Being denied the medical benefits you are entitled to receive can be devastating when you are facing a lengthy recovery from a workplace injury. Without these benefits, and the ability to pay for the medical attention and treatment you need to recover, it can be nearly impossible to get back on your feet and return to your job. If you have a family relying on your income, the stress and turmoil associated with this scenario are likely to be magnified even further. For these reasons, reach out to a Palmdale medical benefits attorney right away if you are denied workers’ comp medical benefits.
Your workers’ compensation coverage is supposed to provide the benefits you need after an injury. These medical benefits can range from medical payments to doctors, specialists, hospitals, and therapists to pay for needed medications, medical equipment, surgeries and procedures, and even transportation to medical appointments. But insurers don’t always act in the best interest of insured workers. They have the power to protect their own interests, and this sometimes means the denial of perfectly valid claims.
As an injured worker, there are certain conditions that you must adhere to before you can expect to receive medical benefits under your workers’ compensation claim. However, if you have satisfied the requirements to receive benefits, but your insurer rejected your claim, then a Palmdale medical benefits attorney may be able to help.
Koszdin, Fields & Sherry has the legal expertise required to advocate for you, appeal the decision to deny your benefits, and help you secure the benefits you need and to which you are entitled.
Common Reasons for Rejecting Claims for Medical Benefits
One of the most often-cited reasons that insurers—and the doctors that review workers’ claims for them—deny medical claims and benefits, in general, is that the length of time allotted to file a claim following the incident has passed.
Under California law, you must report any workplace injury within 30 days and file the resulting workers’ compensation claim for medical benefits within a maximum of one year, where the insurance company has not provided any of the benefits, and a maximum of five years where they have. If you leave too long between the time of sustaining your injury and filing your claim, the insurance company may become suspicious, and treat your case as potentially being a false claim.
A top tip among Palmdale medical benefits attorneys is to make sure to file your claim as soon as possible, rather than waiting until close to the deadline. While this will not guarantee approval, it will reduce the risk of rejection for that particular reason.
Some other common reasons for denying medical benefits claims include:
- The insurer believes that the injury in question was, in fact, a pre-existing condition and, therefore, not eligible for benefits under a workers’ compensation scheme
- The insurer may also believe that the injury occurred while you were off-site or not on the clock, again invalidating your claim
- If the injury or illness you have sustained is minor, the insurer may rule that it is not sufficient to qualify for such benefits
Whatever the reason behind rejecting your claim may be, our expert workers’ compensation attorneys could help appeal and reverse it.
The Appeals Process
When an insurance carrier denies all or part of a workers’ compensation claim, the appeals process, although complicated, is fairly straightforward. If you are denied benefits—including medical and other benefits—under your workers’ compensation claim, it is your right as an injured worker to appeal the decision of the insurance carrier. Challenging the denial through appeal is best done with the assistance of a seasoned workers’ compensation or medical benefits attorney.
The appeal hearing takes place at the Division of Workers’ Compensation (DWC) local district office. Typically, the closest office to the claimant is assigned the duty of hearing the appeal.
The steps to file an appeal include:
- File an Application for Adjudication of Claim.
- File a Declaration of Readiness to Proceed. This is the formal process required to request a hearing to appeal the case.
- Be assigned a hearing date.
- Prepare details necessary for the hearing of the appeal, including all facts that are pertinent to the approval of the medical benefits claim.
- Appear at the hearing and present testimony.
- Await the decision of the judge in your appeals case.
If the judge decides the appeal in your favor, then your medical benefits will be restored. If the judge also finds that the carrier unreasonably denied or delayed your benefits, the carrier can be charged a 25 percent (or up to $10,000) penalty on your behalf.
Schedule Your Free Initial Consultation with a Palmdale Attorney Today
To discuss the specifics of your medical benefits claim with an outstanding and highly experienced lawyer, you need to look no further than Koszdin, Fields & Sherry. Schedule your free initial consultation with our Palmdale medical benefits attorney by calling us today at 800-747-3447.
