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  • Denied Workers’ Compensation Claims

    A person injured at work rightfully believes they would be entitled to Workers’ Compensation benefits. While they are entitled to apply for Workers’ Compensation, they are not always approved to receive those benefits.

    An employer or its Workers’ Compensation insurer can deny benefits, even if you have a legitimate work-related injury. They will send the employee a Notice of Denial or Notice Stopping Temporary Compensation. It can be a shock to receive a notice, and insurers know that many people will not challenge a denied claim. If your legitimate claim was denied, do not just accept the denial. You have options and rights.

    Why Would a Workers’ Compensation Claim Be Denied?

    In most cases, when you apply for Workers’ Compensation benefits, your employer will initially rule on your application. They will usually confer with their Workers’ Compensation insurer to decide whether to approve your application, or the insurer will flat-out deny the claim, even if it is valid.

    Why would the employer or insurer deny a claim? Workers’ Compensation claims cost the company money and loss of productivity if an employee must be off work. The following are other common reasons why Workers’ Compensation claims are denied.

    Injury Not Reported on Time

    According to Pennsylvania law, an employee should report their injury to the employer within 21 days but no later than 120 days from the date of injury.

    Injury Not Related to Work

    This is a common reason for benefit denial. To be compensable, an employee must have been injured within the course and scope of their employment. Insurers will often claim that the injury or illness happened outside of work, forcing employees to use their private medical insurance, rather than Workers’ Compensation benefits. However, the law broadly defines what constitutes the course and scope of employment, especially for traveling employees.

    Pre-Existing Condition

    Another common reason for denying a claim is that the insurer claims you had a pre-existing condition, and therefore, the injury was not related to your job. Be aware that Workers’ Compensation covers pre-existing conditions made worse or aggravated by work responsibilities.

    Injury Not That Severe

    While the employer and insurer may agree you were hurt on the job, they may argue that the injury or illness was not severe and there was no need to be off work. It’s imperative that your injury be properly assessed and diagnosed so that you receive appropriate medical treatment.

    Did Not See a Doctor

    If you were injured at work but did not see a doctor right away or refused medical help at the time of the accident, your employer and its insurer can use this as a reason to deny benefits.

    Note that you may have to go to an employer-approved doctor after a workplace accident.

    Not an Employee

    According to Pennsylvania law, independent contractors are not eligible for Workers’ Compensation coverage. Employers do not have to purchase coverage for them. Some employers misclassify employees as contractors to avoid paying for coverage.

    No Incident Reportdenied workers' compensation claims

    Be aware that you should insist on an official, written incident report at the time of the injury or soon after if you are gravely injured. Review the report before signing and get a copy for your files. While your claim cannot be denied because there was no incident report, an employer could fabricate circumstances if there is no formal documentation.

    Impaired on the Job

    Insurance companies may claim that you were under the influence of alcohol or drugs at the time of injury. Even if the worker had one beer at lunch or took a mild prescription medication before work, they could use this excuse.

    Illegal Activity

    An employer may claim you were involved in illegal activity, such as using illicit drugs, on work time. They can use this as a scare tactic to get you to back down from your claim.

    Not Eligible

    Some employees are not eligible for state Workers’ Compensation benefits, including federal workers, railroad workers, longshoremen, and sole proprietors.

    Missing or Incorrect Information

    Some claims are denied because the information provided is incorrect or some information is missing. Always check to make sure that the information that you provide to your employer and their insurance carrier is accurate.

    Suspected Fraud

    If the employer’s investigation reveals information counter to that provided by the employee in their report, the claim may be denied. An employer may also have contradicting video surveillance, statements from co-workers, or witness accounts.

    Can I Challenge a Denied Workers’ Compensation Claim?

    If you have a legitimate work-related injury, you should challenge the denial. Your first step should be enlisting the help of a Philadelphia Workers’ Compensation lawyer. The process for investigating and filing a claim can be time-consuming, complex, and requires strict adherence to deadlines. Let an experienced lawyer handle that for you.

    Under Pennsylvania law, if your Workers’ Compensation claim is denied, you have up to three years to file a Claim Petition. The following are essential steps to help you with this process:

    • Contact a lawyer. Most lawyers offer a free initial consultation during which they will review the facts with you and evaluate your claim and denial letter.
    • File a Claim Petition. When a Workers’ Compensation claim is denied, the employer’s role is generally over. They will not likely revisit their decision to deny your claim. It’s imperative that you speak to an experienced workers’ compensation attorney so that they can timely investigate the claim, and if necessary, file the appropriate paperwork to have your case heard by a Workers’ Compensation Judge. As mentioned above you have three years from the date of injury to file a Claim Petition.
    • Request a hearing. Once the Claim Petition is filed your case will be assigned to a Worker’s Compensation Judge. The judge will schedule a hearing or hearings and take evidence about your injury.
    • Prepare for the hearing. Your lawyer will collect all vital evidence and records substantiating your injury and lost wages. They may interview co-workers and other witnesses. You may be asked to keep a journal of your health, including dates and outcomes of doctor visits, therapies, and additional pertinent information.
    • Attend the hearing. In most cases, after the parties have had time to present and exchange some evidence, the judge will refer the case to another Workers’ Compensation judge for mediation, in an attempt to settle the case. Mediation can be an effective way to settle cases, however, not all cases settled at mediation. If your case does not settle, the judge, after carefully reviewing all of the evidence will write a decision.

    If the ruling is not in your favor, you can appeal within 20 days to the Workers’ Compensation Appeal Board. The Appeal Board may reverse the judge’s decision if there was an error of law or if there was not substantial evidence to support the judge’s decision. Your lawyer will counsel you on whether it is worth it to appeal the judge’s ruling.

    If you proceed and the Board rules against you, you have 30 days to file an appeal with the Commonwealth Court. The Court will likewise examine the facts and arguments and determine whether there as an error of law or whether there was substantial evidence to support the decision. They will then issue a written decision.

    The appeals process generally does not go past the Commonwealth Court. If that court denies your case and you are determined to proceed, you have 30 days to appeal to the Pennsylvania Supreme Court, which has the final say. There are no more appeals after their ruling.

    The longer the appeals process goes on, the higher the chance your employer and its insurer will be willing to negotiate a settlement rather than spend time and money defending appeals.

    Regardless of the outcome of your claim, stay vigilant at work for any mistreatment, discrimination, harassment, or other activity that appears to be retaliation for your claim. Some employers may try to fire, demote, create a hostile environment, or treat a Workers’ Compensation claimant worse than other employees. This is illegal, and you should contact a lawyer immediately.

    Philadelphia Workers’ Compensation Lawyers at Galfand Berger LLP Advocate for Injured Workers Whose Claims Have Been Wrongfully Denied

    If you have been injured at work and your claim was denied, one of our Philadelphia Workers’ Compensation lawyers at Galfand Berger LLP is ready to assist. Our dedicated legal team will protect your rights and ensure that you receive the assistance you deserve for your work injuries. Call us at 800-222-USWA (8792) or contact us online to schedule a free consultation. From our offices in Philadelphia, Bethlehem, Lancaster, and Reading, Pennsylvania, we serve clients throughout Pennsylvania and New Jersey, including Allentown and Harrisburg.