A denied workers’ compensation claim can leave you wondering how you are supposed to pay your bills, get treatment, and move forward while you are unable to work.
The insurance company’s denial does not necessarily end your claim. Pennsylvania workers can challenge denied claims, and the reason listed on your denial notice can help determine what needs to happen next.
ARM Lawyers represents injured workers in Pennsylvania workers’ compensation cases, including claims that have already been denied.
Already received a Notice of Workers’ Compensation Denial? Keep it handy. The reason given for the denial is an important place to start.
My Workers’ Comp Claim Was Denied. What Should I Do?
Start by keeping everything you received from your employer, the insurance company, and your medical providers. A denial is important, but it is not the same thing as a judge deciding that you are not entitled to benefits.
- Save the denial notice and any letters from the insurance carrier.
- Continue following your doctor’s treatment instructions.
- Keep records showing when and how you reported the injury.
- Save medical records, work restrictions, wage information, and correspondence with the adjuster.
- Find out exactly why the claim was denied.
- Speak with a Pennsylvania workers’ compensation attorney before assuming the claim is over.
The reason for the denial matters. A claim denied because the carrier disputes whether the injury happened at work can require a different response than a claim denied because of a notice issue or a dispute over medical evidence.
What Does a Workers’ Comp Denial Mean in Pennsylvania?
When an employer or workers’ compensation insurance carrier refuses to accept a claim, the injured worker may receive a document called a Notice of Workers’ Compensation Denial, also known as LIBC-496.
The notice should tell you why the claim is being denied.
That reason is important, but it represents the employer or insurance carrier’s position. It does not necessarily represent the final legal outcome of your case.
Pennsylvania has a process for injured workers to challenge denied claims. In many cases, that process involves filing a Claim Petition and presenting evidence before a Workers’ Compensation Judge.
Why Was My Workers’ Comp Claim Denied?
There is no single reason workers’ compensation claims get denied. Sometimes the dispute is about how the injury happened. In other cases, the insurance company questions the medical evidence, the timing of the report, or whether the condition is actually related to the worker’s job.
The Insurance Company Says the Injury Wasn’t Work-Related
The carrier may argue that your condition was not caused by your job or that something outside of work caused your symptoms.
Medical records, the history you gave your doctors, witnesses, and other evidence surrounding the injury can become important when this is disputed.
Your Employer Says the Accident Didn’t Happen at Work
Sometimes the dispute is about the accident itself. The employer may question where it happened, what you were doing at the time, or whether you were performing work-related duties.
The details surrounding the incident and any witnesses or workplace records may become important.
They Say You Reported the Injury Too Late
Pennsylvania has notice requirements for workplace injuries. Disputes can arise over when the employer learned about the injury, who was told, and exactly what was reported.
A denial based on notice should be examined carefully rather than assumed to be correct.
The Insurance Company Disputes Your Medical Evidence
The carrier may question your diagnosis, whether your condition prevents you from working, or whether your current symptoms are connected to the workplace injury.
These disputes can become heavily dependent on medical evidence.
You Had a Pre-Existing Condition
Having an old injury or medical condition does not automatically prevent a workers’ compensation claim.
The real issue may be whether your job caused a new injury or aggravated an existing condition. Those cases often require a close look at your medical history before and after the workplace incident.
The Denial Lists Another Reason
Workers’ compensation cases do not always fit neatly into one category.
The best starting point is often the denial notice itself. Once you know what the insurance company is disputing, you can determine what evidence may be needed to challenge it.
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Can I Appeal a Denied Workers’ Comp Claim in Pennsylvania?
People often describe this as appealing a workers’ comp denial. For a newly denied Pennsylvania claim, the process generally begins by filing a Claim Petition with the Workers’ Compensation Office of Adjudication.
The case can then be assigned to a Workers’ Compensation Judge.
The injured worker may need to establish facts such as:
- how and when the injury happened;
- how the injury is connected to the job;
- when the employer was notified;
- what medical condition resulted from the injury;
- whether the injury caused lost wages or work restrictions; and
- what benefits should be paid.
The insurance carrier can contest the petition and present its own evidence. Once that happens, the claim is no longer simply a disagreement with an adjuster. It is a workers’ compensation case that may involve hearings, testimony, medical evidence, and legal arguments.
What Is a Pennsylvania Workers’ Comp Claim Petition?
A Claim Petition asks Pennsylvania’s workers’ compensation system to decide whether an injured employee is entitled to benefits for a disputed work injury.
A petition may address:
- the date of injury;
- how the injury occurred;
- the medical conditions involved;
- notice to the employer;
- lost wages;
- the employer and insurance carrier; and
- the benefits being requested.
Once a petition is filed, the case can proceed before a Workers’ Compensation Judge. Both sides may have the opportunity to submit testimony, medical evidence, and other information relevant to the claim.
How Long Do I Have to Challenge a Workers’ Comp Denial?
Pennsylvania generally allows three years from the date of injury to file a Claim Petition involving a denied injury claim.
That does not mean waiting is a good idea.
Medical evidence can become harder to obtain. Witnesses move on. Memories fade. Records become more difficult to track down. Other deadlines and notice rules can also apply depending on what happened in the case.
If your claim has already been denied, it makes sense to find out what deadlines apply to your situation now rather than waiting until the general deadline is close.
What Evidence Can Help With a Denied Workers’ Comp Claim?
What matters most depends on why the insurance carrier denied the claim.
Medical Records
Medical records can document your diagnosis, treatment, symptoms, restrictions, and the history of how the injury happened.
Medical Opinions
Some disputed claims require medical evidence connecting the worker’s condition to the workplace injury.
Injury Reports and Employer Records
Reports showing when the injury was reported and what the employer knew can become important, particularly when notice is disputed.
Witnesses
Coworkers, supervisors, customers, or other people may have information about the accident or what happened afterward.
Wage and Employment Records
Pay information can be important when determining lost wages and the benefits being requested.
The Denial Notice
Do not throw the denial away. The reason listed on the notice can help identify exactly what the insurance company plans to dispute.
What Should I Have When I Contact a Workers’ Comp Lawyer?
If you already have these documents, having them available can make the initial review easier:
- Notice of Workers’ Compensation Denial;
- workers’ compensation claim number;
- accident or injury report;
- medical records;
- work restrictions;
- letters, emails, or texts from the insurance adjuster;
- wage information;
- correspondence from your employer; and
- any other workers’ compensation forms you received.
Do not wait to contact an attorney simply because you do not have every document yet. The important thing is to explain what happened and what you have received so far.
Frequently Asked Questions About Denied Workers’ Comp Claims
Can workers’ comp deny my claim in Pennsylvania?
Yes. An employer or workers’ compensation insurance carrier can deny a claim when it disputes whether benefits are owed. An injured worker may have the right to challenge that decision through Pennsylvania’s workers’ compensation system.
What form tells me my workers’ comp claim was denied?
Pennsylvania uses the Notice of Workers’ Compensation Denial, commonly known as LIBC-496, when an employer or insurance carrier denies a workers’ compensation claim.
Is a workers’ comp denial final?
Not necessarily. A denied claim can be contested. Depending on the circumstances, the dispute may be brought before a Pennsylvania Workers’ Compensation Judge.
How do I appeal a workers’ comp denial in Pennsylvania?
People commonly call it an appeal, but challenging an initially denied claim generally begins with filing a Claim Petition.
How long do I have after my workers’ comp claim is denied?
Pennsylvania generally allows three years from the date of injury for a Claim Petition involving a denied injury claim. Other requirements can apply, so the exact facts of the claim matter.
Can workers’ comp deny my claim because I had an old injury?
A pre-existing condition does not automatically prevent a workers’ compensation claim. The dispute may involve whether the workplace caused a new injury or aggravated an existing condition.
What if my employer says I reported the injury too late?
Pennsylvania has notice requirements, but whether adequate notice was given can depend on the facts. When the employer learned about the injury, who was notified, and what was reported may all matter.
What if the insurance company says my injury did not happen at work?
The issue may need to be addressed through medical evidence, testimony, witnesses, workplace records, and other evidence surrounding the injury.
Do I need a lawyer to file a Claim Petition?
An injured worker can file a Claim Petition without hiring an attorney. A disputed claim, however, can involve hearings, testimony, medical evidence, deadlines, and legal arguments. An attorney can handle that process and present the case on the worker’s behalf.
What happens after a Claim Petition is filed?
The petition can be assigned to a Workers’ Compensation Judge. The parties may then present testimony, medical evidence, and other evidence concerning whether benefits should be awarded.