Why was my workers’ comp claim denied?

The usual grounds: late reporting with no witnesses, a pre-existing or degenerative explanation for the condition, a post-termination filing, or simply investigation that ran out of clock — the administrator must accept or deny within 90 days of the claim form or the claim is presumed compensable (§5402). A denial is the carrier’s litigation position, not a ruling; nobody neutral has looked at it yet.

How do I fight a denied workers’ comp claim?

File an Application for Adjudication with the WCAB (within one year — §5405), then take the medical dispute to a panel QME on compensability (§4060). Denied cases get fast-track treatment at the board via priority conference. The QME opinion on whether work caused the condition is usually the whole ballgame — prepare for that exam like it is the trial, because functionally it is.

How do I get money while my claim is denied?

State Disability Insurance through the EDD is the standard backstop — it pays while comp refuses to, and gets reimbursed from the comp recovery if you win. Treatment can continue through group health or on a lien basis. And up to $10,000 in medical care was owed during the decision window itself (§5402(c)) — a right that is routinely overlooked.

Workers’ Comp Claim Denied in California: What Happens Next

A denied California workers’ comp claim is a dispute posture, not a verdict: why claims get denied, the Application and panel-QME path that contests it, the WCAB fast track, how to keep money and treatment flowing while you fight, and the deadlines that matter.

The denial letter reads like the end of the case. It is the beginning of the dispute — a position taken by the party that writes the checks, before any neutral has weighed in. What happens next is a script, and workers who know it recover; workers who take the letter at face value don’t.

What a denial actually is

The administrator had 90 days from your claim form to accept or deny, with the claim presumed compensable if they blew it and up to $10,000 of treatment owed while they decided (§5402). The denial preserves their defenses: late reporting, degenerative-not-industrial, post-termination, intoxication. Every one of those is contestable, and the contest has a referee.

The script: Application, panel, priority conference

Step one is the Application for Adjudication — it opens the WCAB case and must be filed within one year (§5405; run your dates on the deadline calculator). Step two is the compensability med-legal: a panel QME under §4060 answers whether work caused the condition — prepare for that exam like it’s the trial, because functionally it is. Denied cases get the board’s fast track (priority conference) precisely because someone is living without checks. If the QME goes your way, most denials settle before anyone sees a judge — and the settlement math includes the retroactive TD they didn’t pay.

Surviving the gap

Money: SDI through the EDD is the standard bridge — it pays while comp won’t and takes reimbursement from the recovery if you win. Treatment: group health or lien-basis care keeps the medicine (and the medical record) moving. The one thing a denial cannot do is stop the clock from favoring documentation — every visit, every symptom entry is evidence the QME will read.

If you win, the rating works the same

An accepted-after-denial case rates exactly like any other: WPI through the 2005 PDRS pipeline, priced on the calculator the day the P&S report lands — plus the back TD, and §5814 penalties if payments were unreasonably delayed along the way. Denied cases are the clearest lawyer cases in comp; fee comes from the recovery.

Estimates for informational use; not legal advice.

Rate your spine right here

Same engine as the tables above — pick your occupation and age, slide the WPI from the report, and carry it into the full calculator when you’re ready.

Loading the engine…