Common Reasons Claims Are Denied
Understanding why your claim was denied helps you build a winning appeal. Here are the most common denial reasons:
1. "Injury Not Work-Related" (Causation Denial)
Insurance claims you got injured outside work or it's a pre-existing condition unrelated to your job.
How to Overturn Causation Denials:
- • Get doctor's written statement – Treating physician writes detailed letter explaining how job duties caused or aggravated injury
- • Coworker witness statements – Colleagues who saw the injury occur or know your job's physical demands
- • Job description evidence – Documentation showing your work involves the movements/conditions that cause this injury type
- • QME medical opinion – Qualified Medical Evaluator examines you and determines industrial causation
- • Medical literature – Studies showing your job type commonly causes this injury
Real Example:
Denial: "Your carpal tunnel is a degenerative condition, not work-related."
Evidence submitted: Treating doctor's report showing carpal tunnel developed after starting data entry job; EMG test confirming median nerve damage consistent with repetitive typing; job description requiring 8 hours daily typing.
Result: Judge ruled job aggravated condition. Claim accepted.
2. "Injury Didn't Occur at Work" (AOE/COE Denial)
Insurance argues the injury didn't happen during work hours, on work premises, or while doing job-related activities.
How to Prove AOE/COE:
- • Employer incident report – Official documentation you reported injury immediately
- • Time clock records – Proof you were on the clock when injured
- • Witness testimony – Coworkers or supervisors who saw the accident
- • Security camera footage – If injury occurred in recorded area
- • Email/text communications – Messages sent immediately after injury describing what happened
3. "Pre-Existing Condition" (Apportionment Denial)
Insurance digs through medical records, finds prior treatment for a similar body part, and claims "this existed before you started working here."
Important Legal Principle:
California law says you don't need to prove work caused the condition—only that work aggravated, accelerated, or worsened it. Even 1% work contribution qualifies for benefits (though apportionment reduces settlement value).
How to Defeat Pre-Existing Condition Arguments:
- • Medical progression evidence – Compare old medical records (mild symptoms) to current records (severe symptoms) showing work made it worse
- • Doctor's causation opinion – Physician states work activities accelerated the condition's progression
- • Timeline correlation – Symptoms worsened significantly after starting job or after specific work activities
- • Distinguish prior injury – Old injury was different body part, different mechanism, or completely healed
4. "Filed Too Late" (Statute of Limitations)
Insurance claims you missed the deadline to report (30 days) or file within the one-year statute of limitations.
How to Defeat Late Filing Denials:
- • Prove employer had knowledge – Employer knew about injury (provided first aid, witnessed accident) so late notice is excused
- • Cumulative trauma date of knowledge – For gradual injuries, deadline starts when you knew it was work-related, not when symptoms began
- • Tolling exceptions – Employer provided treatment, paid temporary disability, or failed to post required workers' comp notices
- • Fraudulent concealment – Employer discouraged you from filing or misled you about deadlines
5. "You're Not an Employee" (Independent Contractor Claim)
Insurance argues you were an independent contractor, not an employee, so you're not covered by workers' comp.
How to Prove Employee Status:
- • Employment records – W-2 forms, pay stubs, employee handbook, ID badge
- • Control test factors – Employer set your hours, supervised your work, provided tools/equipment, told you how to do the job (not just what to do)
- • AB5 / Dynamex test – California presumes worker is an employee unless employer proves all three ABC test factors
- • Other workers similarly situated – Evidence employer treats others doing same job as employees
6. "No Medical Evidence" (Insufficient Documentation)
Insurance claims there's no proof you're actually injured or need treatment.
How to Build Medical Evidence:
- • Get immediate medical treatment – Delays in treatment hurt your case ("If it was serious, why didn't you see a doctor?")
- • Complete diagnostic testing – MRIs, X-rays, EMG/NCV studies showing objective injury
- • Regular treatment records – Ongoing doctor visits documenting persistent symptoms and functional limitations
- • Doctor's detailed report – Physician writes comprehensive causation opinion with medical reasoning
Types of Denials: Total vs Partial
Total Claim Denial
Insurance denies the entire claim—no medical treatment, no temporary disability, no settlement. This requires filing an Application for Adjudication and proceeding to trial.
Partial Denial (Delay or Dispute Specific Issues)
Insurance accepts some aspects but denies others:
- • Body Part Denial: Accepts back injury but denies shoulder injury from same accident
- • Treatment Denial: Covers conservative treatment but denies surgery (Utilization Review)
- • Temporary Disability Cutoff: Pays TD initially then cuts you off claiming you can return to work
- • Permanent Disability Dispute: Accepts claim but disputes your disability rating percentage
Each type of denial requires different appeal strategies. An attorney identifies which procedures apply to your specific denial.
The Appeals Process: Step-by-Step
How to Appeal a Denied Workers' Comp Claim:
File Application for Adjudication of Claim
Submit DWC Form 1 to the Workers' Compensation Appeals Board. This initiates the formal dispute process. File within one year of injury date.
Serve Insurance Company
Legally notify the insurance company and employer you're challenging the denial. They have 15 days to respond.
Mandatory Settlement Conference (MSC)
Informal meeting with a Workers' Comp Judge who tries to facilitate settlement. 70% of cases settle at MSC without trial.
Discovery and Medical Evaluations
Both sides exchange evidence. You see a QME who provides independent medical opinion. This takes 3-6 months.
Trial Before Workers' Comp Judge
If settlement fails, case goes to trial. Judge hears testimony, reviews medical evidence, and issues a written decision (Findings & Award).
Judge's Decision
Issued 30-90 days after trial. Judge either accepts your claim (orders benefits paid) or denies it. You can appeal to the WCAB if you lose.
Special Appeal: Denied Medical Treatment (UR/IMR)
When insurance denies recommended medical treatment (surgery, injections, therapy), you use a separate faster appeals process:
Utilization Review (UR) Appeal Process:
- 1. Doctor requests treatment – Your treating physician submits treatment request to insurance (RFA - Request for Authorization).
- 2. UR doctor denies treatment – Insurance's Utilization Review doctor (who never examines you) denies the request as "not medically necessary."
- 3. File Independent Medical Review (IMR) – Within 30 days, submit IMR application to Division of Workers' Compensation.
- 4. IMR physician reviews case – Independent doctor (not paid by insurance) reviews medical records and makes binding decision.
- 5. IMR decision issued – Usually within 30 days. If IMR approves treatment, insurance MUST authorize it within 5 days.
IMR Success Rate: Workers win approximately 60% of IMR appeals. The independent doctors are more objective than insurance UR reviewers who are paid to deny treatment.
Timeline: How Long Does an Appeal Take?
Expedited Hearing (Emergency)
30-60 DaysFor urgent issues like denied surgery for serious condition or stopped temporary disability when you can't work. Must show irreparable harm.
Treatment Denial (IMR)
30-45 DaysIndependent Medical Review for denied medical treatment. Faster track than full claim appeal.
Mandatory Settlement Conference
4-8 MonthsFrom filing Application to first MSC. Includes time for QME evaluation, medical record exchange, and case preparation.
Trial and Decision
12-18 MonthsIf MSC doesn't resolve the case, trial is scheduled 6-12 months out. Judge issues decision 30-90 days after trial.
WCAB Appeal (If You Lose)
6-12 MonthsAppeal Judge's unfavorable decision to Workers' Compensation Appeals Board. WCAB reviews for legal errors.
Do You Get Benefits While Appeal Is Pending?
Generally no—denials stop all benefits. However, if insurance unreasonably delays or denies benefits, Labor Code §5814 allows a 25% penalty increase on all late-paid benefits. You also have options to get interim relief:
Options for Temporary Benefits During Appeal:
- • Request expedited hearing – For urgent medical treatment or severe financial hardship from stopped TD payments
- • Self-procure medical treatment – Get treatment outside workers' comp and seek reimbursement after winning appeal (risky—you pay upfront)
- • Negotiate interim agreement – Attorney may negotiate temporary benefits while appeal proceeds
- • State Disability Insurance (SDI) – Apply for SDI through EDD if off work (non-work injury program, but provides income)
What Evidence Wins Appeals?
Workers' Comp Judges base decisions on medical evidence and credible testimony. Here's what carries weight:
Medical Records & Reports (Most Important)
- • Treating physician's detailed causation report
- • QME evaluation supporting your claim
- • Diagnostic tests (MRI, X-ray, EMG) showing objective injury
- • Treatment records documenting ongoing symptoms
Witness Testimony
- • Coworkers who saw the injury occur
- • Supervisors who can testify about job duties
- • Family members describing how injury affects daily life
- • Your own testimony (credibility matters—be honest)
Documentary Evidence
- • Employer incident reports filed immediately after injury
- • Job descriptions showing physical requirements
- • Time cards proving you were working when injured
- • Email/text communications reporting injury
Common Mistakes That Sink Appeals
- 1. Missing deadlines
Filing late destroys your case. Appeals must be filed within one year of injury. IMR must be filed within 30 days of treatment denial.
- 2. Inconsistent statements
Telling doctor one thing, insurance adjuster another, and your attorney something different. Stick to the truth.
- 3. Skipping medical treatment
Gaps in treatment let insurance argue "If you were really hurt, you'd be seeing doctors." Maintain consistent care.
- 4. Going it alone without an attorney
Insurance companies have experienced lawyers. Unrepresented workers lose 70-80% of disputed cases. Don't fight alone.
- 5. Exaggerating symptoms
Judges and doctors can spot exaggeration. Describe symptoms accurately. Overstating destroys credibility and sinks legitimate claims.
Settlement vs Trial: What to Expect
Most Cases Settle (70-80%)
Even after initial denial, most cases settle at the Mandatory Settlement Conference. Insurance realizes they'll lose at trial and offers a reasonable settlement.
Why Cases Settle After Initial Denial:
- • Your QME supports your claim (overrides their denial)
- • Insurance realizes their denial reasons are weak
- • Cost of trial exceeds settlement value
- • Risk of judge awarding you more than settlement offer
- • Your attorney demonstrates strong medical evidence
If Your Case Goes to Trial
Workers' comp trials are less formal than civil court trials—no jury, held in WCAB offices, more relaxed procedures. But the stakes are just as high.
What Happens at Trial:
- • Opening statements – Each side outlines their case
- • Testimony – You testify under oath. Medical experts may testify (usually by written reports)
- • Documentary evidence – Medical records, reports, job descriptions entered into record
- • Closing arguments – Attorneys argue why judge should rule in their favor
- • Judge's decision – Issued in writing 30-90 days later (Findings & Award)
Why You Need an Attorney for Denied Claims
The statistics are stark: Represented workers win 75-85% of appealed denials. Unrepresented workers win 15-25%.
What Attorneys Do That You Can't:
When to Contact a Lawyer About Your Denial
Contact a California workers' comp attorney immediately if:
- • You received any denial letter (full or partial denial)
- • Insurance stopped paying temporary disability without explanation
- • Your requested surgery or treatment was denied
- • Insurance claims your injury isn't work-related
- • They're arguing you filed too late
- • Your claim was accepted but they're disputing your permanent disability rating
- • You're unsure what the denial letter means or what to do next
Free consultations. We'll review your denial, explain your appeal rights, and outline our strategy to overturn it. Most denials can be beaten with proper legal representation.