Appeals Process

Chula Vista Workers’ Comp Appeals Attorneys

Helping Workers Navigate the Appeals Process

When you are injured on the job, you might expect to be fairly compensated for your injuries and taken care of by your employer. After all, California has robust workers’ compensation statutes, and employers operating in the state are required by law to maintain insurance policies for injured employees. Unfortunately, many injured employees who file for workers’ compensation hit a wall when their employer’s insurance company rejects their claim. You may worry that there is no recourse, and you will have to shoulder the costs of your injuries on your own.

When your workers’ compensation claim is rejected by an insurance company, you still have options, including the ability to appeal. Our Chula Vista workers’ comp appeals lawyers at The Sexton Law Firm can help guide you through this process. We are intimately familiar with California’s appeals process for these types of conflicts and understand how to effectively advocate for our clients.

We offer our legal services in English and Spanish. Call (619) 202-8976 or contact us online if you need assistance with a workers’ compensation appeal.

Why Workers’ Compensation Claims Get Denied

California’s workers’ compensation system operates on a “no fault” basis. In theory, this protects and benefits both employees and their employers. Employees do not typically have the ability to pursue legal action against their employees for injuries that occur on a jobsite, but in exchange, employees do not have to prove that an employer was necessarily at fault for the accident.

Instead, California’s workers’ compensation program only requires that employees prove an injury was work-related. Numerous benefits are available to injured workers depending on the nature and extent of the injuries. Employers are required to maintain insurance policies protecting injured employees that pay out when conditions for these benefits are met.

Problems occur when an employer’s insurance company refuses to pay a workers’ compensation claim. Because many workers unfortunately do not understand their rights, insurance companies can frequently get away with arbitrarily denying claims. Many unscrupulous insurance providers make a habit of regularly rejecting most or even all claims, regardless of perceived validity. These companies bank on the assumption that workers do not have the resources, knowledge, or motivation to fight or appeal.

There are legitimate instances in which an insurance company is within its rights to reject a workers’ compensation claim, including situations where:

  • Your injury was not work-related. If you suffered an injury while you were not on the clock or at any location unrelated to your job responsibilities, you will not be able to successfully pursue workers’ compensation.
  • Your injury resulted from work for another employer. An injured worker cannot “double dip” on an accident. If you work multiple jobs, you can only seek workers’ compensation from the employer directly associated with where the injury occurred.
  • Your injury does not require time off. Employees with severe injuries that require hospital stays or otherwise keep you from reporting for work may qualify for temporary disability, permanent disability, and other types of benefits. You will not be able to successfully seek these types of workers’ compensation if your injury does not require that you take time off.
  • Your injury does not require medical attention. Similarly, workers’ compensation is designed to support employees’ treatment costs should the injury be significant enough to warrant a hospital stay or other forms of expensive medical attention. If your injury was not serious enough to require medical costs, you will not be able to seek associated compensation.

As long as the above scenarios do not apply to your situation, your employer’s insurance company policy will likely not have a sufficient reason to deny your workers’ compensation claim. Keep in mind that some insurance carriers will be sneaky in their attempts to justify a denial. They may attempt to suggest that you incurred the injury from somewhere other than your worksite, for example. Be cautious in how you communicate with any insurance agent and be explicit in that your injury was work-related and resulted in damages that warrant workers’ compensation.

Insurance companies can also sometimes undercut a workers’ compensation payout instead of outright rejecting it. This means that, while you will receive some monetary reimbursement for your injuries, it is likely not the full amount to which you are entitled. If your claim was improperly rejected or you believe you are not receiving the entirety of what you are owed, it is important to immediately contact an experienced personal injury lawyer.

How California’s Workers’ Compensation Appeals Process Works

When you wish to dispute an outright rejection of a valid workers’ compensation claim, you will need to request a hearing with your local Workers’ Compensation Appeals Board (WCAB). Specifically, you and your legal representatives will need to file the Declaration of Readiness to Proceed, the formal declaration that you wish to contest your employer’s insurance company’s decision.

How the appeals process develops from here depends on what is being contested and why. If the insurance company is rejecting your claim on the suspicion that your injury did not “arise out of employment” or “in the course of employment,” a judge will set what is called a “priority conference.” These types of disputes are often open and shut and can be settled efficiently, so priority conferences – which are effectively expedited hearings – are used in lieu of more protracted, traditional trials. There is the possibility a denial can be quickly reversed if there is evidence that the injury was work-related.

If your contestation revolves around the number or amount of benefits that have been approved by the insurance company, you will need to go through a somewhat longer process. This can be necessary in situations where an insurance company has accepted parts of your claim but fails to pay out certain benefits or undercuts the appropriate benefit amount. You will likely be summoned for a pretrial hearing, where a WCAB judge will attempt to arbitrate a decision between you and the insurance company. If a resolution cannot be reached, a formal trial date will be set.

If your workers’ compensation case goes to trial before your WCAB, you will likely need to be examined by a qualifying medical professional. Their assessment of your injuries will be paramount to successfully arguing for your benefits.

Our Chula Vista workers’ compensation appeals attorneys can help you through every stage of your dispute. We can evaluate your original claim, assess the stated reasons why it was denied by the insurance company, and strategize on how to frame your Declaration of Readiness to Proceed. We will advocate on your behalf before your WCAB and gather all of the necessary evidence to prove that your injuries qualify for the benefits you need.

Appealing Further Unfavorable Decisions

If your disputed claim goes to trial and receives an unfavorable result before your local WCAB, you have the option to file a second appeal and potentially have your case heard by the WCAB stationed in San Francisco. This decision must be made quickly, and the San Francisco WCAB typically reviews petitions without additional hearings.

Should this strategy prove unsuccessful, we can also explore alternative legal options. Depending on the nature of the initial rulings and facts of your case, we can consider pursuing appeals with the California Supreme Court or seek a writ of review from the state’s appellate court.

Ready To Advocate for You

No matter the circumstances surrounding your workplace injury, our team at The Sexton Law firm is ready to do whatever it takes to get you the benefits you need and deserve. Our Chula Vista workers’ compensation appeals lawyers have over 27 years of legal experience and have helped countless Southern Californians prevail in battles against insurance companies. We have a full understanding of the workers’ compensation appeals system and can leverage our knowledge to efficiently and effectively pursue your case. Whether your claim has been outright denied or you believe that you are not receiving the full extent of the benefits for which you qualify, we are ready to help.

If you are facing a rejection for your workers’ compensation claim, call (619) 202-8976 or contact us online to learn more about how our team can help. We offer free initial consultations.

Why Hire The Sexton Law Firm?

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