How to Get Medical Treatment After a Denied Workers’ Compensation Claim in California

• Mar 30, 2022
• Blog
• Michael Burgis & Associates, P.C

Did you recently get your workers’ compensation claim denied? If so, you’re likely trying to recover on your dime by seeking care from a skilled and experienced physician. Timely medical treatment is key to recovering quickly and getting back on the job. Unfortunately, your decision to seek care could cause problems in the long run – but only if you don’t know your rights.

Take a look at this guide on navigating your case after receiving medical care despite an initial denial.

Why Are Workers’ Comp Claims Denied?

Understanding the reasons behind your claim denial is crucial for building a strong appeal and ensuring you receive the compensation and treatment you deserve.

Common reasons for denial include:

• Missed Deadlines: Failing to notify your employer or submit required documents in time.
• Inadequate Medical Documentation: Lack of proper diagnosis, absence of causal connection to the job injury, or vague treatment notes.
• Disputed Injury Cause: Employers or insurers may argue the injury did not occur at work or is due to pre-existing conditions.
• Out-of-Network Medical Treatment: Seeking care outside the insurer’s approved provider network before approval may lead to disputes.

Every denial has multiple layers, including legal, medical, and administrative. Without addressing each attribute specifically, your appeal may fail, even if the injury is valid.

Continuing Medical Care After a Denial

Your Medical Rights Aren’t Automatically Voided

After getting your workers’ compensation claim denied, it’s always a good idea to appeal. As you do that, you cannot wait for medical care. So, you go to your doctor for care, only to face problems down the road when your claim is finally accepted.

More often than not, workers’ compensation insurance will demand you switch to their medical provider network immediately, interrupting your flow of care. As revisited in the recent Gonzales v. AC Transit case, they simply cannot do that.

How Your Doctor Can Help Secure Continuity of Care

In most cases, you’re entitled to stay with your selected network after a denied claim gets approved after appeal. Your doctor simply needs to fill out paperwork stating that the switch would be detrimental to your health and well-being. Workers’ compensation insurance must then pay your medical providers just as it would for their network.

This makes continuity of care a central attribute in your claim recovery strategy. Your current physician’s familiarity with your case, ongoing treatment plan, and medical prognosis can be leveraged legally to justify staying out-of-network, even after claim approval.

Legal Foundations: Labor Codes, Case Precedents, and Protocols

Labor Code §4600: The Backbone of Your Medical Rights

California Labor Code Section 4600 clearly states that employees injured on the job are entitled to medical treatment that is reasonably required to cure or relieve the effects of the injury, even during claim disputes.

When a denial is reversed after appeal, this code serves as a regulatory anchor for continuing treatment with your chosen physician. Insurers cannot forcibly transfer you without following a proper legal process, which includes Transfer of Care notices, PR-2 forms, and documentation from your doctor affirming the medical risk of switching providers.

The Gonzales v. AC Transit Case: Legal Precedent

In the Gonzales case, it was ruled that forcing patients to change physicians mid-treatment, especially without legal notice, violates state labor laws and risks patient harm. This landmark decision solidifies patient rights in continuity of care battles.

Step-by-Step Appeal Process After Denial

Navigating the appeal process is both legal and procedural. You must balance legal compliance with ongoing medical documentation to strengthen your position.

The Appeal Workflow:

1. File with the Workers’ Compensation Appeals Board (WCAB) using an Application for Adjudication of Claim.
2. Schedule a Qualified Medical Evaluator (QME) exam or secure an Agreed Medical Evaluator (AME).
3. Maintain ongoing care with your physician, documenting all visits and treatment plans.
4. Ensure PR-2 forms are completed to justify medical continuity.
5. Have your attorney demand protocol compliance from the insurer, including proper Transfer of Care notices.

Every step reinforces the semantic link between your injury, medical treatment, and legal protection.

Other Key Concepts You Must Understand

Types of Injuries Most Likely to Be Disputed

Some injuries are statistically more likely to trigger a denial:

• Repetitive stress injuries (carpal tunnel, tendonitis)
• Psychological conditions (stress, PTSD)
• Chronic back or neck issues
• Slip-and-fall injuries with no witnesses

Insurers often challenge these based on causation ambiguity, arguing they are due to pre-existing conditions or off-duty incidents.

Network vs. Non-Network Providers: What’s the Real Difference?

• Network Doctors: Approved by the insurance company. Often provide conservative treatment due to policy limitations.
• Non-Network Doctors: Chosen independently. Can offer more aggressive or customized care, but require legal justification for compensation.

Frequently Asked Questions (FAQs)

Can I see my doctor if my workers’ compensation claim was denied?

Yes, especially if urgent care is needed. However, continuity of treatment with that provider post-approval must be legally justified.

Will workers’ comp pay me back for treatment I received before approval?

Yes, retroactive compensation is possible if care was medically necessary and documented, and if your appeal is successful.

What is a Transfer of Care notice?

It’s a formal notice from the insurer informing you that they want to shift your care to their medical network. They must provide legal notice and justification.

What if my employer says my injury didn’t happen at work?

Gather witness statements, medical evaluations, and incident reports. This is a common tactic, but your lawyer can challenge it with proper documentation.

How long do I have to appeal a denied claim?

You have one year from the date of denial or injury, whichever is later, to file an appeal with the WCAB.

When to Contact a Workers’ Compensation Attorney

Despite the ruling, workers’ compensation insurance will likely demand that you switch to their medical provider network after finally approving your claim. Even worse, they’ll usually do just that without following the set protocol of sending out transfer of care notices.

So, it’s often best to work with an experienced lawyer to ensure their actions follow the right protocols. Your lawyer will insist that they send out the transfer of care notices as required by law. Then, they will ensure they recognize your doctor’s orders if they determine you need uninterrupted care for your serious chronic condition.

Workers’ compensation lawyers will cite cases like Gonzales v. AC Transit, plus bring up the applicable labor codes to keep the insurance company operating within the confines of the law. You can then simply focus on getting the care you need to properly recover from your on-the-job injuries.

Contact Michael Burgis & Associates: Your Legal Lifeline After Denial

If you’re dealing with issues related to a workers’ compensation claim, get the help you deserve with a call to 888-287-4471.

At Michael Burgis & Associates, we’re experienced in fighting for the rights of workers injured on the job. We can help you avoid interruptions to your medical care treatments while ensuring you can simply focus on getting well.

Why Choose Us?

• Over 15 years of legal experience in workers’ comp
• Deep knowledge of California labor codes and case law
• Dedicated attorneys who specialize in denied claim appeals
• Compassionate care from consultation to resolution

Schedule your free consultation today and let our team analyze your situation, review your documentation, and build a plan to protect your medical and legal rights.