Having a medical benefits claim rejected can be devastating when you are facing a lengthy recovery from a workplace injury or illness. Without these benefits, and the ability to pay for the medical attention and treatment you need to recover, you may find it incredibly difficult to get back on your feet and return to your job. Of course, if you have family and dependents relying on your income to survive, it quickly becomes an even more urgent problem. A Santa Clarita medical benefits attorney may be able to appeal your case and help you get the benefits you need.
Your employer’s workers’ compensation coverage has been put in place to provide the benefits you need after an injury. But benefits derived from this coverage are administered by insurance companies selling the policies, and these insurers often choose to protect their own financial interests, thus denying what seems to be a perfectly valid claim.
There are certain conditions to satisfy before a claim for medical benefits can be approved but, when you have adhered to each of these only to have your claim rejected, a Santa Clarita medical benefits attorney from Koszdin, Fields & Sherry has the legal expertise required to appeal this decision.
Why Might My Medical Benefits Claim be Rejected?
One of the most common reasons for the insurers funding workers’ compensation schemes to reject claims is the length of time that has passed since the incident in question occurred. Under California law, you must report any workplace injury within 30 days and file the resulting workers’ compensation claim for medical benefits within a maximum of one year, where the insurance company has not provided any of the benefits, and a maximum of five years where they have. If you leave too long between the time of sustaining your injury and filing your claim, the insurance company may become suspicious and treat your case as potentially being a false claim.
One of the top tips your expert Santa Clarita medical benefits lawyer can offer is to file your claim as soon as possible, rather than waiting until close to the deadline. While this will not guarantee approval, it will at least remove one potential reason for being turned down and, thus, forced to appeal.
Some other common reasons why medical benefits tend to be denied include the following:
- The insurer believes that the injury in question was, in fact, a pre-existing condition and, therefore, not eligible for benefits under a workers’ compensation scheme
- The insurer may also believe that the injury occurred while you were off-site or not on the clock, again invalidating your claim
- If the injury or illness you have sustained is minor, the insurer may rule that it is not sufficient to qualify for such benefits
Whatever the reason behind rejecting your claim may be, our expert workers’ compensation attorneys could help appeal and reverse it.
The Appeals Process for Workers’ Compensation in California
If you have a rejected or denied workers’ comp claim in the state of California, then you should take steps immediately to reverse the decision in your case. You can appeal the decision to deny your claim by requesting a hearing. The hearing will be before a judge at your district’s local Division of Workers’ Compensation (DWC) office. The judge presides over the appeals board.
Much like an informal type of trial, the appeals hearing in your workers’ compensation case involves the appeals judge listening to both sides of your case ad then making a decision as to whether or not your insurance carrier should accept and approve of your workers’ compensation claim.
The first step in the claim appeals process in order to fight the denial of your claim is to file (through your Santa Clarita medical benefits attorney if possible), an Application for Adjudication of Claim. This will give you a workers’ compensation case number, which you will need when you file the next document in the appeal—the Declaration of Readiness to Proceed, or DOR.
Keep in mind that if the insurance carrier’s denial was based on its belief that your workplace injury did not arise from your employment, then an expedited conference date may be held with a workers’ compensation appeals board judge. This sometimes allows for issues to reach resolution faster so that the claim can be either denied or accepted. These claim denials, which are known as AOE (arose out of employment) or COE (in the course of employment) claims due to the carrier’s mistrust of the nature of the injury, are indicated by checking the box for a Priority Conference on the Declaration of Readiness to Proceed form.
It is altogether possible for a pre-trial conference to be held ahead of the hearing if the carrier denied the claim based on anything other than AOE or COE issues. Often, issues are resolved at the pre-trial conference without heading to full trial.
Are Worker’s Compensation Appeals Board decisions appealable? Yes, they are. If the judge in your case does not force your insurance carrier to accept your workers’ comp claim, the judge’s decision is not written in stone. It can also be appealed, and your Santa Clarita medical benefits attorney can help you do just that.
Schedule Your Free Initial Consultation with a Santa Clarita Attorney Today
To discuss the details of your medical benefits claim with an outstanding and highly experienced lawyer, you need to look no further than Koszdin, Fields & Sherry. Schedule your free initial consultation with our expert legal team by calling today at800-747-3447.
