San Francisco, CA asked in Workers' Compensation for California

Q: Can the insurance carrier deny your benefits for something that they’ve known for almost two years

I have been appealing my claim for over a year and a half and I just received a denial letter saying they accepted the doctors report of ttd and dates but are denying benefits because I was terminated for cause. Why did they wait this long to send me this letter? They have known of this and has gave me that excuse ever since I was injured. This denial letter does not have any medical or legal evidence to support the denial. The legal reason they use is “ttd is not owed under California labor code and applicable caselaw”. Isn’t there a time limit for them to dispute?

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2 Lawyer Answers
Ronald Mahurin
Ronald Mahurin
Answered
  • Workers' Compensation Lawyer
  • Point Arena, CA
  • Licensed in California

A: Yes, the insurance carrier can deny your case at any time. However, there may be consequences if the denial is improper. Technically, if your claim is not denied within 90 days of notice, then it is presumed to be a work injury by statute. This appears to be the case with you.

At this point, since you have been appealing your case for so long, it might be time to seek representation.

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

A: Denying there was any injury and denying responsibility for payment of TTD are very different. It sounds like responsibility for THE CLAIM was accepted, but that a physician wrote you have been Temporarily Totally Disabled ONLY because the employer failed to provide any modified work. Where an employee is injured but can perform some modified work but is terminated for good cause, the employer does not provide modified duty and the insurer does not pay TTD. IF you were terminated in retribution for requesting workers comp benefits, you have already blown the statute for the 132a Petition for reinstatement and an increase in benefits, as that must be filed within one year of the discrimination/termination. IF YOU can prove the doctor says you are Totally Temporarily Disabled whether or not this employer might have provided some modified/light duty, you can get an Expedited Hearing and get that evidence to a judge for an order that back TTD and the 4620 penalty are due. BUT IF a doctor's report is that you are TTD ONLY because the employer failed to provide light work, the judge won't award TTD or penalties (until you prove that the termination was improper and unwarranted). It sounds like you should have had a local, very experienced attorney on this at least one year ago.

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