Workers' Comp Denied? Here are Your Next Steps

The denial of your workers’ compensation will be determined by a “claims administrator”. This is a bureaucratic administrator who is tasked with the process of evaluating your workers’ compensation claim, though it is important to remember that these people work for the insurance company. This means that their primary goal is to make money for their company and to deny as many claims as possible.

Your primary care physician (also known as a PCP or “personal physician”) is not beholden to the insurance company, so it is likely that they will be sympathetic to your plight and will help you secure the benefits that you need to cover your work-related injury. In many cases, in fact, our attorneys have worked with our clients’ personal physicians to secure a workers’ comp ruling that is advantageous to them. In other words, your workers’ comp attorney and your personal physician are natural allies.

If you have been denied workers’ comp, that means that your claims administrator is disagreeing with your PCP’s medical opinion about your injury and/or illness and how best to treat your condition. If such a disagreement arises, then you may need to see:

1. A “qualified medical evaluator” (also known as a QME) - This is a physician who has undergone additional training and education in order to secure a QME license. The state of California has granted them this license to practice as medical physicians, chiropractors, osteopaths, dentists, psychologists, optometrists, acupuncturists, or podiatrists. They have also received certification by the Medical Unit of the Division of Workers’ Compensation to perform these legal/medical evaluations.
2. An “agreed medical evaluator” (also known as an AME) - These are clinicians that are mutually agreed upon between the legal teams of the employer and claimant to perform legal/medical evaluations in a workers’ compensation case that is under dispute. They may be QMEs (though not always) and can only be called upon if the claimant has a workers’ comp attorney who is representing them.

Essentially, a QME is a clinician who is provided by the Medical Unit of the Division of Workers’ Compensation (also known as the DWC). The DWC is the California regulatory agency that handles these matters, and it has local offices that are located throughout the state. Residents of Los Angeles can find their local branch at 320 W 4th Street in the city of Los Angeles. This branch is open Monday through Friday, 8 AM to 5 PM and their number is (213) 576-7335.

In some cases, however, it is preferable to have an AME consider your medical case. Unlike finding a QME, AMEs are not be provided by the DWC-Medical Unit. If you have an attorney in your corner, arguing your case, then state law allows for you to be examined by an AME who is mutually agreed upon by your attorney and the insurance company. In some cases, the insurance company will dig their heels in and refuse to agree on an AME, but the attorneys at Workers Compensation Attorney Law Firm have the experience and know-how to avoid such a situation.

When a QME is requested by your attorney or the claims administrator, then the DWC-Medical Unit will send a list of three (3) potential QMEs to examine your case. This list is randomly generated and will comprise of specialists in the relevant area of medicine (for example, if you have a spinal injury, then orthopedic specialists will be provided).

This is where things get complicated, however. Many claims administrators will develop working relationships with QMEs, and will eventually know which of them are most favorable to their rulings. In other words, all QMEs are ideally impartial, but the reality is that they sometimes are less favorable to claimants and more favorable to the insurance companies.

However, working relationships with these QMEs also extends to our legal teams at Workers Compensation Attorney Law Firm. Over the period of time that we have been practicing law, we have also developed working relationships with many of the QMEs in the state of California and will frequently know which ones are most favorable to claimants.

When the list of three (3) QMEs is first provided to you and your attorneys, there are strict timeframes under which the relevant clinician must be selected. This timeframe is usually decided by the claims administrator, and if you do not act within this period of time then you essentially forfeit your right to choose your QME. Subsequently, it is crucial that your attorney handle your case as they will be able to:

1. Identify which QME will be most favorable to your situation.
2. Choose the QME that will be handling your case.
3. Interact with the QME in case there are disputes over your diagnosis and/or treatment.
4. Do all this within the narrow timeframes that the claims administrator will impose.

Following your medical visits, the QME will then generate a report about your medical case. If you disagree with the QME’s assessment about your injury or illness, then there is the possibility of you requesting a supplemental report or potentially negotiating a compromise with your claims administrator. This is a complicated process, however, and requires the experience and knowledge of a workers’ comp attorney to help you. In most cases, you will have thirty (30) days from the date of the report to request a supplemental analysis.

Both QMEs and AMEs are required to determine specific parameters of your work-related injury and/or illness, including:

1. If your work was the cause of your injury and/or illness.
2. If you need to undergo medical treatment for your injury.
3. If you need to take a leave of absence from work to stay home and recover from your injury and/or illness.
4. If your medical condition has a “permanent and stationary date”.
5. If you suffer from a preexisting condition and if this preexisting condition was exacerbated by the work-related injury and/or illness.
6. If you have a new and/or further disability.
7. What your “permanent disability rating” will be.

The “permanent and stationary date” refers to the date when your condition has stabilized and is not likely to improve. This is can be determined by your personal physician, though it is unlikely that the claims administrator will accept their judgment. In these cases, the QME or AME will determine if your condition has reached this level and, if so, what the exact date is.

Furthermore, the clinician in question will determine your “permanent disability rating” as well. This is to provide an accurate, medical assessment of your physical impairment and to determine the severity of your injury and/or illness. Again, it is possible that your personal physician can determine this rating, but it is most likely that the claims administrator will request that a QME or AME make this final assessment.

Determining this rating is done through a variety of tests that are specific to whatever body part you may have injured or the symptoms of whatever occupational illness you may have contracted. Whatever the case may be, these tests are mandated by the DWC-Medical Unit and are the same in every doctor’s office. This is to ensure that the results are standardized and accurate. Ultimately, this rating is legally binding, so it is absolutely vital that the tests applied are the same, all across the board.

Ultimately, the doctor in question will be working off of a 100-point scale that will assign a disability percentage to each affected body part. For example, you may be assigned a 15% disability of the left shoulder and a 25% disability of the right shoulder.

This permanent disability rating can also determine the level of benefits that you receive as well as consider the reduction of your future capacity to earn income. There is a direct correlation between the disability rating and the amount of monetary compensation that you receive due to your work-related injury and/or illness. In the state of California, the percentage of your disability coincides directly with how many weeks worth of wages you will receive as part of your compensatory package. For example, a rating of 10% permanent disability equals thirty (30) weeks worth of wages.

There are a variety of other reasons that your employer may use to justify denying your worker’s compensation claim. Identifying why your claim is being denied is arguably the most important step in the entire process as it will influence the entire legal strategy that your attorney will take in appealing your case.

Due to our breadth of experience and knowledge in workers’ compensation cases, we have seen the entire gamut of potential responses that an unscrupulous employer may use in order to avoid granting your lawful workers’ compensation benefits, including:

1. Denial due to a “preexisting condition” - This is, by far, the most common reason (about 28% of cases) that an employer will give for the denial of a workers’ compensation claim. However, a preexisting condition is not always an impediment to receiving workers’ comp benefits, and the state of California allows for workers’ compensation to be paid if a preexisting condition has been “exacerbated” by a work-related injury and/or illness.
2. Failure to notify employer - If a worker is injured, then they must notify their employer of their work-related injury and/or illness. Under California state law, you must notify your employer within thirty (30) days of your injury and/or being diagnosed with your work-related illness. If you do not report your injury and/or illness within this period of time, then your employer can outright reject your claim.
3. Lack of insurance coverage - Workers’ compensation insurance does not automatically provide coverage for every worker. The most common exemptions from this type of coverage are independent contractors, domestic employees, certain executives, or agricultural workers. Although the employer may still be held responsible for the employee’s injury and/or illness, they may not have to do so via workers’ compensation.
4. California statute of limitations - Every state has a statute of limitations for how long an employee may file a workers’ comp claim following their injury. In California, this statute of limitations is one (1) year, after which any claims for workers’ comp that are filed are automatically rendered null and void. There are some exceptions to this statute of limitations, such as when the employee suffers from some kind of occupational illness.
5. Intentional action caused the injury/illness - Workers’ comp is only given for situations that are legally deemed to be accidents. It is possible that it will provide coverage for situations of negligence, but it will emphatically not cover any intentional actions. Furthermore, workers’ comp is never available if the injuries and/or illness were self-inflicted in order to file a fraudulent claim.
6. The claimant exhibited willful negligence - In this particular situation, the claimant engaged in a type of behavior that they knew would likely result in their injury. There is a fine line between simple negligence and willful negligence, so it is best that you have a legal expert go over your case to help you make a strong argument for workers’ comp coverage.
7. The claimant failed to seek medical treatment - Receiving benefits from workers’ comp is contingent upon the fact that the claimant in question seeks out medical treatment. Otherwise, the employer may make the claim that the injury/illness was not that severe if the claimant did not need to treat it. Furthermore, the claimant in question may be legally required to undergo an independent medical examination in order to determine the exact cause and nature of their injury and/or illness.
8. The injury/illness is not covered - There are injuries and/or illnesses which are not compensable under California law, including repetitive or stress-related injuries.
9. The injury and/or illness is not serious enough to merit workers’ compensation - The key aspect of a workers’ compensation case is whether or not the injury and/or illness in question prevent the claimant from performing their job. In some cases, they may experience a partial loss of ability whereas in other cases, there is a complete loss of ability that can be either temporary or permanent.

As you can see, these run the range from relatively mild to utterly egregious. Once the precise reason has been identified, then your legal team can lodge an appeal before the state regulatory agency that oversees workers’ compensation cases. Depending on the specifics of your case and the reasons behind the insurance company’s denial of your claim, this will likely result in a trial before a civil judge with a binding and final ruling on your compensability.

The state of California and the Division of Workers’ Compensation (DWC) give you the legal recourse to appeal your denial of workers’ compensation. This is a fundamental right that is extended to every employee working in the state, whether it be in the private or public sector. In order to begin this process, there are two forms that you and your lawyer will have to file:

1. An Application for Adjudication of Claim - This is the first step in filing your official claim and is absolutely mandatory as it will provide you with your workers’ compensation case number. This case number is necessary to have in every other step of the process.
2. Declaration of Readiness to Proceed form (also known as a DOR) - Using your workers’ compensation case number provided by your Application for Adjudication of Claim, you then file a DOR to request a hearing before the Workers’ Compensation Appeals Board (this is known as the WCAB).

Once your DOR is filed, then the judge who is presiding over your appeals process before the WCAB will schedule a legal hearing known as the mandatory settlement conference (MSC). This is not like a criminal trial that is done before a jury, but it does consist of presenting evidence to argue your case. This is a complex and potentially overwhelming legal maneuver, so it is vital that you have a workers’ compensation attorney who can present your case before the WCAB judge.

Furthermore, the WCAB has various local offices. Residents of Los Angeles can find their local branch at 6150 Van Nuys Boulevard #110 in the city of Van Nuys. They are open Monday through Friday, 8 AM to 5 PM and their number is (818) 901-5367.

In the course of your claims denial, the insurance company will give one of the nine (9) reasons listed above and claim that either:

1. Your injury did not “arise out of employment” (also referred to as AOE) - This means that the claims administrator is formally declaring that your injury and/or illness was emphatically not caused by your occupational activity (remember that it is in their best interest to make that claim, as then they avoid having to provide you with your legally entitled financial compensation).
2. Your injury did not happen “in the course of employment” (also referred to as COE) - This means that the claims administrator is formally declaring that the activity that was the cause of your injury and/or illness was not work-related (again, it is in their financial best interest to make this claim).

Once you have secured a WCAB judge to oversee your appeals process, they will first set a “priority conference” or “expedited conference” date to resolve these questions of AOE or COE claims denial. As with every step in the process, it is best that you have a workers’ compensation lawyer present to argue your case and push back against the claim administrator’s spurious arguments.

However, there is a possibility that the insurance company and claims administrator will admit that you have suffered a work-related injury and/or illness and that the AOE or COE parameters do not apply to your case. It is still possible for them to deny financial compensation on the basis that you do not need medical treatment and/or that you are not entitled to temporary disability payments while you are away from work. In these cases, a “pre-trial conference” will be set by the WCAB judge and they will try to make a final determination of your workers’ compensation.

However, if no final determination can be made, then the judge will set up a trial date. Before this trial date, there will be a “discovery plan” so that your attorneys may gather the necessary evidence. This will usually consist of:

1. Medical evaluations - Mostly from the QME or AME assigned to your case, though our skilled lawyers can also incorporate the medical opinions of your personal physician.
2. Your testimony - This will be your account of what happened and how it has affected your life.
3. Expert testimony - This may be necessary to explain why your injury and/or illness has debilitated you.
4. Eyewitness accounts - This will consist of testimony from any witnesses, if applicable.

Once this discovery plan is complete, then both sides can argue your case before the WCAB judge. At this point in time, the judge will make a ruling on your compensability that will be final and binding. This is a potentially fraught time and the opposing side will almost certainly try to overwhelm you with medical/legal jargon or terminology, but our lawyers are highly experienced in navigating these situations and have a long track record of success in these appeals processes.

Don’t let yourself be bullied your employer and insurance companies. They have their own interests in mind, so it is crucial that you retain a legal firm that can guide you every step of the way. If you are a resident of Los Angeles, then contact our workers compensation lawyer at 310-956-4277 for a complimentary consultation.