My workers’ comp claim was denied in California. What now?

A denied workers’ comp claim in California means the claims administrator, the person or company handling the employer’s claims, has decided the injury is not covered. It is not a judge’s ruling, and the Division of Workers’ Compensation (DWC) says the worker has the right to challenge it. A medical dispute can go to a qualified medical evaluator (QME). An Application for Adjudication of Claim opens a case at the Workers’ Compensation Appeals Board (WCAB), and it generally must be filed within one year (Labor Code 5405).

What does “denied” mean in a denial letter?

The DWC’s guidebook for injured workers says “denying” a claim means the claims administrator believes the injury is not covered. Disputes are decided at the WCAB, which the DWC’s Fact Sheet G calls “a special court that hears and decides disputed workers’ compensation claims.”

A delay letter is different. It means the claims administrator is still investigating and must explain what information it needs and when it expects to decide (guidebook, chapter 5).

What is the 90-day rule?

Under Labor Code 5402(b), if liability is not rejected within 90 days after the claim form is filed, the injury is presumed compensable, or covered. The presumption can be rebutted only by evidence discovered after the 90-day period. For the injuries listed in Labor Code 3212 to 3212.85 and 3212.9 to 3213.2, the period is 75 days.

While the decision is pending, section 5402(c) requires the employer to authorize treatment, with its liability limited to $10,000.

Why do claims administrators deny claims?

The common reasons track the conditions for compensation, most of them in Labor Code 3600:

• The injury did not arise out of and in the course of the employment.
• The worker was not an employee. The guidebook says a worker may be covered as an employee even if called an “independent contractor.”
• Notice came too late under Labor Code 5400. Under Labor Code 5403, late notice bars a claim only if the employer was misled or prejudiced by it.
• The claim was filed after a notice of termination or layoff, which section 3600(a)(10) bars unless a listed condition applies, such as the employer knowing of the injury before that notice.
• A psychiatric injury did not meet Labor Code 3208.3, which generally requires six months of employment with that employer, though the six months need not be continuous.
• An exclusion in section 3600(a) applies, such as intoxication or an intentionally self-inflicted injury.

Under 8 CCR 9812(i), a notice denying all benefits must give the reasons and go out within 14 days of the decision. It must include a copy of any medical report the denial relies on, with an exception for some psychiatric reports.

What is a QME, and why does it matter after a denial?

A qualified medical evaluator (QME) is a physician, certified by the DWC Medical Unit, whose medical-legal report becomes evidence when the dispute is medical, such as whether work caused the injury. The DWC’s FAQ for employees says a QME can be requested when a claim is delayed or denied and an evaluation is needed to find out whether it is payable.

An agreed medical evaluator (AME) is a doctor both sides choose, used only when the worker has an attorney (Fact Sheet E). Labor Code 4060 governs evaluations on whether an injury is compensable. For a worker without a lawyer, the claims administrator’s notice that it wants an evaluation, or that it has not accepted liability, must come with the QME panel request form (4060(d), (e)).

How is the QME chosen?

It depends on whether the worker has a lawyer. Without one, the worker requests a panel on QME Form 105 under Labor Code 4062.1 and 8 CCR 30(a). Whoever submits the form picks the specialty, and the claims administrator may submit it only if the worker has not done so within 10 days of receiving it (4062.1(b)).

The DWC Medical Unit sends a list of three QMEs within 20 working days of the request. Within 10 days of the panel’s issuance (the DWC counts from the date the list is printed and mailed), the worker picks one, makes the appointment and tells the claims administrator. Otherwise, the claims administrator may choose (4062.1(c); DWC FAQ for employees).

With a lawyer, for injuries on or after January 1, 2005, Labor Code 4062.2 applies. Either side may request a three-member panel online through the DWC’s site (8 CCR 30(b)). Each side may strike one name within 10 days of the panel’s assignment, and the remaining QME does the evaluation. What happens at the exam is in what is a QME exam.

What is an Application for Adjudication of Claim?

It is the form that opens a case at the WCAB. The DWC’s I&A Guide 4 says to complete it when the worker wants the local WCAB to resolve a disagreement with the employer or its insurer, or when the WCAB may be needed later and the time to file could run out. In general, it must be filed within one year from the date of injury or from the last date benefits were provided (Labor Code 5405; Fact Sheet G).

No hearing is scheduled until a party files a Declaration of Readiness to Proceed, DWC-CA form 10250.1 (I&A Guide 5; Fact Sheet G). When a represented worker’s dispute is over employment or whether the injury arose out of and in the course of employment, Labor Code 5502(c) calls for a priority conference within 30 days after that declaration.

What can a DWC Information and Assistance officer do?

Information and Assistance (I&A) officers are DWC staff who answer questions, provide forms and help resolve problems with claims. The DWC’s FAQ says they help workers understand how to act on their own behalf but do not act for them the way an attorney would. Orange County has two DWC district offices with I&A units:

Office	Address	I&A phone
Santa Ana	2 MacArthur Place, Suite 600, Santa Ana, CA 92707	(714) 942-7576
Anaheim	1065 N. Link, Suite 170, Anaheim, CA 92806	(714) 414-1801

The DWC’s statewide line is 1-800-736-7401. Both office pages list monthly workshops for injured workers by Zoom, in English on the first Friday and in Spanish on the third Friday. Other offices are on the DWC I&A page (read October 8, 2026).

Which deadlines apply after a denial?

Deadline	Time limit	Rule
Written notice of the injury to the employer	30 days from the injury; a supervisor’s knowledge counts	LC 5400, 5402(a)
Accept or deny the claim	90 days from the claim form (75 for injuries in LC 3212 to 3212.85 and 3212.9 to 3213.2), or the injury is presumed compensable	LC 5402(b)
Send in a QME panel request form the claims administrator provided, worker without an attorney	10 days from receiving it, or the claims administrator may request the panel and pick the specialty	LC 4062.1(b); DWC FAQ; Fact Sheet E
QME panel issued, worker without an attorney	20 working days from the request	DWC FAQ
Pick a QME and make the appointment, worker without an attorney	10 days from the panel’s issuance (the DWC counts from the date it is printed and mailed)	LC 4062.1(c); DWC FAQ
Strike a name, worker with an attorney	10 days; the statute counts from the panel’s assignment, the regulation from service of the panel list	LC 4062.2(c); 8 CCR 30(b)
File the Application for Adjudication of Claim	Generally 1 year from the injury or the last benefit provided, not counting the time from filing the claim form to the denial	LC 5405, 5401(d); DWC Fact Sheet G
Priority conference, represented worker, dispute over employment or work-relatedness	Within 30 days of the Declaration of Readiness to Proceed	LC 5502(c)

Sources: Labor Code 5400, 5401, 5402, 4062.1, 4062.2, 5405 and 5502; the DWC FAQ for employees, Fact Sheet E and Fact Sheet G. Read October 8, 2026.

What do people get wrong after a denial?

• Taking a treatment denial to a QME. A utilization review decision on a treatment request can be reviewed or appealed only through independent medical review (Labor Code 4610.5(e)), explained in how independent medical review works.
• Assuming the one-year period waits while the claims administrator reconsiders. Filing the DWC 1 pauses the Labor Code 5405 limit only until the claim is denied or becomes presumed compensable (Labor Code 5401(d)). After a denial the clock runs again from the dates in section 5405: the injury, the end of the last disability payment period, or the last medical treatment furnished.

What should I read next?

• What a denied-claim case involves: denied workers’ comp claims.
• The medical-legal exam: what is a QME exam.
• Conferences, trials and the district offices: what happens at the WCAB.
• Filing deadlines by section: how long you have to file a workers’ comp claim.

Whether a particular denial will hold up depends on facts and medical records this page cannot see.

Where does the Law Office of Jesse Melendrez fit?

When a worker has an attorney, the attorney handles the filings and appears at the hearings.

The Law Office of Jesse Melendrez is in Newport Beach. We limit our practice to California workers’ compensation and represent injured workers only, with cases at the WCAB district offices in Santa Ana, Anaheim, Los Angeles, Riverside and San Diego. Attorney Jesse Melendrez (State Bar of California #263751) has represented injured workers since 2009.

This page explains how a denial is challenged. It is not legal advice about your claim. If you would like us to review your denial letter, tell us what happened.