Apple Valley, CA asked in Workers' Compensation for California

Q: After workers comp insurance accept your claim can they deny it 5 years later prior to any settlement?

The company I used to work for and their workers comp insurance accepted my claim I went through years of therapy and doctors all agreeing that I am 100% disabled but now after 4 and a half years they send me to one of their doctors even after I have seen all sorts of qualified specialists now they are trying to deny my continuing claim even though im on permanent and total disability and have been released from my main doctor for a year and a half or more

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1 Lawyer Answer
Nancy J. Wallace
Nancy J. Wallace
Answered
  • Workers' Compensation Lawyer
  • Grand Terrace, CA
  • Licensed in California

A: 'THEY ARE TRYING TO DENY MY CONTINUING CLAIM' needs some clarification. Does this mean you received a written notice the insurer now denies it is responsible for anything at all? Are you saying the insurer wrote it has no liability?

OR: are you trying to say when a doctor wrote a Request For Authorization for some medications, a Utilization Review company 'non-certified' your medication Rx?

People get confused and thing the entire claim is denied when the insurer refuses to pay for the prescription (or an xray or some therapy). Just because some disagnostic test or some pain pills get refused does NOT mean the insurer is denying all responsibility for the entire claim.

You write that the employer 'agreed' you were 100% permanently disabled. THIS IS EXTREMELY RARE. Most insurers right this through trial. Assuming you are correct, the document making this clear would be Stipulations With Request For Award, where the parties write their agreement you were hurt on the job as filed and that you sustained 100% permanent disability as a result. If this was signed and the judge approved it, the insurer cannot 'undo' it now.

If there is not Award on Stipulations, then the employer and insurer can go get evidence showing you are not 100% disabled OR evidence that the disability was not cause by employment, and so change their position. When the insurer/employer disagree with the findings of the treating physician, they get a Qualified Medical Evaluation...and when that QME writes that the worker's disability is not caused by employment, the employer has the right to say it disputes and denies responsibility.

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