What happens when a workers compensation insurance claim is denied?

A workers compensation claim is denied, now what?

The investigation is complete. Statements have been taken, medical reports have been received, and a decision has been made: a denial.

A California Workers Compensation Insurance claim can be denied for various reasons and can lead to a complex process. There are typically three options an injured worker may select in the event of a claim denial: 

• Personal Decision: An injured worker decides to take the insurance company’s denial at face value and stop pursuing their claim which would eventually lead to the claim being closed.  
• Independent Physician’s Review: If an injured worker decides to dispute the insurance company’s denial, they have the option of going through a Qualified Medical Evaluator (QME) process where they object to the decision made and request the Division of Workers Compensation issue them a panel of independent physicians to choose from.  They meet and both sides present their information. The injured worker attends a separate physical examination with the Qualified Medical Evaluator for a physician’s decision.  This report could potentially overturn a denial. If the denial is overturned, the claim will remain open for medical care and until medical discharge, settlement or decision by a Worker’s Compensation Appeals Board (WCAB) Judge.   
• Legal Representation: A third option involves an injured worker choosing to obtain representation from an attorney.  Attorneys often add body parts, pursue additional Qualified Medical Evaluators (QME’s) for the various new alleged body parts, set hearings, and attempt to drag out the claim all in the name of driving up costs while we work to mitigate these factors. Claims are not completed until dismissed, settled, or a judge issues an order called a Findings and Award. 

So, as you now know, a denial is more than likely not the end of a claim but is an important step in the process to ultimate resolution. 

The denial process can be complex and involve numerous parties. It is important to have certified Workers Compensation Claims Professionals on your side. For questions, please feel free to reach out to Preferred's Claims Adjusting Team at [email protected].