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– Attorney Eric Overholt

“We will ensure the settlement you receive is the best possible.”

What if my workers’ compensation claim was denied?

On Behalf of | May 4, 2023 | Workers' Compensation |

Injured workers in San Diego rely on their workers’ compensation benefits to help them get through a troubling time. These benefits can provide them with medical care and for lost wages as they recover. For some who are permanently disabled, it is their only means of income.

Sadly, some workers face a nightmare scenario when their workers’ compensation claim is denied.

This can leave a worker wondering what they will do to get the treatment they need and find the money to make ends meet. Knowing why the claim was denied is one part of the process. It is also vital to know what options are available to appeal the denial and try to get approved for workers’ compensation.

With these complex cases in which people’s future is at stake, it is essential to have comprehensive assistance from the start. This can be a fundamental part of assessing the case, seeing why it was denied and doing whatever possible to eventually be approved for benefits.

Understanding denied workers’ compensation claims

The case will be assessed by a claims administrator representing the insurer to determine if workers’ compensation benefits are warranted. Not every case is approved at first. The claims administrator might decide that the person’s injury is not compensable. The worker will then receive a letter informing them that the claim was denied.

Naturally, this will be a worrisome time for the injured worker. When there is a dispute between the claims administrator and the treating physician as to the extent and severity of the injury and what treatment is appropriate, the worker has alternatives. Seeking evaluation from a qualified medical examiner can be a potential avenue to eventually be approved. This could settle a simple dispute about the treatment being provided.

The QME or an agreed medical evaluator (AME) will conduct their own examination of the worker to try and settle a disagreement. The difference is that QMEs are medical doctors and specialists who have a certification to do these evaluations. AMEs are agreed upon by both sides to make their evaluation to try and settle a case. AMEs will be used when there is a legal representative for the injured worker.

If there is a denial, the worker can appeal it and ask for a judge to decide. The claims administrator, the worker and the worker’s legal representative will appear before a judge. The judge could try to forge a settlement of the dispute. Short of that, there is an extensive process to detail the topic of dispute, present evidence and call witnesses. A separate judge will oversee the trial, if one is needed.

There are many reasons why a claim might be denied ranging from the condition not believed to have come about from work; the worker not getting the proper medical care; or that it did not happen on the job. Regardless of why the claims administrator denied the claim, there are ways to appeal.