California Workers’ Comp: Application and Denial Guide

• Apr 28, 2022
• Blog
• Michael Burgis & Associates, P.C

If you or someone you love has been involved in a work-related claim for a severe injury, you probably know there’s often some haggling with the insurance company. If a doctor has certified that you can’t work, but the insurance company has denied the claim, you’re not receiving the benefits you deserve. Fortunately, there’s help. You can get the legal representation and support you need to ensure you’re applying for benefits you’re entitled to after your work injury. At Michael Burgis & Associates, our experienced team is dedicated to helping you secure the compensation you need to recover financially, physically, and emotionally.

This guide explains the workers’ compensation process, why claims get denied, and how legal representation can help. Whether you’re just starting your claim or facing a denial, we’ll walk you through the steps to protect your rights.

What Is a Work-Related Injury?

A work-related injury occurs while performing job duties and may entitle you to workers’ compensation benefits. These injuries, also called occupational injuries, can range from minor sprains to severe conditions like traumatic brain injuries. Workers’ compensation benefits typically cover:

• Medical Expenses: Costs for doctor visits, surgeries, medications, and rehabilitation.
• Lost Wages: A portion of your salary while you’re unable to work.
• Vocational Rehabilitation: Training or support to return to work, if applicable.

According to the U.S. Bureau of Labor Statistics, approximately 2.8 million nonfatal workplace injuries and illnesses were reported in 2023, highlighting the prevalence of such incidents across industries.

Common Types of Work-Related Injuries

Work-related injuries vary by industry and job role. Some of the most common include:

• Back and Spine Injuries: Often caused by lifting heavy objects or poor ergonomics, common in construction or warehouse work.
• Fractures and Dislocations: Resulting from falls or machinery accidents, are frequent in manufacturing.
• Repetitive Strain Injuries: Such as carpal tunnel syndrome from repetitive tasks like typing or assembly line work.
• Head and Brain Injuries: Common in high-risk industries like construction or transportation.
• Burns and Electrical Shocks: Prevalent in electrical or chemical-related jobs.

Understanding the type of injury you’ve sustained can help you determine your eligibility for benefits.

How to File a Workers’ Compensation Claim

Filing a workers’ compensation claim involves several key steps:

1. Report the Injury: Notify your employer within 30 days of the injury, as required by California law.
2. Seek Medical Attention: Visit a doctor to document your injury and inability to work.
3. Submit the Claim: Complete a claim form (DWC-1) and submit it to your employer’s insurance company. You have one year from the injury date or last disability payment to file.

Applying the Right Way Matters

How you go about applying for benefits can have nearly as much impact as the application itself. That means you’ll want to pursue the issue in the best possible way for your needs right from the very beginning. When you do that, you reduce the chances of denials. If your claim is denied, working with an attorney with workers’ compensation experience can make it easier to get your claim through. Don’t settle for missing out on the benefits you deserve from a work injury!

Why Do Workers’ Compensation Claims Get Denied?

Insurance companies may deny claims for several reasons, but you can appeal with the right support. Despite a clear process, many claims face initial denials. Common reasons include:

• Insufficient Medical Documentation: Lack of evidence linking the injury to your job duties.
• Disputes Over Work-Relatedness: Claims that the injury was pre-existing or occurred outside work.
• Missed Deadlines: Failing to report the injury within 30 days or file a claim within one year.
• Alleged Violations: Claims that you were under the influence or violated safety protocols.

For example, a construction worker with a back injury might face a denial if the insurance company argues the injury stemmed from a prior condition. In such cases, medical records and expert testimony can clarify the injury’s cause.

Statistics on Claim Denials

While exact denial rates vary, studies suggest that 10-20% of workers’ compensation claims are initially denied, depending on the state and industry. The California Division of Workers’ Compensation reported that in 2022, over 600,000 claims were filed, with a significant portion requiring appeals due to denials. Understanding these challenges can help you prepare a stronger case.

How Can Legal Representation Help?

An experienced workers’ compensation attorney can increase your chances of securing benefits. If your claim is denied, working with a firm like Michael Burgis & Associates can make a significant difference. Our attorneys can:

• Review Your Case: Identify errors or gaps in the initial claim.
• Gather Evidence: Collect medical records, witness statements, and workplace incident reports.
• File an Appeal: Submit a formal appeal to the Workers’ Compensation Appeals Board (WCAB).
• Negotiate with Insurers: Advocate for temporary disability payments until your case is resolved.

Why Choose Michael Burgis & Associates?

Our firm offers:

• No Fees Unless We Win: You pay nothing unless we secure your benefits.
• Free Consultations: Discuss your case with no upfront cost.
• Proven Expertise: Years of experience in workers’ compensation law.

Don’t let a denial stop you from getting the compensation you deserve. Contact us today for a free consultation.

Applying for State Disability Benefits Through EDD

By applying for your state disability benefits through California’s Employment Development Department (EDD), you’ll be paid two-thirds of your weekly salary (e.g., $667 for a $1,000 weekly salary) for up to 52 weeks. That’s true whether or not the injury is proven to be industrial. You’ll be working with an attorney during that time, which gives you and your legal advocate a year to get everything straightened out for insurance to pick up the claim. The claims process doesn’t always move quickly, but you must be receiving some financial help during the process. That’s why EDD is so beneficial.

How to Apply for EDD Benefits

1. Visit the EDD website at edd.ca.gov.
2. Complete the Disability Insurance (DI) application online or by mail.
3. Provide a medical certification from your doctor confirming your inability to work.

EDD benefits act as a financial lifeline while your workers’ compensation claim is processed, ensuring you have income during recovery.

Eligibility for EDD Benefits

To qualify, you must:

• Be unable to perform your regular job duties for at least eight days.
• Have earned at least $300 in wages subject to State Disability Insurance (SDI) deductions.
• Be under a doctor’s care with certification of disability.

Transitioning to Insurance Coverage

Insurance Will Pick Up the Claim Later. By the end of that year, when EDD resolves, insurance will theoretically pick up the claim. You don’t want that claim to be denied, or you could end up right back where you started. The right attorney matters because they can help you make your case to the insurance company. Then you’ll be getting temporary disability through the insurance company until your situation is resolved and you can return to work.

What Happens During the Transition?

Once your workers’ compensation claim is approved, the insurance company takes over, providing:

• Temporary Disability Payments: Typically, two-thirds of your average weekly wage.
• Medical Treatment Coverage: Ongoing care until you reach maximum medical improvement.
• Permanent Disability Benefits: If your injury results in a lasting impairment.

An attorney ensures a smooth transition by:

• Verifying benefit calculations.
• Addressing any disputes or delays.
• Preparing for hearings if the claim faces further challenges.

Frequently Asked Questions (FAQs)

To address common long-tail queries, here are answers to frequently asked questions about work-related injury claims:

What should I do if my workers’ compensation claim is denied?

If your claim is denied, consult a workers’ compensation attorney immediately. They can review your case, gather evidence, and file an appeal with the Workers’ Compensation Appeals Board (WCAB). Contact Michael Burgis & Associates for a free consultation.

How long do I have to file a workers’ comp claim in California?

You must report your injury to your employer within 30 days and file a claim with the insurance company within one year of the injury or the last disability payment.

Can I get benefits if I’m partially at fault for my injury?

Yes, workers’ compensation is a no-fault system. You can receive benefits as long as the injury occurred during your employment, even if you were partially responsible.

What types of injuries are covered under workers’ compensation?

Workers’ compensation covers physical injuries (e.g., fractures, burns), occupational diseases (e.g., lung conditions from chemical exposure), and work-related mental health conditions (e.g., stress-induced anxiety).

How does the appeals process work for a denied claim?

If your claim is denied, you can file an appeal with the WCAB. Your attorney will submit a Declaration of Readiness to Proceed, and a hearing will be scheduled to review your case.

What is the difference between EDD benefits and workers’ compensation?

EDD benefits provide temporary income (up to 52 weeks) regardless of whether the injury is work-related, while workers’ compensation covers work-related injuries with benefits like medical care and permanent disability payments.

How much will I receive from workers’ compensation?

Temporary disability payments are typically two-thirds of your average weekly wage, subject to state maximums. For example, if you earn $1,500 weekly, you may receive approximately $1,000 per week.

Take Control of Your Claim Today

Dealing with a work-related injury is challenging, and a denied claim can make it even harder. At Michael Burgis & Associates, we understand the worries you have. We’re here, and we can help you get the fair and just compensation you deserve while you’re recovering from a workplace injury. Our team offers free consultations and works on a no-fee-unless-we-win basis, so you have nothing to lose.

Reach Out to Get Started Today

If you have questions about disability for a work-related injury or dealing with an insurance company denial, reach out to us today. Don’t let a denial stand in your way; take the first step toward securing your benefits.

Contact Michael Burgis & Associates