Reasons for a Workers’ Compensation Claim Denial in California

 Posted on July 04, 2025 in Denied Claims and Appeals

Receiving a denial for a workers’ compensation claim can feel defeating. However, there are common reasons that these claims are denied, and an experienced Gilroy, CA workers’ compensation attorney can help you fight an unfair judgment. The first step is to understand why your claim was not accepted. More often than not, there is an obvious solution.

Common Reasons for Workers’ Compensation Claim Denials in California

The most common reasons for workers’ compensation claim denial in California are related to issues addressed under state labor laws:

• Lack of medical evidence: If your medical records do not clearly connect your injury to your work duties, your claim may be denied.

• Injury not reported on time: Injured workers must notify their employer within 30 days of the injury, according to Labor Code § 5400.

• Dispute over whether the injury is work-related: Employers or insurers might argue that your injury did not happen at work.

• Pre-existing conditions: Insurers may deny claims if they believe your injury was solely due to a prior condition rather than your job.

• Failure to seek approved medical care: California law may require you to see doctors in your employer’s medical provider network (MPN). Seeing a doctor outside the MPN without authorization can result in a denial.

• Missed deadlines for filing a claim: Generally, Labor Code § 5405 sets the deadline for filing a claim at one year from the date of the injury.

• Suspicion of fraud: If the insurer suspects false statements or exaggerated injuries, it may deny the claim and investigate further.

• No lost time or medical treatment required: Minor injuries that require no medical care or lost wages may be denied because no compensation was needed.

Read the letter of denial carefully. It should explain why your claim was denied. Sometimes, it can be as simple as missing paperwork. Then, talk to an experienced workers’ compensation attorney about filing an appeal. They will help you gather evidence, like medical records and anything showing that you suffered a work-related injury.

What To Do If Your Workers’ Compensation Claim Is Denied in California

If your workers’ compensation claim is denied in California, you still have rights and options for fighting the decision. The first step in the appeals process is to file a Petition for Reconsideration with the California Workers’ Compensation Appeals Board (WCAB). The WCAB will review the case and the documents that you submit with the petition. One of four things may happen next:

• They can deny your petition by agreeing with the original decision. 

• They can issue a decision, which could include returning the case to the original judge for further proceedings.

• They can order actions, like holding a rehearing, obtaining a new medical exam, or referring the case for further study.

• They may dismiss the petition, which can be for many different reasons.

The appeals process can be complex, and the deadlines for workers’ comp claims are strict in California. Seeking legal representation as fast as possible is the best chance you have to get your case reviewed and resolved as quickly and efficiently as possible.

Talk to a Santa Clara County, CA Workers’ Compensation Attorney Today

At Cramer + Martinez, we have been serving clients in Gilroy and the surrounding area for nearly 30 years. Our team of Gilroy, CA workers’ compensation lawyers brings more than two decades of combined experience in workers’ comp law. With our help, you may still secure the benefits you deserve. Call 408-848-1113 to schedule a free consultation.