As a general rule, injured California workers will likely be eligible for workers’ compensation benefits if:
- The worker was injured at work
- The worker suffered an occupational disease or illness caused by the job
- The injury or illness arose out of and during the course of employment
Most injuries and illnesses suffered by workers will meet this standard, but some circumstances may occur that lead to a workers’ comp claim denial. Know that you have a right to appeal a claim denial, so an initial denial is not the final say on the matter. With the help of an Orange County workers’ comp lawyer, you can fight this decision and navigate the legal process to receive benefits after a successful outcome on appeal.
Still, it is important to know the most common reasons for a claim denial, both to avoid simple mistakes and to better understand how an attorney can help you succeed when appealing the denial.
The Filing Process Was Delayed
One of the most important things to understand about California workers’ comp law is that you generally have just 30 days to report an injury or illness to an employer. If you fail to do this, you may lose the right to collect benefits.
Also, California typically gives injured workers one year to file a claim if the insurance company did not pay out any benefits, or five years if some benefits were paid out by the insurance company.
Your attorney may still be able to successfully argue that you should be eligible for workers’ comp benefits despite a late filing if certain legal exceptions apply to your case. But, it is naturally in your best interests to report your injury quickly and take quick and decisive legal action with the help of a lawyer to avoid such scenarios.
The Denial Is Based on the Facts Surrounding the Injury Itself
Two common reasons for denying a workers’ comp claim are as follows:
- The injury was unrelated to work because it was caused by a “preexisting condition.”
- The injury happened offsite and away from work
Disputes over whether the injury was work-related are often at the heart of a claim denial, but your lawyer can gather the evidence needed to rebut such arguments. Obtaining witness testimony, medical evidence and physician statements can be keys toward a successful appeal when claims are denied on these grounds.
An Injury or Condition Does Not Meet California Legal Guidelines
Some claims can be denied because an injury is not “severe” enough or is not recognized by California law. This does not mean the insurance company’s legal interpretation is correct, however.
Similarly, a claim may be denied because an injured or ill worker did not receive medical treatment. Ordinarily, injured workers are expected to receive treatment in order to qualify for workers’ comp.
A thorough review of the facts and evidence can reveal that the injury suffered is, in fact, serious or “severe” enough to justify receiving workers’ compensation benefits in California. Tricky legal arguments like these absolutely require an experienced workers’ comp lawyer in Orange County who will provide a strong legal argument based on the evidence and California law.
If your workers’ comp claim has been denied for any reason, our team at The Ledger Law Firm is here to help. Contact us online today for a legal consultation to speak with an Orange County workers’ comp lawyer about your claim denial.