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Appealing Worker’s Compensation Decisions

In California, every employer—even with one employee—has to provide worker’s compensation benefits for their employees. The vast majority of companies buy private insurance, but they can also be “self-insured” if they prove to the state that they have the assets to pay benefits. Companies that do will typically hire a worker’s compensation insurance company to manage their claims.

Either way, these private entities will make decisions that affect the injured worker’s benefits.

Types of Appeals

All appeals can be put in two main categories: appeal of a decision by the private insurance company or appeal a decision by the California’s Worker’s Compensation Appeals Board (WCAB). The vast majority of the appeals are to a contrary decision by the insurance company.

Appeals to Insurance Company’s Decisions

Some of the common reasons that employee might want to appeal a decision by their company’s worker’s compensation insurance (WCI):

  • Injury not work-related: Benefits are not contingent on finding fault with the employer, but the injury does have to be in the “course and scope of the employment” of the business, and WCI says it wasn’t.
  • Ability to work: Sometimes the WCI will deny that a person is temporarily disabled even though a doctor said that the worker can’t return to work.
  • Restriction: The WCI might deny certain restrictions placed on the employee’s ability to work.
  • Disability Duration: The length of time the employee is unable to work or under restrictions can be challenged by the WCI.
  • Disability Rating: A doctor will issue a percentage of permanent disability after treatment has concluded, and WCI companies routinely disagree with this and contest the rating.
  • Any Contrary Decision: This is a catch-all category meaning that any decision by the WCI that negatively affects your benefits can be appealed.

Appeals to the Appeal Board’s Decision

When the injured worker appeals the insurance company’s decision, the WACB will make a ruling which will decide the contested issue. If the ruling goes against the employee or employer, either may appeal to the state’s court of appeals.

Appeal Process

When an employee gets an adverse decision by the WCI, he or can file an appeal to the WCAB which will eventually rule on their case.

Application for Adjudication of Claim

To start the appeal, the worker files an Application of Adjudication of Claim with the WACB. The petition will be filed in the county where the injury took place and will spell out the reason for the appeal. The employee or their attorney is responsible to fill out the form and get it filed.

The application must be filed before a deadline otherwise the ability to appeal might be lost. Generally speaking, the deadline is a year from either the date of injury or the last date employer provided medical benefits. There are circumstances where this deadline might be different, so the best thing to do is to contact an attorney who can assist you with your appeal.

Hearing Before a Judge

The WCAB will send you notice that they have received your application, and they will assign you a case number that will be used from then on to identify that case. Once you are ready to have your case heard, you can file a Declaration of Readiness to Proceed which will request a hearing date.

You will then be given a date to appear at before a judge.

Mandatory Settlement Conference

At your first appeal meeting, you will have a meeting with the judge and a representative of your employer’s WC insurance company. Here the judge will encourage the parties to settle, but if a settlement doesn’t happen, then a trial date will be set where the appeal will be decided.

Hearing the Appeal

After the settlement conference, if no settlement was reached, the WCAB will set a date for a hearing, and at that time the employee will present their case for their appeal. After hearing the evidence, the judge will rule on the issue.

Petition for Reconsideration

This decision can be appealed to the State Appellate Court, but before that, the losing party has to file a Petition for Reconsideration before the WACB. The board will review the judge’s decision to see if any mistakes were made. If this fails, then the next option is to appeal to the state appeals court.

Appealing the Appeal

If this is denied, then you can file Writ of Review to the State Appellate Court to appeal th e WACB’s ruling. Once heard by the Appellate Court, an adverse decision can be appealed to the California Supreme Court.

Contact a Sacramento Workers’ Compensation Attorney

While it’s not required to have an attorney when you make your appeal of the denial of your WC claim, it is wise to do so because an experienced attorney stands a much better chance of success.

In almost all cases when someone is injured on the job, the worker will get the best possible outcome by hiring an experienced Sacramento workers’ compensation lawyer.

Attorney Alice A. Strömbom focuses exclusively on Workers’ Compensation Law. She is very familiar with the tactics insurance companies use to avoid providing the medical treatment and disability benefits injured workers deserve, and has a recognized track record in combating such issues.

Contact us today for a free, confidential consultation and case evaluation.