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The Path Forward: What to Do After Your Workers’ Comp Claim is Denied

Receiving a letter that your workers’ compensation claim has been denied can feel like a devastating blow. After all you’ve been through, it’s frustrating and confusing to be told that the injury you sustained—the one that has caused you pain and disruption—is not covered. But please, take a moment and don’t lose heart. A denial is not the end of the road. It is simply a challenge that can be overcome. Many initial rejections are successfully overturned, and a denial is your official notice that it’s time to take the next step.

So, why might your claim have been denied, and more importantly, what can you do now?

Understanding the Reasons Behind Your Denial

When a claims administrator denies your case, it means they believe your injury is not covered by workers’ compensation insurance for a specific reason. It’s easy to feel like this is a personal judgment, but more often than not, it’s related to a procedural issue or a disagreement over the facts. When you receive that denial letter, it’s crucial to remember you have the right to challenge the decision. But don’t delay—there are deadlines for filing your appeal.

Common reasons for a denial often include:

  • Late Filing: We know how busy and overwhelming things can be after an injury. Unfortunately, there are strict deadlines for reporting an injury to your employer and filing a claim. Missing these can be a primary reason for denial.
  • Insufficient Medical Data: The administrator may feel there isn’t enough medical evidence to definitively link your injury to your job.
  • Off-the-Clock Injury: Workers’ compensation is designed to cover injuries that occur while you are performing your job duties. If the injury happened outside of work, it may not be covered.
  • Employer Dispute: It can be upsetting to learn, but sometimes your employer may dispute that the injury happened at work or that it was caused by your job.
  • Errors in Paperwork: Simple, honest mistakes on your claim forms can lead to an immediate denial, as the system flags incomplete or incorrect information.

While these reasons can feel daunting, they are often hurdles that can be cleared. It’s important to know that many legitimate claims face an initial rejection.

When Disagreements Arise: Seeking an Impartial Opinion

At some point during your claim, there might be a disagreement between you, your treating physician, and the claims administrator about the extent of your injury or the necessary treatment. This is a normal part of the process, and it doesn’t have to stall your claim. Instead, it triggers a step to get an impartial expert opinion.

This is where a Qualified Medical Evaluator (QME) comes in. A QME is a physician who has gone through additional training and testing to be a neutral medical expert in workers’ compensation cases. If you don’t have an attorney, you will be given a list of QMEs to choose from. After meeting with the QME, they will issue a report that can help resolve the dispute.

If you have an attorney, they and the claims administrator may agree on a single doctor to resolve the medical issues. This doctor is called an Agreed Medical Evaluator (AME). The report from an AME is often highly influential and can be a powerful tool in your favor.

Taking Control: Your Options After a Denial

You have power in this situation, and your denial letter simply means you must choose which path to take. You are not without options.

  1. Deciding to Stop: One option, though difficult, is to accept the insurance company’s denial and stop pursuing the claim. For many, this is a path chosen to avoid further stress, and it will lead to the claim being closed. While it brings an end to the process, it also means you will not receive any financial or medical benefits.
  2. The Independent Physician’s Review: If you are determined to fight the denial, you can choose to go through the QME process. By formally objecting to the denial, you can request an independent physician to review your case. This physician’s report has the potential to overturn the denial, which would keep your claim open for medical care, a settlement, or a final decision by a judge.
  3. Seeking Legal Representation: For many people, navigating this system alone is overwhelming. Choosing to hire an attorney can feel like a weight lifted off your shoulders. A skilled workers’ compensation attorney can take on the burden of the process. They can help with issues like adding new body parts to your claim, arranging for additional QMEs, and setting up hearings. An attorney’s job is to represent your best interests and ensure you get a fair and just resolution, whether that’s through a settlement or a judge’s final order.

Your Very First Step

No matter which path feels right for you, the first and most important step to take is to gather all your documents.

  • The denial letter itself.
  • All medical records and reports related to your injury.
  • Any communication you have had with your employer or the claims administrator.
  • Your initial claim form.
  • Any other paperwork related to your injury and employment.

Take control of your situation by collecting and organizing everything you have: the denial letter, all medical reports, and any communication with your employer or the claims company. Having these documents ready and in order will empower you to move forward with clarity and confidence.

Remember: This is just the beginning of your journey. Consulting with multiple attorneys and finding one who resonates with your needs and personality is crucial. To find the right one, we can help with a list of the top 10 workers’ compensation attorneys in Los Angeles.

If you have any questions or concerns regarding a work injury, unsafe working conditions or unfair treatment, be sure to contact us for a free consultation/case review.

To learn more or share your experiences call the Workers’ Compensation Group of Los Angeles at (877) 292-4888, email: info@workercompla.com or schedule a consultation online.

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Disclaimer: This blog is for informational purposes only and does not constitute legal advice. Consult an attorney for legal guidance specific to your situation.