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Denied Claims

Fresno Denied Workers' Compensation Claims

All too often, employees are wrongfully denied workers’ compensation benefits after suffering an on-the-job injury. This may occur when insurers are reluctant to pay for an employee’s costly medical expenses, lost wages and disability benefits. However, a denied workers’ compensation claims lawyer can help you determine if you have options to reverse an insurer’s decision on your claim.

At Berry, Smith & Bartell, our Fresno workers’ compensation lawyers are qualified to handle every aspect of the claims process. We have detailed knowledge of California’s workers' compensation laws and have helped numerous workers in several industries appeal denied workers’ compensation claims. Our team of accomplished attorneys has a successful track record of assisting injured workers and their loved ones after suffering a work-related injury. Senior Partner and Founder Wm. Todd Berry is a member of the Fresno County Bar Association and has been taking cases to the Workers' Compensation Appeal Board since 2007. We understand that handling the workers’ compensation process on your own can be difficult, and that many people are unaware of the challenges of obtaining fair benefits. With more than 130 years of combined legal experience, we are prepared to help you through every step of the process to help you recover the benefits you deserve.

We will provide you with a free, no obligation consultation to review your claim and the reason it was denied. If we find that your employer or its insurer made a mistake in refusing to provide you workers’ compensation benefits, we will not hesitate to take appropriate legal action. Our attorneys work on a contingency fee basis and will only charge you if we help you obtain benefits for your claim.

Call 1-800-848-6288 today to schedule a free consultation.

Common Reasons Workers’ Compensation Claims Are Denied

When an insurer reviews a workers’ compensation claim, its main intention is to save itself money. Unfortunately, this often comes at the cost of denying legitimate claims filed by employees who suffer work-related injuries.

There are several reasons why an insurer may deny a workers’ compensation claim:

  • Your injury was not work-related: An insurer may claim your injury did not result from a workplace accident. An insurer may also allege that you are suffering from a pre-existing injury that could have occurred during the course of your job’s required duties.
  • You failed to file your claim in time: Employees must report a work-related injury to their employer. In California, you have 65 days to provide written notice to your employer that you suffered a work-related injury. Then, you have one year from the date of your injury to file your DWC-1 Claim Form. If you do not comply with these deadlines, an insurer will likely not approve your claim.
  • Your injury is not compensable: Insurers may claim that you cannot prove your injury is work-related and cannot be compensated. Common examples of non-compensable injuries are those that could be attributed to pre-existing conditions, such as heart injuries or mental distress. Some insurers may claim that repetitive-trauma injuries are non-compensable, but, California has laws specifically covering this type of condition.
  • You did not receive medical treatment: To receive workers’ compensation benefits, you must acquire medical attention to diagnose and treat your injury. If you do not receive medical attention, an insurer will deny your claim.
  • Your employer disputes your claim: An insurer may also deny your claim if your employer alleges that your injury happened outside of work or resulted from horseplay, fighting or coming to work intoxicated.

If you believe your workers' compensation claim has been wrongfully rejected, you should consider contacting an experienced attorney for help with your claim. He or she will explain the reason your claim was denied and inform you of the options are available to obtain the benefits you need.

To get started, complete a Free Case Evaluation form.

Appealing a Denied Workers’ Compensation Claim

When your workers’ compensation claim has been denied, it typically means the claims administrator believes your injury is not covered by workers’ compensation insurance. However, you may have the right to challenge this decision by filing an appeal with the Workers’ Compensation Appeals Board (WCAB).

The WCAB exercises judicial powers regarding California’s Labor Code and reviews the decisions made by the Division of Workers’ Compensation (DWC). There are several steps you must follow to appeal a denied workers’ compensation claim in California:

Adjudication of Claim Form

To begin appealing a denied workers’ compensation claim in California, you must submit an Application for Adjudication of Claim form with the WCAB. You may file the application with the WCAB’s local district office closest to you.

You must file your form within one year after:

  • Suffering your injury
  • The last day you received medical benefits
  • The day you stop receiving temporary disability benefits

When the DWC receives your application, it will send you a notice containing your case number and how to proceed with the next steps.

Declaration of Readiness to Proceed

Once you have received notice from the DWC, you will need to file an application called Declaration of Readiness to Proceed. You will need to submit your completed application to the WCAB.

After you have filed this form, your case will be scheduled for a hearing. However, the WCAB will try to resolve your workers’ compensation claim dispute through a settlement conference before proceeding to the hearing.

Mandatory Settlement Conference

When you are assigned a date for your workers’ compensation hearing, you will also receive a date for your Mandatory Settlement Conference. This is a last attempt to settle your workers’ compensation claim dispute with your employer’s insurer before proceeding to a hearing.

During your Mandatory Settlement Conference, a temporary judge will hear your case and the insurance company’s reason for denying your workers’ compensation claim. The judge will hear the facts of each case and try to find a solution that each party accepts. If you are unable to resolve the denied claim during the conference, your case will proceed to a hearing.

Workers’ Compensation Hearing

During your workers’ compensation hearing, you will present your case to an administrative law judge. At the beginning of the hearing, you and the insurance company will provide evidence supporting evidence for each side of the dispute.

At the beginning of the hearing, you and the insurance company will give the judge evidence to review, including:

  • Medical bills
  • Medical records
  • Employment records
  • Evidence of your lost wages
  • Reports by expert witnesses

Additionally, you may also testify at the hearing. Your testimony may describe how you became injured and how your injury has affected your ability to perform your job. You should also describe any disabilities you may have suffered as a result and whether you have been forced to find new employment as a result.

Petition for Reconsideration

If you are not satisfied with the decision made by the WCAB, you may file a Petition for Reconsideration. The only grounds for reconsideration are:

  • The appeals board or workers’ compensation judge acted outside of its scope of power
  • The decision was based on fraud
  • The decision is not justified by the evidence provided by either party
  • There is evidence that was discovered after the hearing that would have affected the decision
  • The findings of fact do not support the decision

You have 20 days to file the petition from the date of receiving the decision to deny your claim, according to CA Labor Code § 5903. However, if the decision was mailed to you instead of being handed to you personally, you will have 25 days to file your petition.

Once our petition has been submitted, the seven-member panel of the WCAB will review your case and either accept or reject the decision to deny your workers’ compensation claim.

Free Case Evaluation form us to discuss appealing your Fresno denied workers' compensation claim.

How Can an Attorney Help Me?  

Anytime you are in a dispute with an insurance company, it is in your best interest to consult with an attorney to discuss your situation. During a workers’ compensation claim dispute, an attorney will act as your advocate. There are many ways an attorney can help you obtain the compensation you need. This includes:

Gathering Evidence

Your attorney will carefully investigate every aspect of your claim to establish a connection between your workplace accident and the resulting injury. This includes finding evidence that shows your injury could not have occurred outside of the workplace. To prove this, your attorney will use the following types of evidence:

  • Accident report: It is important that you obtain a copy of your accident report from your employer. Your accident report will state the cause of the accident, the type of injury you suffered, the location of the accident, which parties were involved and may have witnessed your accident, when the accident occurred and when you first reported it to your employer.
  • Medical bills: These documents will also show the medical expenses you have incurred since suffering your workplace injury. You should carefully store any receipt or invoice that states the cost of your medical treatment, prescription medication, doctors’ appointments, medical assistive equipment, and cost of travel to and from doctors’ appointments.
  • Medical records: An attorney will use your medical records to establish a link between your injury and your workplace accident. Your medical records will also show that you sought medical treatment immediately after an accident, the severity of your injury, the type of medical treatment you need, and how long it will take for you to recover.
  • Employment records: Your employment records can help show that you were on-duty at the time of the accident and the wages you are owed if you missed work due to your injury.

Speaking to Witnesses

If you are appealing your denied workers’ compensation claim, your attorney may use witnesses and expert witnesses to support your case. These may include:

  • Medical expert: Your attorney will consult with health care providers who can testify in support of the severity of your injury, the type of medical treatment you need, and how long it may take for you to recover. Additionally, a medical expert can describe the effects of your injury and how it may impair your ability to work or if you suffer from a permanent disability.
  • Occupational expert: Your attorney may use an occupational or vocational expert to explain how your injuries affect your ability to perform your job’s required duties.
  • Economic expert: If you suffered a disabling injury, an economic expert can help estimate your loss of earning capacity and the amount of income you would have earned in your career.
  • Co-workers and other witnesses: Your co-workers, supervisor or any other bystanders who were present at the time of your accident can also testify that your injury is work-related.

Representing You During the Appeals Hearing

If you have an attorney, he or she will represent you during the appeals hearing. Your attorney will present your case to the judge and negotiate with the insurance company to reach a fair settlement on your behalf. Your attorney will also cross examine witnesses to help describe the seriousness of your injury and how it has affected you since the accident.

Complete a Free Case Evaluation form today.

Schedule a Consultation with a Denied Workers’ Compensation Claims Lawyer

Reversing an insurer’s decision to deny your workers’ compensation claim on your own can be difficult. Seeking qualified legal representation during this process may provide you several advantages to obtain the benefits you need after suffering a workplace injury.

Schedule a free, no obligation consultation with Berry, Smith & Bartell Fresno denied workers’ compensation claims lawyers. We have a strong understanding of California’s labor laws and know how to negotiate with insurers. Our attorneys are dedicated to reaching the fairest results for our clients.

For a free case evaluation with Berry, Smith & Bartell, a Professional Law Corporation call 1-800-848-6288 today!

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