Use this template language for your workers' comp dispute:
[Your Name]
[Your Address]
[City, State ZIP]
[Phone Number]
[Date]
[Insurance Company Name]
Claims Department
[Address]
Re: Dispute of Claim Denial
Claim Number: [Claim Number]
Injured Worker: [Your Name]
Date of Injury: [Date]
Employer: [Employer Name]
Dear Claims Administrator:
I am writing to dispute your denial of my workers' compensation claim dated [Denial Date]. The denial is incorrect, and I demand that you accept my claim and provide all benefits to which I am entitled under the California Labor Code.
FACTS OF INJURY
1. On [Date of Injury], I was employed by [Employer] as a [Job Title].
2. While performing my regular job duties, I sustained injury to my [Body Parts] when [Describe how injury occurred].
3. I immediately reported this injury to my supervisor, [Name], on [Date].
4. I have received medical treatment from [Doctor/Facility] for this injury.
REASONS THE DENIAL IS INCORRECT
Your denial letter stated: "[Quote exact reason for denial]"
This denial is wrong because:
[For "Not Industrial" Denial:]
My injury arose out of and in the course of my employment as required by Labor Code Section 3600. At the time of injury, I was:
- At my assigned work location
- Performing my normal job duties
- Acting within the scope of my employment
My treating physician, Dr. [Name], has opined that my injury is industrially caused.
[For Pre-Existing Condition Defense:]
Even if I had a pre-existing condition, under the Hikida doctrine and Labor Code Section 4663, an employer takes an employee as they find them. Work activities need only be a contributing cause of the injury, not the sole cause.
[For Late Reporting Defense:]
Under Labor Code Section 5402, the statute of limitations is tolled because [explain circumstances - e.g., employer failed to provide DWC-1 form / injury developed gradually / etc.].
DEMAND
I demand that you:
1. Accept my claim as compensable
2. Provide authorization for all recommended medical treatment
3. Pay temporary disability benefits from [Date] at the statutory rate
4. Provide a copy of all documents in your claims file
If you do not accept my claim within 30 days, I will file an Application for Adjudication of Claim with the Workers' Compensation Appeals Board.
Sincerely,
[Your Signature]
[Your Printed Name]
cc: [Attorney, if represented]
Division of Workers' Compensation
[Employer HR]
INDEPENDENT MEDICAL REVIEW APPLICATION
(Per Labor Code Section 4610.5)
TO: Administrative Director
Division of Workers' Compensation
P.O. Box 71010
Oakland, CA 94612
FROM: [Your Name]
[Your Address]
[Phone Number]
[Email]
CLAIM INFORMATION:
Injured Worker: [Your Name]
Claim Number: [Number]
Insurance Company: [Name]
Date of Injury: [Date]
Body Parts: [List body parts]
REQUEST FOR INDEPENDENT MEDICAL REVIEW
I hereby request Independent Medical Review of the following Utilization Review denial:
Date of UR Denial: [Date]
Treatment Denied: [Describe treatment - e.g., "Lumbar MRI recommended by Dr. Smith"]
Reason for Denial: [Quote from UR letter]
GROUNDS FOR IMR
The UR denial should be overturned because:
1. MEDICAL NECESSITY:
My treating physician, [Name], has recommended this treatment because:
[Explain medical reasons for treatment]
The UR denial is based on [incorrect medical assumptions / failure to consider my specific condition / misapplication of the MTUS guidelines].
2. SUPPORTING MEDICAL EVIDENCE:
The following medical records support the need for this treatment:
- [List relevant medical reports]
- [Include dates and findings]
3. HARM FROM DENIAL:
Without this treatment, I am unable to [describe impact - recover, work, function, etc.].
ATTACHMENTS:
1. Copy of UR Denial Letter
2. Doctor's Treatment Request (RFA)
3. Supporting Medical Records
4. [Any other relevant documents]
I understand that the IMR decision is final and binding on the issue of medical necessity.
Signed: _________________________
Date: _________________________
[Note: This form should be accompanied by the official DWC IMR Application Form]
WORKERS' COMPENSATION APPEALS BOARD
STATE OF CALIFORNIA
Case No.: ADJ[Number]
[Your Name],
Applicant,
vs.
[Employer Name]; [Insurance Company],
Defendants.
DECLARATION OF READINESS TO PROCEED
Applicant [Your Name] hereby declares that this matter is ready to proceed to hearing on the following issues:
ISSUES TO BE DECIDED:
[ ] Injury AOE/COE (Arising Out of Employment/Course of Employment)
[ ] Parts of Body Injured
[ ] Temporary Disability
[ ] Permanent Disability
[ ] Need for Medical Treatment
[ ] Apportionment
[ ] Other: _________________
TYPE OF HEARING REQUESTED:
[ ] Mandatory Settlement Conference (MSC)
[ ] Expedited Hearing (Labor Code 5502)
[ ] Priority Conference
[ ] Trial
REASON FOR EXPEDITED HEARING (if applicable):
[Explain urgent circumstances - e.g., medical treatment being withheld, TD not being paid]
EFFORTS TO RESOLVE:
I have made the following good faith efforts to resolve this case:
1. [Date] - Sent demand letter to claims administrator
2. [Date] - Attempted to discuss settlement
3. [Date] - Exchanged medical reports
The matter cannot be resolved without a hearing because:
[Explain - e.g., "Defendant disputes compensability" or "Parties cannot agree on PD rating"]
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date: _____________
_________________________
[Your Signature]
[Your Name], In Pro Per
[Address]
[Phone Number]
[Email]
PROOF OF SERVICE
I served a copy of this document on all parties as follows:
[Insurance Company/Defense Attorney Name and Address]
Method: [U.S. Mail / Personal Service / Email]
Date: _____________
_________________________
Signature