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When your workers comp claim is denied

Most employees in California know if they sustain a work-related injury, they may be able to get medical and wage-loss coverage by filing a workers' compensation claim. What many people may not realize is the filing process can be complicated, involving strict deadlines and paperwork requirements.

If you receive a denial, you should get a written notice that also explains the reason. While each case is different, there are a few common reasons for claim denials in California.

Formal requirements

One frequent reason workers face denial is failing to follow technical requirements. Missing a deadline or neglecting to provide complete information can torpedo your claim. For this reason, even if you think you have a fairly straightforward case, it often makes sense to consult an attorney promptly after your injury.

Relationship between your job and your injury

In other cases, the claims adjuster may believe the injury was not work-related. Questions about this issue can arise when a worker is off the employer's premises or performs a task outside the scope of his or her job description. Someone who travels on business will still not be working 24/7, so there may be questions as to whether an injury during business travel would be work-related. Because premiums can be high, employers may look for reasons to argue your injury falls outside the scope of workers' comp coverage.

Medical necessity

Another common situation arises when your doctor says you need certain treatments and time off work, yet the claims adjuster thinks your injury is not bad enough to warrant coverage.

Appealing a denial

A denial does not have to be the end of the road. An experienced attorney can review your claim and advise you as to whether you should file an appeal. This process may involve additional medical examinations as well as a hearing. A successful appeal can help you get the benefits you need to recover from or manage your injury in an optimal way.

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