in the mail.
Appealing a WCAB Decision
For all intents and purposes, WCAB decisions are final. While you can technically file a writ of review with the California appellate court the effort is almost always futile. Writs of review cannot dispute any of the facts found in the WCAB decision, only the decision itself. Unless the WCAB decision is particularly egregious in light of the facts, the appellate courts will not alter the decision. Applicants must file a writ of review within 45 days. In a similar vein, appellate court decisions can be appealed to the California Supreme Court, but the same limitations apply.
A Workers’ Compensation Attorney Can Help
Opening a workers’ compensation claim after a workplace accident can be stressful and confusing. Any improper actions can lead to a claims denial. An experienced workers’ compensation lawyer can help you file your first time claim and fight a claim denial. The Law Offices of Scott Warmuth helps the victims of workplace accidents receive the medical treatment and financial compensation they need.