Workers’ Compensation Claim Delays in California: Your Rights and Solutions

• May 16, 2022
• Blog
• Michael Burgis & Associates, P.C

Navigating a workers’ compensation claim in California can feel overwhelming, especially when insurance carriers delay or deny the benefits you’re entitled to. Did you recently file a workers’ compensation claim for an on-the-job injury sustained in California? Does it feel like you’re getting the runaround from the workers’ comp insurance carrier? If so, you need to know that you’re not powerless to stop their actions. You can hold the insurance company accountable, pushing them to process your claim as the law requires. Ready to get started? Here’s what you need to know about ending the runaround from the workers’ comp insurance company.

This comprehensive guide explores the workers’ compensation system in California, focusing on how to address delays and denials by insurance carriers. We’ll cover the claims process, legal penalties, settlement options, and the role of experienced legal counsel, such as Burgis Law. With updated regulations and practical advice, this post aims to empower injured workers to protect their rights and secure the benefits they deserve in 2025.

Understanding Workers’ Compensation in California

Workers’ compensation is a state-mandated insurance program designed to provide benefits to employees injured on the job. In California, the Division of Workers’ Compensation (DWC) oversees this system, ensuring employers provide coverage for medical expenses, lost wages, and rehabilitation costs. According to the DWC, over 500,000 workers’ compensation claims were filed in California in 2023, with approximately 20% experiencing delays due to insurance carrier issues.

The system is governed by the California Labor Code, particularly sections like 5402 (claim acceptance timeline) and 5814 (penalties for delays). Despite these regulations, some insurance carriers engage in practices that delay or deny benefits, leaving injured workers in financial distress. Understanding your rights and the legal framework is crucial to overcoming these challenges.

Why Fight Against Workers’ Comp Insurance Carriers

When workers’ compensation insurance carriers act in bad faith, they often unreasonably delay or unfairly deny the benefits you need. By giving you the runaround, they likely hope to avoid paying benefits by making you give up on the case.

If you don’t know your rights, they can get away with that, leaving you without the support needed to focus on recovering from your on-the-job injuries. You may then end up on the hook for your medical bills and have no recourse in collecting your lost wages. These delays can exacerbate physical and emotional stress, making it harder to return to work or regain financial stability.

Common Reasons for Delays and Denials

Insurance carriers may delay or deny claims for various reasons, including:

• Lack of Medical Evidence: Insufficient documentation linking the injury to the workplace.
• Causation Disputes: Claims that the injury was not work-related.
• Administrative Errors: Delays in processing paperwork or miscommunication.
• Bad Faith Practices: Intentional stalling to reduce payouts or pressure claimants to abandon their claims.

Fighting these practices ensures you receive timely benefits, covering:

• Medical treatment (e.g., doctor visits, surgeries, physical therapy).
• Temporary disability payments for lost wages.
• Permanent disability benefits for lasting impairments.
• Vocational rehabilitation, if you cannot return to your previous job.

The Workers’ Compensation Claims Process

Understanding the claims process is key to identifying where delays occur and how to address them. Here’s a step-by-step overview:

1. Report the Injury: Notify your employer within 30 days of the injury, per Labor Code section 5400.
2. File a Claim: Complete the DWC-1 form, which your employer submits to their insurance carrier.
3. Claim Review: The insurer has 14 days to notify you of the claim’s status (acceptance, denial, or pending investigation), per Labor Code section 5402.
4. Investigation: The insurer may request additional medical evaluations, often through a Qualified Medical Evaluator (QME), within 90 days.
5. Benefit Provision: If accepted, benefits begin, covering medical costs and wage replacement.
6. Dispute Resolution: If denied or delayed, you can appeal through the DWC or seek legal assistance.

Delays often occur during the investigation phase, especially if the insurer disputes causation or requests excessive documentation. Knowing these steps helps you monitor progress and identify unreasonable delays.

A Look at Workers’ Compensation Penalties

After you file your claim with the workers’ comp insurance company, they have 14 days to notify you of the status of your claim. They will either need to start paying benefits or deny the claim on reasonable grounds by the end of that period.

If the insurance carrier does not respond at all during that time, you may be able to collect a penalty. Sometimes, the insurance company wraps a self-imposed penalty into your benefits payment. They will automatically add the 10% fine to your payment, giving themselves more time to process your claim.

You can raise the issue when that doesn’t happen, but the burden of proof will fall on you. Thankfully, you can get help handling the claim from a skilled workers’ compensation attorney. With their use, you can file a penalty petition with the court and then submit the necessary evidence to show that an unreasonable delay occurred.

Upon proving the case, you can get 25% or up to $10,000 in penalties added to your payment, as outlined in Labor Code section 5814. The petition also sends the message that you understand your rights and can see the missteps made by the insurance company.

How Penalties Work

Under Labor Code section 5814, penalties are imposed for unreasonable delays in providing benefits. Key details include:

• Penalty Amount: Up to 25% of the delayed benefit amount or $10,000, whichever is less.
• Self-Imposed Penalties: Insurers may voluntarily add a 10% penalty to delayed payments to avoid litigation.
• Filing a Penalty Petition: Requires evidence of delay, such as correspondence with the insurer or medical records.
• Role of the DWC: Penalty petitions are filed with the Workers’ Compensation Appeals Board (WCAB), which may schedule a hearing before an administrative law judge.

Penalties not only compensate for delays but also deter insurers from engaging in bad faith practices.

Penalties Can Help Resolve Your Case Through a Settlement

Penalties can help you resolve your case faster through a settlement if that’s your goal. Workers’ comp insurance companies are incentivized to complete a lump sum buyout as the penalties add up.

Also known as a compromise and release, this buyout allows both parties to settle the matter outright. You will then get a one-time payment covering your lost wages, medical bills, and other losses sustained due to the on-the-job injury. This option is ideal for workers seeking to avoid prolonged disputes and secure immediate financial relief.

Types of Settlements

There are two main types of workers’ compensation settlements in California:

• Compromise and Release (C&R): A lump-sum payment that closes the entire claim, covering all benefits (medical, wage loss, etc.).
• Stipulations with Request for Award: An agreement to pay benefits over time, leaving future medical care open.

Settlements require approval by a WCAB judge to ensure fairness. An attorney can negotiate to maximize your settlement amount and protect your interests.

Additional Challenges in Workers’ Compensation Claims

Beyond delays, workers may face other challenges, including:

• Medical Provider Disputes: Disagreements over treatment plans or costs, often requiring a QME evaluation.
• Permanent Disability Ratings: Disputes over the extent of disability, impacting benefit amounts.
• Return-to-Work Issues: Challenges in securing modified duties or vocational rehabilitation.
• Third-Party Claims: If a non-employer (e.g., a contractor) caused the injury, you may pursue additional compensation through a civil lawsuit.

Addressing these challenges often requires legal expertise to navigate the DWC’s processes and appeal denials effectively.

Best Practices for Managing Your Claim

To avoid delays and protect your rights, follow these best practices:

• Document Everything: Keep records of all communications with your employer and insurer, including emails and claim forms.
• Seek Medical Evidence: Obtain detailed medical reports linking your injury to the workplace.
• Monitor Deadlines: Ensure the insurer responds within 14 days and investigates within 90 days.
• Consult an Attorney: Work with a workers’ compensation attorney to file penalty petitions, negotiate settlements, or appeal denials.
• Use DWC Resources: Access guides and forms from the DWC website to understand your rights.

Frequently Asked Questions (FAQs)

What happens if my workers’ comp claim is delayed?

If your claim is delayed beyond the 14-day notification period, you may be eligible for a penalty of up to 25% of the delayed benefits or $10,000, per Labor Code section 5814. Consult an attorney to file a penalty petition.

How can I appeal a denied workers’ comp claim in California?

File an Application for Adjudication of Claim with the Workers’ Compensation Appeals Board (WCAB). An attorney can help gather evidence and represent you at a hearing.

What is an unreasonable delay in workers’ compensation?

An unreasonable delay occurs when the insurer fails to notify you of your claim status within 14 days or delays benefits without valid reasons, such as insufficient evidence.

What are the penalties for workers’ comp delays in California?

Penalties include a 10% self-imposed fine by the insurer or up to 25% of delayed benefits (max $10,000) if you file a penalty petition and prove unreasonable delay.

Can I sue my workers’ comp insurance company for bad faith?

While workers’ comp is a no-fault system, bad faith practices may allow penalties or, in rare cases, a civil lawsuit for additional damages. Consult an attorney for guidance.

What is a compromise and release in workers’ compensation?

A compromise and release (C&R) is a lump-sum settlement that closes your claim, covering medical bills, lost wages, and other losses. It requires WCAB approval.

How long does it take to settle a workers’ comp claim in California?

Settlement timelines vary, but delays or penalties can expedite negotiations. A C&R typically takes 30–60 days to finalize after agreement, pending WCAB approval.

What role does a Qualified Medical Evaluator (QME) play in my claim?

A QME provides an independent medical evaluation to resolve disputes over injury causation, treatment, or disability ratings, often required during claim investigations.

Can I get workers’ comp if my injury was caused by a third party?

Yes, you can receive workers’ comp benefits and may also pursue a third-party lawsuit for additional damages, such as pain and suffering, through the civil justice system.

How do I find a workers’ comp attorney in California?

Contact a reputable firm like Burgis Law at 888-287-4471 for experienced legal support in managing your claim and addressing delays.

Need Help Navigating Through Your Workers’ Comp Case?

Navigating your workers’ compensation case is often fraught with challenges, especially when insurance companies violate your rights. Thankfully, you don’t have to go it alone. With a call to 888-287-4471, you can get the support you need from our team at Michael Burgis & Associates.

We have the skills and experience necessary to manage your claim while protecting your rights effectively. So, please feel free to give us a call whenever you’d like assistance with your workers’ comp case.

Don’t let insurance carrier delays jeopardize your recovery. Take control of your workers’ compensation claim today by contacting Burgis Law. Our experienced attorneys can help you secure penalties, negotiate settlements, and protect your rights. Schedule a free consultation now to get the support you deserve.

Conclusion

Workers’ compensation claims in California are designed to support injured workers, but insurance carrier delays and denials can create significant obstacles. By understanding your rights under Labor Code sections like 5814 and 5402, documenting your case, and seeking legal support, you can hold insurers accountable and secure the benefits you’re entitled to. Whether pursuing penalties for delays or negotiating a compromise and release, professional guidance is key to navigating the complex DWC system.

As of today, the workers’ compensation landscape continues to evolve, with stricter enforcement of penalties and streamlined appeal processes. Stay informed and proactive to ensure your claim is handled fairly. For expert assistance, trust Burgis Law to advocate for your rights and deliver results.