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Common Reasons Why Your Workers' Compensation Claim May Be Denied

Posted by Lawrence I. Stern | Nov 05, 2021 | 0 Comments

In California, if you are injured while on the job, you usually have a right to workers' compensation. Chances are that you qualify for benefits if you are injured at work.

Although most workers' compensation claims are submitted without problems, this is not always the case. Many injured employees fall victim to minor mistakes when filing. These may seem harmless at the first but can cause serious consequences, such as receiving denied claims.

Who Determines The Outcome Of Your Workers' Compensation Claim?

This decision relies on the “claims administrator” in charge of your particular case. Your claim can be denied for a number of factors, four of the most common include :

1. Failure To Report The Injury On Time

2. Not Obtaining Medical Treatment

3. Incorrectly Filed Paperwork

4. Employer Disputes The Claim

1. Failure To Report The Injury On Time

As previously mentioned, the state of California expects all employers to follow their laws by providing workers with adequate protection policies. It is important to note, however, that employees are also expected to follow specific rules and procedures. More often than not, employees sustain injuries that may be difficult to view as work-related. Repetitive-motion injuries are the most common injuries that go unnoticed since such developed over a long period of time. Because of this, it is important to have the right professional counseling and information to avoid falling behind. Once an employee determines their illness or injury to have developed at or during their workplace, he/she should inform their employer within 30 days or sooner. Preferably in a written notice, this is done with the intent to avoid future disputes of miscommunication as well as to document everything for future cases. 

2. Not Obtaining Medical Treatment

Insufficiency of evidence is yet another common reason for denial in a workers' compensation claim. A worker who does not get adequate review and help from a medical professional is not only putting their health in further damage but also their workers' compensation claim. Not having a medical record or documentation of such injuries or illness may benefit the disputing party, such as workers' compensation insurance attorneys. They may claim that your injury or illness is not suitable for WC benefits, and reinforce such claim with the argument that they are not serious damages as they did not require immediate medical attention. PLEASE keep in mind that workers' should not only conform to receive medical attention but also describe (in detail) all their injuries/ illnesses and follow all future required instructions such as follow-up appointments, therapy, or medication set by their doctor.

3. Incorrectly Filed Paperwork 

You should request an "Employee's Claim for Workers' Compensation Benefits" form from your supervisor (it's also known as a DWC 1 form). Your employer must give or mail you a claim form within one working day after learning about your injury or illness.

Fill out the employee section of the DWC 1 claim form carefully and correctly, making sure to include all the parts of your body you feel may be hurt or affected by your workplace injury or illness. Once completed you can return the form to your supervisor as soon as possible. Make sure to keep a copy of the completed form as your receipt and ask your employer to return the form to you with the employer section completed. By law, your employer has 24 hours to return the completed form to you.

The application for adjudication of a claim is a form that is filled out if there is a dispute between an injured worker and the employer's insurance company.

4. Employer Disputes Claim

In most cases, injured workers prove their case successfully, making their reasoning for compensation clear and justified. Unfortunately, this is not always the case. In some cases the WC filling process may become more problematic, the employer may dispute the reasoning behind their employer's claim, questioning things like if the injury occurred inside work? if it did, was the employer doing work-related activities? , or did this illness/injury arise from a pre-existing condition? In broad and demanding cases like these, we encourage workers' to seek experienced professional assistance.

If your workers' compensation claim is denied, the claims administrator will send you a letter informing you. If you disagree with the claims administrator's decision, you have the right to challenge this decision. This can be done by filling an audit complaint form, which can be easily accessed with the link below:

If your benefits have already been denied, you still have a right to appeal, and many benefits are granted in the appeals process. Again, talk to one of our experienced workers' compensation attorneys about appealing a denied claim.

Please keep in mind that if you choose to file a claim, your case will be heard by a workers' compensation administrative law judge (WCJ). You may choose to represent yourself or hire a professional attorney like our attorneys here at Mallery & Stern, APC who have represented a wide range of workers including union, non-union labor, as well as both public and private sector employees for more than 40 years of successful dispute experience!

About the Author

Lawrence I. Stern

As a California State Bar Certified Workers' Compensation specialist, Lawrence Irving Stern has over three decades of experience fighting for the rights of California's injured workers.Mr. Stern has a successful track record in obtaining substantial awards and settlements in challenging and serio...


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