Workers Comp Appeals in California: How to Fight a Denied Claim

Why Claims Get Denied

Before fighting a denial, understand why it happened. Insurance companies deny claims for various reasons, some legitimate, many not:

Common Denial Reasons

• Disputed causation: The insurer claims your injury isn't work-related
• Pre-existing condition: They blame your symptoms on prior injuries or conditions
• Missed deadlines: You allegedly reported the injury too late
• Insufficient documentation: Medical records don't clearly support your claim
• Disputed mechanism: They argue the accident couldn't cause your injuries
• Independent contractor status: They claim you weren't an employee
• Off-the-clock injury: They say you weren't working when injured

Illegitimate Denial Tactics

Insurance companies sometimes deny claims hoping workers will give up. Common bad-faith tactics include:

• Denying without proper investigation
• Ignoring medical evidence supporting the claim
• Relying on biased IME doctors
• Misrepresenting policy terms or legal standards
• Creating artificial deadlines to pressure acceptance of unfair settlements

The California Workers' Comp Appeals Process

California has a structured system for resolving workers' comp disputes. Understanding each step helps you navigate your appeal.

Step 1: Application for Adjudication of Claim

The appeals process formally begins when you file an Application for Adjudication of Claim with the Workers' Compensation Appeals Board (WCAB). This form:

• Opens an official case with the WCAB
• Identifies the parties involved
• States the basic facts of your injury
• Lists the issues in dispute

You have up to one year from the date of injury (or up to five years in some cases) to file this application. Don't wait until the deadline approaches.

Step 2: Declaration of Readiness to Proceed

When your case is ready for hearing, you file a Declaration of Readiness to Proceed. This tells the WCAB you want a hearing scheduled. You must certify that discovery is complete and you've attempted to resolve the dispute.

Step 3: Mandatory Settlement Conference (MSC)

Before trial, most cases go through a Mandatory Settlement Conference. A workers' comp judge reviews the case and attempts to help the parties settle. If settlement fails, the judge identifies issues for trial and sets a trial date.

Step 4: Trial

Workers' comp trials are less formal than civil court trials. There's no jury. A workers' comp judge hears evidence and makes decisions. Trials typically involve:

• Medical reports and records entered as evidence
• Testimony from you about your injury and limitations
• Deposition transcripts from medical experts
• Legal arguments from both sides

Step 5: Findings and Award (or Denial)

After trial, the judge issues a Findings and Award (if you win) or an order denying benefits. This decision addresses the specific issues raised.

Step 6: Petition for Reconsideration

If you disagree with the judge's decision, you can file a Petition for Reconsideration with the WCAB Appeals Board within 20 days. This asks the board to review the decision for legal errors.

Step 7: Writ of Review

If reconsideration fails, you can seek review by the California Court of Appeal through a writ of review. This is a rare final step that requires showing significant legal errors.

Evidence That Wins Appeals

Overturning a denial requires evidence. The stronger your evidence, the better your chances. Key evidence types include:

Medical Evidence

Medical reports are the foundation of most appeals. You need:

• Treating physician reports: Detailed documentation from your doctors establishing diagnosis, treatment needs, and work connection
• Medical expert opinions: Reports from specialists who can explain complex medical issues
• QME or AME reports: Qualified Medical Evaluator opinions carry significant weight
• Diagnostic studies: MRIs, X-rays, EMGs, and other objective tests

Witness Testimony

• Coworkers: People who saw the accident or know your work conditions
• Supervisors: Those who can confirm your job duties and the incident
• Family members: People who can describe how the injury affects your life

Documentary Evidence

• Accident reports: Employer documentation of the incident
• Work records: Time cards, job descriptions, safety logs
• Photos/videos: Images of the accident scene, equipment, or your injuries
• Prior medical records: Showing your condition before the work injury

Your Own Testimony

Your credible, consistent account of what happened matters. The judge will consider:

• How the accident occurred
• Your symptoms and limitations
• How the injury affects your daily life
• Your work history and ability to return to work

Factors That Determine Appeal Success

Credibility

Consistency matters more than anything. If your story changes, or your actions contradict your claimed limitations, judges discount your testimony. Be honest and consistent.

Medical Causation

A doctor must connect your injury to your work. Ideally, this comes from a treating physician or QME who thoroughly examines you and reviews your records. Vague opinions get less weight than detailed analysis.

Documentation Quality

Detailed, contemporaneous records beat sparse, after-the-fact summaries. The more documentation supporting your claim from the time of injury forward, the better.

Legal Presentation

How evidence is presented matters. Knowing which issues to emphasize, what objections to raise, and how to frame arguments requires legal expertise.

Timeline and Deadlines

Missing deadlines can destroy your case. Key timeframes include:

• Reporting the injury: Tell your employer within 30 days
• Filing a claim: Up to one year from date of injury (five years for some conditions)
• Petition for Reconsideration: 20 days from the judge's decision (or 25 days if served by mail)
• Writ of Review: 45 days from denial of reconsideration

Common Appeal Strategies

Challenging the IME

If your claim was denied based on an insurance company's IME, we can:

• Depose the IME doctor to expose weaknesses in their opinion
• Obtain your own QME evaluation
• Show the IME doctor's history of bias toward insurers
• Present your treating doctor's contrary opinions

Proving Work Connection

When causation is disputed, we build evidence showing:

• The mechanism of injury matches your condition
• You had no prior symptoms before the work accident
• Your work activities could cause this type of injury
• Similar injuries are common in your occupation

Addressing Pre-existing Conditions

Even with pre-existing conditions, you can prevail by showing:

• The work injury aggravated your condition
• You were functioning fine before the work accident
• Your current symptoms exceed what the pre-existing condition caused

Overcoming Late Reporting

If your claim was denied for late reporting, we can argue:

• The employer actually knew about the injury
• You had good cause for delayed reporting
• The delay didn't prejudice the employer's investigation
• You reported as soon as you knew the condition was work-related

What Happens If You Win

A successful appeal can result in:

• Medical treatment authorization: The insurer must pay for recommended care
• Temporary disability benefits: Back pay for time you couldn't work
• Permanent disability award: Compensation for lasting impairment
• Supplemental job displacement benefit: Voucher for retraining if needed
• Future medical care: Ongoing treatment for your condition

What Happens If You Lose

An unfavorable decision isn't necessarily final. Options include:

• Petition for Reconsideration: Ask the Appeals Board to review the decision
• Supplemental evidence: In some cases, new evidence can support further proceedings
• Writ of Review: Appeal to the Court of Appeal for significant legal errors
• Negotiated settlement: Sometimes parties settle even after unfavorable rulings

Real Appeal Success Stories

Frequently Asked Questions

Why You Need an Attorney for Appeals

Appeals require legal expertise that most injured workers don't have. An experienced attorney:

• Understands the legal standards for overturning denials
• Knows which evidence carries the most weight
• Has relationships with medical experts who can help
• Understands WCAB procedures and deadlines
• Can depose opposing experts effectively
• Knows how to present your case to judges
• Can negotiate settlements when appropriate
• Handles all paperwork and filings correctly

We work on contingency. You pay nothing unless we win. Initial consultations are free.

Don't Accept an Unfair Denial

Insurance companies deny claims knowing many workers will give up. They count on people not understanding their appeal rights. Don't let them win through intimidation.

If your workers' comp claim was denied, you have options. Many denied claims are successfully overturned on appeal. The key is taking action promptly and presenting your case effectively.