Filing Your Workers Compensation Claim
After you report your workplace injury, your employer is required to give you a workers' compensation claim form, called a DWC 1. You need to complete this form and give it to your employer to start the process of claiming your benefits.
In principle, workers' compensation should be a simple process. You report your injury and fill out the form, then your employer pays your medical bills and other expenses incurred as a result of your injury.
In practice, many claims aren't so simple. Filing your claim may be the start of a difficult workers' compensation process in which your employer and their insurance company fight to pay out as little as possible.
Completing and filing the claim form
Once you receive your DWC 1, you need to fill out the "employee" section only. Make sure you describe your injury in detail, including every affected part of your body. Once the employee section is complete, it's best to return the form to your employer by hand. If you cannot do so - for instance, if you are bedridden due to the injury - use first-class or certified mail and buy a return receipt. Do this as soon as possible, as a delay might cause problems with your claim.
Your employer is responsible for filling out and signing the "employer" portion of the form and giving it to a claims administrator. In most cases, the claims administrator works for a workers' compensation insurance company or another organization that handles claims for your employer. However, if you work for a large company that handles its own claims, the claims administrator may be someone who works for your employer as well.
Within one business day of receiving the filed form, the claims administrator is required to authorize up to $10,000 in medical treatment while your claim is being investigated. Within a reasonable time, the administrator must decide whether to accept or deny your claim. In most cases, if the administrator doesn't send you a letter accepting or denying the claim within 90 days, the claim is presumed accepted by default.
Appealing denied claims
In many cases, the claims administrator will issue a denial notice, which states that your injury is not covered by workers' compensation. There are many reasons your employer might deny your claim. They may argue your injury was not work-related, that you were not on the employer's premises at the time, or even that you were not an employee at the time of your injury. Sometimes, claims are denied for reasons that have nothing to do with the injury itself, such as a negative relationship between you and your employer.
However, a denial letter is not the end of the process. You have a right to dispute the claims administrator's decision and file an appeal. To do so, you need to file an Application for Adjudication of Claim - usually just called an Application - with the Workers Compensation Appeals Board.
You have the right to appeal a denied claim yourself, but it's generally not a great idea to do so. Once a claim becomes adversarial, you'll be at a disadvantage. Your employer and their workers' compensation insurance company will have dedicated adjusters and attorneys on their side.
You need your own advocate to level the playing field. You need the Law Office of Robert A. McLaughlin. We have successfully helped injured San Diego workers file for workers' compensation and appeal denied claims. Contact us today to schedule your free case evaluation.