How to deal with denied Work Comp claims

The letter in the mail has a bold heading "Notice Regarding Denial of Workers' Compensation Benefits". The insurance company explains you have 10 days to appeal by something called a QME. Further down, hidden on the second page it states you can contact an attorney. What should you do now?

Simple. You should contact an attorney in your area who has experience in California Work Comp claims. Why wouldn’t you? Most attorneys will not charge you to discuss the claim, answer your questions or even meet to review the facts and discuss the benefits you are entitled. Further, they deal with these claims daily. Let them help you through your claim. The best part, if the Work Comp lawyer cannot overcome the denial, you owe them nothing.

There are a number of reasons the insurance company might give for denying your injury claim, including:


  • The injury didn't happen at work or in the course and scope of your employment.

  • Your medical or physical problems are the result of a pre-existing problem.

  • You were not an "employee" as defined by the work comp laws in California.

  • There is a lack of medical evidence.

  • There is an affirmative defense which bars your recovery.


But the big one seems to be:

  • There is no medical proof or support for your claimed injury.


There are other defenses to a work comp claim but these are the most common. The insurance industry is more likely to deny a case if it can find one of the above to stand on. Their job is to make money. Should they approve every claim, they would not be making money. Some people will see this denial and drop the claim there. The insurance company counts on this. However, just because a case is initially denied, does not mean it is not a valid work injury.

Many people simply do not hire a lawyer or “make waves” with their employer because they believe there is nothing they can do. Other people assume if the claim is denied, the insurance company must be correct and there is no claim to pursue. Or, it might just seem easier to let your health insurance company pay the medical bills and continue to work in pain every day. 

None of these are good options if you were hurt on the job. Choosing to walk away from a potential work injury claim is simply a bad idea. It benefits the insurance company by saving them money. It hurts you if you have a legitimate claim which should be paid by workers compensation, not only now, but if you continue to have problems down the road with your current or a new employer. It only gets more difficult to prove a claim the longer you wait. In addition, you will not receive workers' compensation benefits if you ignore the claim.

At the very least, it’s a good idea to consult with an attorney to see if you have a claim. Once an employees claim has been denied often they are intimidated by the insurance company or afraid to fight back. Or, they are afraid hiring a lawyer will cost them a lot of money. Sometimes our attorneys will find there is not a claim to pursue. More often than not, however, people we speak with have legitimate claims which are definitely worth pursuing. Work Comp Law Center offers a FREE consultation to discuss your potential claim with our attorneys. There is no cost to you should you wish to pursue the claim, as we work on a contingency basis. So no recovery, no fee.

The insurance company has lawyers and experienced claims adjusters handling their cases. They are aware many of the denied claims are legitimate but the people will not pursue them. Chalk another victory up to the insurance company. Let us help fight back for you!


Our Recommendation:

If you have been injured on the job, or if you have a medical condition or disability which you believe was caused or aggravated by your work activities, immediately file a report of injury with your employer. If the claim is then denied or if you have any questions or concerns, contact a workers' compensation attorney for a FREE consultation to discuss your rights, benefits, and options.

© 2020 Riley & Associates. Representing Injured Workers with offices in Redding, and Susanville.

The materials on this website do not, nor are they intended to create an attorney-client relationship or constitute legal advice. All California Workers' Compensation claims are different.

For advice regarding your claim, please contact a workers' compensation attorney.