Getting a denial letter from the workers' comp insurance carrier is frustrating, especially when you are injured and unable to work. But a denial does not mean your claim is dead. In our experience, many denials are based on incomplete investigations or aggressive medical opinions that don't hold up on appeal.
Why Carriers Deny Claims
Under Labor Code § 5402, the insurance carrier has 90 days from the filing of a claim form (DWC-1) to accept or deny. If they miss that deadline, the claim is presumed compensable. When carriers do deny within the window, common reasons include: a dispute about whether the injury is work-related, a claim that the condition is pre-existing, alleged late reporting under Labor Code § 5400 (which requires notification within 30 days), or a medical opinion from the carrier's doctor contradicting your treating physician. Not every denial reason is legitimate. Carriers have financial incentives to deny, and some denials are issued as a matter of course.
Your Right to Appeal
California's workers' comp system provides a formal appeals process through the Workers' Compensation Appeals Board (WCAB). To initiate, you file an Application for Adjudication of Claim and a Declaration of Readiness to Proceed (DRP). This gets your case before a workers' comp judge. The carrier must then present evidence supporting the denial. We file these appeals regularly, and a significant percentage of denied claims are overturned or settled favorably at the WCAB level.
Medical Disputes: QMEs and AMEs
If the denial rests on a medical opinion, the dispute is resolved through a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME). Under Labor Code § 4060-4062, when there's a disagreement between your doctor and the carrier's doctor, a neutral physician evaluates you and issues a report. The QME/AME opinion carries significant weight in proceedings. Selecting the right evaluator matters, and having an attorney who understands the medical-legal process can make the difference between a favorable report and an unfavorable one.
Treatment Denials: UR and IMR
Sometimes the carrier accepts the overall claim but denies specific treatment your doctor recommended (surgery, MRI, physical therapy). This goes through Utilization Review (UR). If UR denies the treatment, you can request Independent Medical Review (IMR) under Labor Code § 4610.5-4610.6. An independent physician reviews the case and makes a binding determination. The IMR process is time-limited, and the carrier must comply with the decision. We handle the UR and IMR paperwork to make sure nothing falls through the cracks.
Late Reporting: Is Your Claim Really Barred?
Labor Code § 5400 generally requires you to notify your employer within 30 days of a workplace injury. But late notice doesn't automatically bar a claim. If the employer had actual knowledge of the injury through other means (a supervisor saw the accident, you went to the company nurse), that can satisfy the notice requirement. And for cumulative trauma injuries (repetitive stress, gradual onset), the reporting timeline doesn't begin until you knew or should have known the condition was work-related. We evaluate each late-notice case individually.
When Your Claim Triggers Other Legal Issues
A workplace injury sometimes involves more than workers' comp. If a third party caused the injury (a defective product manufacturer, a negligent subcontractor), you may have a separate personal injury claim under Civil Code § 1714. If your employer fired or demoted you for filing the claim, that is retaliation under Labor Code § 132a and you have an employment law claim. If the insurance carrier unreasonably denied benefits, that may be actionable bad faith. We practice in all of these areas, so we identify overlapping claims that a workers' comp-only attorney might not.
Claim denied? Call Lightview at (818) 646-8156. We will review the denial and explain your options at no cost.