Case Study: Overturning a Denied Workers' Comp Claim
When a workers' comp claim is denied, many injured workers assume there is nothing they can do. This case study follows a healthcare worker -- we will call her Maria -- whose claim was denied because the insurer blamed a pre-existing condition. We walk through how we built the evidence, challenged the denial at the WCAB, and ultimately secured a $94,000 settlement for injuries the insurer said were not covered.
The Injury and the Denial
Maria was a 51-year-old certified nursing assistant (CNA) at a skilled nursing facility in Los Angeles. She had worked in healthcare for 23 years, spending most of her career lifting, repositioning, and transferring patients. In September 2024, while transferring a bariatric patient from a wheelchair to a bed, Maria felt a sharp pop in her lower back followed by severe pain radiating down her right leg.
An MRI revealed a large disc herniation at L5-S1 with nerve root compression. Maria filed a workers' comp claim immediately. The employer's insurer initially authorized emergency medical treatment -- but 28 days later, Maria received a formal denial letter.
The Denial Reason
The insurer denied Maria's claim based on a review by their medical consultant, who noted that Maria had been treated for lower back pain by her primary care physician in 2019 and 2021. The denial stated that Maria's disc herniation was "a pre-existing degenerative condition not causally related to industrial activity" and that her work merely caused a "temporary symptomatic flare-up of a non-industrial condition."
This denial was devastating. Maria was in severe pain, unable to work, and suddenly had no temporary disability payments and no authorized medical treatment. Her personal health insurance refused to cover what they considered a work injury. She was caught in a gap that many denied workers face: workers' comp says it is not their problem, and private insurance says it is not theirs either.
Case Timeline
Maria's claim was denied in early October. She contacted our office within a week. After reviewing her medical records and the denial letter, we identified significant weaknesses in the insurer's position and agreed to represent her. We immediately filed a Declaration of Readiness to Proceed (DOR) with the WCAB to begin the dispute resolution process and requested a QME panel under Labor Code §4060.
We subpoenaed Maria's complete medical records from her primary care physician and obtained her full employment history including job descriptions and physical demand analyses. A QME in orthopedic surgery was selected from the panel. We submitted a detailed cover letter to the QME with our position on causation, along with all relevant medical records and Maria's job description documenting 23 years of patient lifting.
The QME issued a comprehensive report finding that Maria's disc herniation was predominantly caused by 23 years of cumulative trauma from patient handling, with the September 2024 incident as the specific event that herniated an already-weakened disc. The QME concluded the injury was industrial. Based on the QME report, the insurer reversed its denial and accepted the claim. Medical treatment authorization and retroactive TD payments began immediately.
With the claim accepted, Maria received the treatment she needed: epidural steroid injections, physical therapy, and ultimately a microdiscectomy when conservative measures failed. She recovered well from surgery and was declared at MMI in October 2025 with a permanent lifting restriction of 20 pounds and restrictions on prolonged bending.
The QME's supplemental report after MMI established a 22% PD rating, adjusted for Maria's age (51) and occupation group (heavy -- healthcare patient handling). After negotiations that included a Mandatory Settlement Conference, we reached a $94,000 Compromise & Release settlement that included retroactive temporary disability, permanent disability benefits, a future medical buyout, and penalty payments for the insurer's unreasonable delay.
How We Built the Case to Overturn the Denial
The insurer's denial was based on the premise that Maria's back condition was pre-existing and not related to her work. Our strategy focused on dismantling that argument with overwhelming medical and occupational evidence.
1. Reframing the "Pre-Existing Condition" Narrative
The insurer pointed to two visits to Maria's primary care doctor in 2019 and 2021 for "lower back pain." We obtained the full records for those visits and discovered they told a very different story than the insurer suggested:
- The 2019 visit was for mild muscle soreness after a weekend of gardening. Maria was prescribed ibuprofen and told to rest. No imaging was ordered. She was back to full duty in three days.
- The 2021 visit was for a "twinge" in her lower back after a particularly demanding shift. Again, she was given over-the-counter pain medication and returned to work the next day. No imaging, no referral, no follow-up.
Neither visit involved radiating leg pain, nerve symptoms, or any indication of disc herniation. The insurer's characterization of these as evidence of a "pre-existing degenerative condition" was a significant overstatement. We presented this evidence to the QME, who agreed that occasional mild back pain in a 51-year-old healthcare worker does not constitute a pre-existing disc condition.
2. Establishing the Cumulative Trauma Theory
Our most powerful argument went beyond the single September 2024 lifting incident. Under California workers' comp law, injuries can be caused by "cumulative trauma" -- the gradual wearing down of body parts through repetitive work activities. We argued that Maria's disc herniation was the culmination of 23 years of patient lifting, not just one bad transfer.
Evidence We Assembled
- Job analysis: Maria's CNA position required an average of 15-20 patient transfers per shift, each involving lifting, pivoting, and supporting patients weighing 100-350+ pounds
- Employment records: 23 years of continuous healthcare employment with consistent patient-handling duties across multiple facilities
- Biomechanical literature: Published studies showing that healthcare workers who perform patient transfers have 2-3 times the rate of lumbar disc herniation compared to the general population
- Facility injury logs: The nursing facility's OSHA 300 logs showed back injuries were the most commonly reported injury among CNAs, confirming the hazardous nature of the work
- Treating physician declaration: Maria's treating orthopedic surgeon provided a detailed causation opinion linking the disc herniation to cumulative occupational trauma
3. The QME Report: The Turning Point
The QME's report was the decisive document. After reviewing all medical records, examining Maria, and considering the occupational evidence, the QME concluded:
"It is my opinion, to a reasonable degree of medical probability, that the applicant's L5-S1 disc herniation is predominantly industrial in causation. Twenty-three years of repetitive patient-handling activities -- involving significant spinal loading, flexion, rotation, and lifting forces -- constitute a substantial contributing cause of the disc pathology. The September 2024 patient transfer was the precipitating event that caused the final herniation of a disc that had been progressively weakened by decades of occupational exposure. The two prior episodes of mild back pain documented in 2019 and 2021 do not constitute a pre-existing disc condition and are, in fact, consistent with the early stages of cumulative occupational injury."
This report effectively ended the insurer's pre-existing condition argument. Under Labor Code §5300, the QME's causation finding created a strong presumption in Maria's favor. The insurer reversed its denial within three weeks of receiving the report.
The Apportionment Battle
Even after accepting the claim, the insurer attempted to reduce Maria's PD rating through apportionment under Labor Code §4663. Their position: even if the injury was industrial, 35% of the disability should be attributed to age-related degeneration.
We challenged this apportionment on two grounds:
- The QME did not support it. The QME's report found that the disc herniation was "predominantly industrial" and assigned only 10% apportionment to non-industrial factors. The insurer's 35% figure came from their own paid medical consultant, not the agreed QME.
- Legal precedent. California case law is clear that when an evaluating physician finds cumulative occupational injury to be the predominant cause, the employer cannot artificially inflate apportionment based on speculation about age-related changes.
The final settlement reflected the QME's 10% apportionment, not the insurer's 35% -- a difference of approximately $18,000 in Maria's settlement.
Penalty Payments for Unreasonable Denial
An important component of Maria's recovery was penalty payments. Under California law, when an insurer unreasonably delays or denies benefits, the WCAB can impose penalties of up to 25% on the delayed benefits. We argued that the insurer's denial was unreasonable because:
- The denial was based on two minor primary care visits that did not support a pre-existing disc condition
- The insurer did not obtain a complete review of Maria's medical records before issuing the denial
- Maria was left without medical treatment or income for five months during the denial period
The settlement included penalty payments on the retroactive temporary disability benefits that Maria should have received during the five-month denial period. This added approximately $8,500 to her total recovery.
The Settlement Breakdown
Total Recovery: $94,000
- $49,280 Permanent disability benefits (22% PD rating after 10% apportionment, adjusted for age 51 and heavy occupation group)
- $26,220 Future medical care buyout (estimated cost of ongoing pain management, medication, and potential future treatment)
- $10,000 Retroactive temporary disability (for the 5-month denial period when TD should have been paid)
- $8,500 Penalties for unreasonable denial and delay of benefits
- Separate $6,000 SJDB voucher + $5,000 return-to-work supplement
Key Lessons from This Case
- A denial is not the end. Maria's claim was flatly denied. Twenty months later, she received $94,000. Insurance companies count on injured workers giving up after a denial. Do not let them win by default.
- Pre-existing conditions rarely bar a claim. Under California law, if work caused, contributed to, or aggravated a pre-existing condition, the injury is compensable. Two mild back pain episodes over five years did not constitute a pre-existing disc condition.
- Cumulative trauma is a powerful theory. For workers in physically demanding jobs like healthcare, the cumulative trauma theory allows recovery even when the insurer tries to isolate one incident and claim it is not sufficient to cause the injury. Decades of wear and tear are recognized as a legitimate cause of injury. Learn more about pre-existing conditions in our pre-existing conditions guide.
- The QME report is everything. In denied claim cases, the QME's causation opinion often determines whether the claim survives or dies. Thorough preparation -- including a detailed cover letter, complete medical records, and occupational evidence -- is essential.
- Unreasonable denials have consequences. The penalty payments in Maria's case added $8,500 to her recovery. Insurance companies should pay a price for denials that lack a reasonable basis. For more on what to do after a denial, see our guide on next steps after a claim denial.
Maria's Outcome
Maria can no longer work as a CNA due to her permanent lifting restrictions. The 20-pound limit and restrictions on prolonged bending make patient handling impossible. She used her SJDB voucher to pursue a medical billing and coding certification -- a career that leverages her 23 years of healthcare knowledge in a desk-based role. The $94,000 settlement, combined with approximately $52,000 in temporary disability benefits she received during treatment, provided the financial bridge she needed during her career transition.
Most importantly, Maria got the surgery and treatment she needed to address her pain and regain quality of life. Without overturning the denial, she would have been left with an untreated disc herniation, no income, and no path forward. Learn more about insurance company tactics and how to fight them.
Frequently Asked Questions
How common are workers' comp claim denials in California?
Claim denials are more common than most workers realize. Estimates suggest that 20-30% of initial workers' comp claims are denied or disputed in some way. Common denial reasons include alleged pre-existing conditions, missed reporting deadlines, disputes over whether the injury is work-related, and insufficient medical documentation. However, a denial is not the end -- many denied claims are successfully overturned through the QME process, WCAB hearings, or appeals.
What should I do if my workers' comp claim is denied?
First, do not panic -- and do not give up. Request a copy of the denial letter and understand the specific reason. File a Declaration of Readiness to Proceed with the WCAB to initiate the dispute resolution process. Request a QME evaluation to get an independent medical opinion. Most importantly, consult with an experienced workers' comp attorney who can evaluate the denial and develop a strategy to overturn it. Many denials are reversed with proper legal representation.
Can a pre-existing condition prevent me from getting workers' comp?
No. Under California law, if your work activities caused, contributed to, or aggravated a pre-existing condition, your injury is compensable. You do not need to prove that work was the sole cause -- only that it was a contributing cause. This is sometimes called the 'eggshell plaintiff' doctrine: an employer takes workers as they find them. Even if you had prior back problems, a new work injury that worsens your condition entitles you to full workers' comp benefits for the industrial component.
How long does it take to overturn a denied claim?
The timeline varies depending on the complexity of the case and the WCAB's caseload. A straightforward denial reversal through the QME process may take 4-8 months. If the case goes to a WCAB hearing or trial, it can take 12-24 months or longer. In our case study, the entire process from denial to final settlement took approximately 20 months. Having an attorney who moves aggressively on deadlines and discovery can significantly shorten the timeline.
Do I need an attorney for a denied workers' comp claim?
While you are not required to have an attorney, the odds of successfully overturning a denial increase dramatically with legal representation. Insurance companies have experienced attorneys and medical consultants working to uphold denials. Studies consistently show that represented workers receive higher settlements than unrepresented workers, and this gap is even larger in denied claim cases where legal strategy, medical evidence, and WCAB procedure expertise are critical.
Was Your Claim Denied?
If your workers' comp claim has been denied -- whether for a pre-existing condition, causation dispute, or any other reason -- do not give up. Our free consultation will review your denial letter, evaluate the strength of your case, and develop a strategy to fight back. We have overturned hundreds of denials and know how to build the evidence that wins at the WCAB.
Legal Disclaimer: This case study is based on a real client's case with identifying details changed to protect privacy. The settlement amount and case details are specific to this individual's circumstances. Past results do not guarantee future outcomes. Every workers' compensation claim denial involves unique facts, and your outcome will depend on the specific reasons for your denial, the strength of your medical evidence, and other factors. Contact our office for a free evaluation of your denied claim.
David Lamonica (State Bar #165205) has successfully overturned hundreds of denied workers' comp claims throughout California. He specializes in cases involving pre-existing condition disputes, cumulative trauma injuries, and WCAB appeals.