Denied Claims
Attorney in California

Carrier disputes that the injury arose out of and in the course of employment. Most common in cumulative trauma cases and where the injury wasn't witnessed. Reversed through treating physician opinions, panel QME selection, and contemporaneous medical evidence.

Carrier argues the injury existed before the work incident under § 4663 apportionment. Usually defeated by showing the prior condition was asymptomatic and the work injury was the cause of the current disability.

Carrier claims you missed the 30-day notice requirement under § 5400 or the 1-year filing window under § 5405. Many late-notice denials still result in compensable claims under § 5412 (date-of-knowledge rule for cumulative trauma) or excusable-late-notice exceptions.

Carrier alleges the worker was intoxicated or engaged in willful misconduct at the time of injury. Held to a strict carrier burden of proof — toxicology must be tied to causation, and willful misconduct must be intentional, not mere negligence.

Specific treatment (surgery, MRI, medication) denied through the UR/IMR system. Appealable through IMR within 30 days, and reviewable at the WCAB when the IMR decision conflicts with MTUS guidelines.

Held to the higher 'actual events of employment' standard (§ 3208.3). Reversed by documenting specific qualifying events — assault, witnessing a fatal accident, sustained harassment — and securing a psychiatric QME report.

Carrier or employer suggests immigration status disqualifies the claim. California law explicitly protects all workers regardless of status under Labor Code § 3351. Status-based denials are reversible and may also support § 132(a) retaliation petitions.

Carriers have 90 days after notice of injury to accept or deny the claim. Failure to deny within 90 days creates a presumption of compensability — the burden shifts to the carrier to overcome that presumption with substantial evidence.

The WCAB retains jurisdiction over a case for 5 years from the date of injury, allowing reopening when new evidence emerges or when the injury worsens. Even claims that were resolved with low awards can be reopened within 5 years.

Disputes over compensability (§ 4060), permanent disability (§ 4061), and medical issues (§ 4062) are resolved through the panel QME process. Panel QME selection is one of the most consequential strategic decisions in a denied case.

Carriers must approve or deny treatment requests through UR within strict timelines. Late or improper UR is invalid, and treatment requests deemed timely-approved cannot later be denied.

When UR denies treatment, the worker has 30 days to appeal through IMR. IMR decisions are reviewable at the WCAB on narrow grounds — bias, conflict with MTUS guidelines, or material factual errors.

For cumulative trauma and occupational illness, the statute of limitations starts when the worker first knew (or reasonably should have known) the injury was work-related — defeating many late-notice denials.

If the denial is part of a retaliation pattern (termination, demotion, hour reduction), a separate § 132(a) petition can be filed for a 50% award increase (capped at $10,000), plus reinstatement and back pay.

The Application for Adjudication of Claim starts the formal WCAB process. From there: pre-trial conferences, discovery, depositions, panel QME, mandatory settlement conference, and trial before a workers' comp judge.

When the denial was wrong, the carrier owes back-TD from the date of injury. Often combined with penalties for unreasonable delay under § 5814 (up to 25% of the amount delayed).

Once compensability is established, the case proceeds to standard PD evaluation. Most denied claims that get to trial settle in this range based on injury severity and rating.

Spinal cord injuries, TBIs, and amputations that were initially denied often produce seven-figure recoveries once liability is established, including lifetime medical care.

When carriers deny benefits without genuine medical-legal basis, courts impose penalties as deterrent. We pursue § 5814 in every case with clear bad-faith conduct.

When the denial coincided with termination or adverse employment action, the § 132(a) petition runs alongside the comp case.

When the employer's intentional safety violations caused the injury, § 4553 increases the award 50% without cap. Applies in many denial cases involving Cal/OSHA-cited employers.

Most AOE/COE denials are based on the carrier's internal claims examiner review, not a medical-legal opinion. Once a panel QME evaluates the case, AOE/COE denials often reverse — the QME report carries more weight than the claims-examiner conclusion.

Apportionment requires substantial medical evidence that the prior condition was symptomatic and contributed to current disability. Vague apportionment based on MRI findings alone is legally insufficient and routinely defeated.

Late-notice defenses have multiple exceptions: § 5412 date-of-knowledge rule for cumulative trauma, excusable-late-notice when the employer had actual notice, and reopening under § 5803. Many late-notice denials are technically valid but practically defeatable.

Intoxication defense requires the carrier to prove intoxication caused the injury — not just that drugs were present. THC metabolites can stay in the system for weeks; positive results don't establish intoxication or causation under California law.

Psychiatric injuries require 'actual events of employment' as the predominant cause (51%+). Reversed through documentation of specific qualifying events (assault, fatality witnessed, sustained harassment) and a psychiatric panel QME with experience in workers' comp.

California Labor Code § 3351 covers all employees regardless of status. Status-based denials are unlawful and may support both reversal of the underlying claim and a § 132(a) retaliation petition.