Denied workers’ comp treatment claims are not the end of your medical care or benefits. They are the start of your fight for rightful treatment, lost wage compensation, and your recovery.
If a workers’ compensation claim for medical treatment is denied, you should first understand the reason for the denial. Then, you can pursue an appeal, which may involve requesting a hearing or mediation, and potentially consulting with a workers’ compensation lawyer. If the appeal is unsuccessful, you may need to consider further legal options.
About 15% of initial workers’ comp claims are denied, but at Scher, Bassett & Hames, we guide injured California workers through robust appeals and litigation when treatment claims are denied.
In this article, I’ll explain the common reasons why workers’ comp treatment claims are denied, the steps you can take to appeal a denial, and how experienced workers compensation lawyers can help you secure the medical treatment and benefits you deserve.
Why Are Workers’ Comp Treatment Claims Denied?
- Disputed work-relatedness: The insurer claims your injury is unrelated to your job, arguing it happened outside of work or during personal time.
- Pre-existing conditions: They argue your injury existed before your work incident and was not aggravated by your job duties.
- Insufficient documentation: Missing medical records, incomplete claim forms, or lack of detailed physician reports can result in a denial.
- Late reporting: California law requires timely reporting of injuries, and failing to report quickly can lead to denial.
- Utilization Review denial: Treatment is denied by the employer’s Utilization Review doctor, often based on insufficient medical justification or lack of authorization.
- Discrepancies in your report: If your statements about the injury vary between your initial report, your employer’s documentation, and your medical provider’s records, this can trigger a denial.
- Missed medical appointments: Failing to attend scheduled medical evaluations may lead the insurer to deny treatment.
Workers’ compensation claims can be denied for a variety of reasons, and understanding these can help you prepare a stronger case.
Action: Read your denial letter thoroughly. It will explain the reason for denial, the type of denial, and your specific deadline to appeal, which can be as short as 20 days in some cases. Act promptly to protect your right to treatment and benefits.## Detailed Step-by-Step Guide: How to Appeal a Denied Claim
Step-by-Step Process to Appealing a Denied Workers’ Comp Treatment Claim
Before diving into the detailed steps for appealing a denied workers’ comp treatment claim, it’s important to understand that the process can be complex and time-sensitive. Each step is designed to ensure that your rights are protected, and that you have the best chance to secure the medical treatment and benefits you deserve.
By following this step-by-step guide, you will be better equipped to navigate the workers’ compensation system, gather the necessary evidence, and present a strong case in your appeal. Now, let’s walk through the essential actions you need to take after receiving a denial.
1. Understand Your Denial
- Identify the exact reason for denial.
- Note the type of denial (Utilization Review, administrative, or factual dispute).
- Record the deadlines listed in the letter.
2. File an Application for Adjudication of Claim
- This formally disputes the denial with the Workers’ Compensation Appeals Board (WCAB).
- Must be filed in the county where you live or where you were injured.
- You will receive a case number for all future filings.
3. Request a Hearing (Declaration of Readiness)
- File a Declaration of Readiness to Proceed (DOR).
- Request a Mandatory Settlement Conference (MSC) where a judge attempts to settle the dispute.
- If unresolved, the judge will set a trial date.
4. Gather Strong Evidence
- Updated medical records, treatment plans, and physician notes.
- Witness statements confirming your injury or treatment denial.
- Workplace incident reports.
- Pay stubs showing wage loss.
5. Request a QME (Qualified Medical Evaluator)
- A QME is an independent medical professional who evaluates your condition.
- Use this if your treatment necessity is disputed. Medical causation is often a reason for a denied workers’ comp claim, and a QME can provide an impartial evaluation to support your case.
- Selection must follow California QME panel request procedures.
6. Request an IMR (Independent Medical Review)
- If your denial is based on Utilization Review, you can file for an IMR.
- An independent reviewer will decide if treatment should be approved.
7. Consider Legal Representation
- A workers’ compensation attorney increases your chance of overturning a denial.
- Attorneys in California typically work on contingency, so there are no upfront fees.
What Happens at Hearings and Trials?
- You and your attorney will present evidence, including medical records, witness testimony, and documentation, to a workers’ compensation judge.
- The claims administrator will present their side, potentially bringing their own witnesses or medical evaluations.
- The judge may encourage settlement discussions to resolve the dispute without proceeding to a full trial.
- If no settlement is reached, the judge will set a trial date where testimony is taken under oath, evidence is formally submitted, and legal arguments are made.
- After the trial, the judge will review all evidence and issue a written decision, typically within 30–90 days, explaining the outcome and next steps for either party.## If Appeals Are Unsuccessful
- Further Appeals: Take your case to the California Court of Appeal if warranted, which may involve complex filings and briefing schedules requiring legal counsel.
- Civil Lawsuit: Rarely, a civil suit may be possible if gross negligence or third-party liability is involved, but this process can be lengthy and requires clear evidence.
- Continue Treatment: Seek treatment through liens, Medical Provider Networks, or private insurance while continuing to dispute the denial, ensuring you maintain documentation and follow all medical recommendations to support ongoing claims and appeals.
California-Specific Strategies to Strengthen Your Claim
- Report your injury immediately, ideally in writing, to create a clear record. An injured worker must report the injury to their supervisor to avoid denial.
- Seek treatment from authorized workers’ compensation providers to avoid disputes and strengthen your medical record.
- Maintain a detailed injury journal documenting pain levels, symptoms, treatment dates, and limitations on daily activities.
- Keep organized copies of all medical records, denial letters, correspondence with your employer, and any forms submitted.
- Follow all medical recommendations and attend all appointments to demonstrate your commitment to recovery and to prevent insurers from using noncompliance as a reason to deny treatment or benefits.
- Request written confirmation of all communications with your employer and claims adjuster to document your efforts to comply with California workers’ compensation requirements.
Costs and Timeline Considerations
- Deadlines are strict; missing them can permanently end your claim, with California often requiring appeals within 20 to 30 days.
- Appeals may take several months to over a year depending on complexity, the need for hearings, or additional medical evaluations.
- Understand potential out-of-pocket expenses while your case is pending, including transportation to medical appointments, interim medical costs if using liens or private insurance, and potential lost wages if treatment delays impact your ability to work.
Take Action to Protect Your Health and Rights
If your workers’ comp treatment claim has been denied, do not wait. Contact Scher, Bassett & Hames for a free consultation. We will evaluate your denial, explain your options, and fight to secure the medical treatment and compensation you deserve under California law.
Resources for Injured California Workers
