What Happens if My Claim Is Denied?
Few things are more discouraging than suffering a serious workplace injury and then receiving a letter saying your workers’ compensation claim has been denied. You may be counting on those benefits to cover medical bills and lost wages, and suddenly you’re left wondering what went wrong and what to do next.
The good news is that a denial doesn’t have to be the end of your claim. California’s workers’ compensation system includes a formal process for disputing denials and getting your case reviewed by a judge. With the right legal help, you may still be able to obtain the benefits you deserve.
At Invictus Law, P.C., we help injured workers throughout Orange County and the Inland Empire challenge unfair claim denials and make sure insurance companies follow the law. Here’s what you need to know if your workers’ compensation claim has been denied. For more information or immediate assistance with your claim, call our office to speak with a skilled and experienced Southern California workers’ compensation lawyer.
Why Workers’ Compensation Claims Get Denied
A denial can happen for many reasons—some valid, some not. Understanding why your claim was rejected is the first step toward fixing the problem.
Common reasons include:
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Missed deadlines. In California, you must report your injury to your employer within 30 days and file a workers’ comp claim within one year. Missing these deadlines can give the insurer an excuse to deny coverage.
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Disputes about whether the injury is work-related. The insurance company might argue that your injury happened outside of work or that it resulted from a preexisting condition.
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Insufficient medical evidence. If your doctor’s report is unclear, incomplete, or fails to connect the injury to your job, the insurer might deny the claim.
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Employer challenges. Sometimes an employer disputes that an injury occurred on the job or claims you weren’t acting within the scope of your employment.
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Administrative errors. Paperwork mistakes, missing forms, or miscommunication between you, your employer, and the insurance company can also lead to wrongful denials.
Even if the insurer has a reason for denial, that doesn’t mean they’re right. Many denials are overturned when workers appeal with the help of an experienced attorney.
What to Do After a Denial
If you receive a denial letter—called a Notice of Denial—don’t panic. Read the letter carefully. It should explain the reason for the denial and outline your right to challenge the decision.
Your next step is to file an Application for Adjudication of Claim with the Workers’ Compensation Appeals Board (WCAB). This form officially opens your case and allows a judge to review the evidence. You’ll receive a case number and be assigned to the WCAB district office nearest you, such as the Anaheim or San Bernardino office for workers in Orange County and the Inland Empire.
Once your case is filed, your attorney can request a hearing or conference to discuss the denial and attempt to resolve it. In some cases, disputes can be settled informally; in others, a formal trial before a workers’ compensation judge may be necessary.
Gathering the Evidence You Need
When a claim is denied, it’s often because the insurance company doesn’t believe your injury is work-related or properly documented. To challenge that decision, you’ll need strong evidence supporting your claim.
This may include:
- Medical reports linking your condition directly to your job duties or workplace exposure
- Witness statements from coworkers who saw the accident or can confirm your work environment
- Employment records showing your job duties and schedule
- Safety or incident reports filed at the time of the injury
Your attorney may also request an independent medical evaluation by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to provide an impartial opinion on your condition. A well-prepared medical report can make all the difference in reversing a denial.
What Happens at a Workers’ Compensation Hearing
If your case goes to a hearing, you and your attorney will appear before a workers’ compensation judge. The judge will review the evidence, listen to both sides, and decide whether the denial should stand or be overturned.
These hearings are less formal than courtroom trials but still follow specific legal procedures. The judge may issue a decision immediately or take the case under submission and mail the ruling later. If you win, the insurance company will be ordered to begin paying your benefits and cover your reasonable medical expenses.
If the judge upholds the denial, you may still have the right to appeal to a higher panel of the WCAB or, in some cases, to the California Court of Appeal. Your lawyer will advise you on the best next step based on your case’s outcome and evidence.
Don’t Give Up After a Denial
Many injured workers assume that once their claim is denied, there’s nothing more they can do. That’s a costly mistake. Denials are common, but they are not final. With the right representation, denials can be overturned, and benefits can be granted or restored.
At Invictus Law, we frequently see cases where denials were based on incomplete medical records, a misunderstanding of how an injury occurred, or simple administrative oversights. Once we step in, gather proper documentation, and present the facts clearly, insurance carriers often change their position, or judges rule in our clients’ favor.
How Invictus Law Can Help
The workers’ compensation system can be confusing and intimidating, especially when you’re simultaneously dealing with an injury and financial stress. Our firm handles every aspect of the appeals process with expertise, including:
- Filing the Application for Adjudication and all necessary paperwork
- Coordinating medical evaluations and expert reports
- Representing you at hearings and conferences
- Negotiating settlements and ensuring you receive all the benefits you’re entitled to
We know how insurers operate, and we know how to fight back when they wrongfully deny valid claims.
Talk to Invictus Law, P.C. About Your Denied Claim
A workers’ compensation denial can feel like a setback, but it’s not the end of the road. You have rights…and options. The key is to act quickly and get the right legal help on your side.
At Invictus Law, P.C., we’re dedicated to protecting injured workers throughout Orange County and the Inland Empire from unfair claim denials and insurance company tactics. If your workers’ comp claim has been denied, contact us today at our offices in Orange or Ontario for a free consultation. We’ll review your case, explain your options, and fight to get you the benefits you deserve.
