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Key Takeaways
- A denial is the claims administrator’s opinion, not a final ruling. California law gives you a formal way to challenge it.
- If liability is not rejected within 90 days of your claim form, the injury is presumed compensable (Lab. Code § 5402(b)(1)).
- Your employer must authorize treatment within one working day and cover up to $10,000 while the claim is investigated (§ 5402(c)).
- You generally have one year to start proceedings, measured from injury or from the last benefit received (§ 5405).
- The challenge starts with an Application for Adjudication of Claim, not a phone call to the adjuster.
- Most denials turn on medical evidence, resolved through a qualified medical evaluator (QME) or agreed medical evaluator (AME).
- The often-quoted “20 days” applies to reconsidering a judge’s decision, not to the insurer’s denial letter.
If your California workers’ compensation claim was denied, you have not lost your case. A denial means the claims administrator has decided your injury is not covered by workers’ compensation, and California law gives you a formal process to put that decision in front of a workers’ compensation judge.
What matters is what you do next. Denial reasons are usually narrow and fixable: a report that arrived late, a medical file that does not clearly tie the injury to the job, a form filled in incorrectly. Below is what a denial means, what your employer still owes you while the claim is disputed, and the exact sequence for challenging it.
What a denial actually means
When your claim is denied, the claims administrator (your employer’s insurer or third-party administrator) has concluded your injury is not covered. The California Division of Workers’ Compensation puts it plainly: a denial reflects that party’s belief, and you have a right to challenge the decision.
That distinction matters. The adjuster is a party to your case, not a neutral decision-maker. Only a workers’ compensation judge can decide whether your injury is compensable, and you reach that judge by filing paperwork, not by arguing with the adjuster. You may represent yourself or hire an attorney. Either way, the state’s own guidance is blunt about timing: do not delay, because there are deadlines for filing the necessary papers.
The 90-day rule that may already be working for you
Under Labor Code section 5402(b)(1), if liability is not rejected within 90 days after you file your claim form under section 5401, your injury is presumed compensable. That presumption can only be rebutted with evidence the employer could not have discovered during those 90 days.
So the date on your denial letter is not a formality. If the denial arrived more than 90 days after you filed your DWC-1 claim form, the legal starting point shifts substantially in your favor. Compare the two dates, and keep both documents.
Your medical treatment while the claim is disputed
A denial does not switch off your right to treatment during the investigation period. Labor Code section 5402(c) requires your employer to authorize treatment within one working day of your claim filing, and makes the employer responsible for up to $10,000 of it until the claim is accepted or rejected. Providing that treatment is not an admission of liability, but the obligation is real, and it exists so injured workers are not left untreated while adjusters investigate. If you were told to stop treating the moment your claim was questioned, that instruction did not match the statute.
Why California claims get denied
Denial letters are often vague. Most fall into a few categories, each with a different path back.
| Stated reason | What it really turns on | Governing provision |
|---|---|---|
| Injury reported late | Whether you gave notice within 30 days of the injury, and whether an exception applies | Lab. Code § 5400 (subject to §§ 5402, 5403) |
| Injury is not work-related | Medical evidence connecting the injury to your job duties | Lab. Code § 4060 |
| Insufficient medical evidence | Whether a qualified evaluator has examined you and written a report | Lab. Code §§ 4062.1, 4062.2 |
| Pre-existing condition | Whether work aggravated or accelerated the condition, not whether it existed before | Lab. Code § 4060 |
| Discrepancies in the file | Consistency between your incident report, your statements and your medical records | Evidentiary, resolved at hearing |
| Claim filed after termination | Timing and documentation of the injury relative to your separation | Lab. Code § 3600 et seq. |
Most are evidentiary, not legal. A denial reading “not work-related” says the file, as it stands, has not persuaded the adjuster. Files can be added to.
How to challenge a denial, step by step
Step 1: File an Application for Adjudication of Claim
This opens a case with the Workers’ Compensation Appeals Board and assigns a case number. Until it is filed, no judge has authority over your dispute. It converts a disagreement with an adjuster into a legal proceeding.
Under Labor Code section 5405, you generally have one year to commence proceedings, measured from the date of injury, the expiration of payments under section 4650 and following, or the last date a benefit under section 4600 and following was furnished. If you received treatment or payment after your injury, the clock may run from that later date.
Step 2: Resolve the medical dispute through a QME or AME
Because most denials rest on medical evidence, the medical-legal evaluation is usually where the case is won or lost. Labor Code section 4060 governs evaluations used to determine whether an injury is compensable, and the procedure depends on whether you have an attorney.
If you are not represented, section 4062.1 applies. Either party may ask the medical director to assign a panel of three qualified medical evaluators, though the employer may not submit that request unless you have failed to within 10 days of being furnished the form. Once the panel is assigned, you have 10 days to select a physician, schedule the appointment, and tell your employer both. If you do not, the employer may choose for you. You may decline an evaluation for good cause, including bias, and request a new panel.
If you are represented, section 4062.2 applies. The parties may agree on a single agreed medical evaluator at any time, and once they do, a panel cannot be requested on that issue unless the agreement is canceled in writing. Absent agreement, either party may request a three-member panel no earlier than the first working day at least 10 days after notification or objection. Each party then has 10 days from assignment to strike one name, and the physician left standing performs the evaluation. Fail to strike in time and the other side picks from whoever remains.
Those 10-day windows are short and easy to miss while you are recovering. Missing one hands the choice of evaluator to the other side.
Step 3: File a Declaration of Readiness to Proceed
An open case does not schedule itself. When it is ready to be heard, you file a Declaration of Readiness to Proceed. This is separate from the Application, and cases sit idle when workers assume the Application alone was enough.
Step 4: The mandatory settlement conference
You and the claims administrator, or their attorney, appear before a judge, who discusses the case with both sides and works to help you reach a settlement. Many disputes end here, because filing changes the insurer’s calculation: an adjuster who denied a thin file now faces a judge, a medical report and a deadline.
Step 5: Trial and decision
If the conference does not resolve the case, it proceeds to trial before a different judge, who issues a written decision by mail. That decision typically arrives 30 to 90 days after trial.
Step 6: Petition for Reconsideration, if needed
If you disagree with the judge’s decision, Labor Code section 5903 allows you to petition for reconsideration within 20 days after service of a final order, decision or award. The statute limits the grounds to five and no others: the appeals board acted without or in excess of its powers; the decision was procured by fraud; the evidence does not justify the findings of fact; you discovered new material evidence that reasonable diligence could not have produced at the hearing; or the findings do not support the decision.
This is the source of the “20 days” figure that circulates online, and it is frequently misreported. That clock starts when a judge issues a decision. It is not the deadline for responding to your insurer’s denial letter. Confusing the two can cost you a year of case-building, or trigger panic over a deadline that has not started.
The deadlines that actually control your case
| Deadline | What it governs | Runs from | Authority |
|---|---|---|---|
| 1 working day | Employer must authorize treatment | Filing of the claim form | Lab. Code § 5402(c) |
| 10 days | Selecting or striking a QME panel name | Assignment of the panel | Lab. Code §§ 4062.1, 4062.2 |
| 20 days | Petition for Reconsideration | Service of a judge’s final order, decision or award | Lab. Code § 5903 |
| 30 days | Notice of injury to your employer | Occurrence of the injury | Lab. Code § 5400 |
| 90 days | Insurer must accept or reject, or the injury is presumed compensable | Filing of the claim form under § 5401 | Lab. Code § 5402(b)(1) |
| 1 year | Commencing proceedings (Application for Adjudication) | Injury date, end of § 4650 payments, or last § 4600 benefit furnished | Lab. Code § 5405 |
Four mistakes that turn a fixable denial into a lost claim
- Treating the denial letter as the end. It is one party’s position on an incomplete file.
- Waiting for the adjuster to reconsider. Calls and emails toll no deadline. The one-year clock under section 5405 runs regardless.
- Letting the QME window lapse. Missing 10 days transfers the choice of evaluator, and that report is usually the pivot point of the case.
- Stopping treatment. Gaps in a medical record read as gaps in the injury. If cost is the obstacle, raise it before you go untreated.
When your denial is part of a larger injury
Some workplace injuries generate more than one claim. A worker hurt by a defective machine or injured on a site controlled by another contractor may have both a workers’ compensation claim and a separate third-party case, with different rules and deadlines. A denial in one does not extinguish the other. Serious injuries draw the hardest scrutiny: see our pages on back and spine injuries and our guide to workers’ compensation benefits. If the injury has kept you off work, state disability insurance may apply while your claim is disputed.
Frequently asked questions
Talk to a San Diego workers’ compensation attorney
Banker’s Hill Law Firm has represented injured workers across San Diego County since 1991, handling claim evaluation and filing, denied and disputed claims, settlements, and death benefits. Maxwell Agha and our workers’ compensation team can walk you through what happens next, in English or Spanish.
Your consultation is free. There is no upfront cost. In California, workers’ compensation attorney fees are a percentage of your recovery — commonly 9% to 15%, subject to Labor Code section 4906 — and must be reviewed and approved by a workers’ compensation judge.
If your claim was denied, call (619) 230-0330 or contact our San Diego office. We also serve the South Bay, including Chula Vista, Spring Valley and El Cajon, and you can read what our clients say.
This article is general information about California law, not legal advice. Reading it does not create an attorney-client relationship. Deadlines and procedures vary with the facts, and you should speak with an attorney about your situation.
