Work injuries can be common depending on which industry you work in. In the event you find yourself injured and unable to work and are expecting high medical bills or future discomfort, you should consider filing for workers’ compensation. Do not be discouraged if your claim is denied. Unfortunately, employers and insurance often fight against and deny workers’ compensation claims.
Receiving a denial for your workers’ compensation claim can be a frustrating and stressful experience, especially when you’re dealing with a work-related injury. If your claim was denied, it’s crucial to understand that you are not out of options. It is important to know when employees qualify for workers’ compensation and what your rights are if a valid claim is rejected by an employer or insurance company.
In Western Pennsylvania, many claims are initially denied for reasons ranging from missed deadlines to disputes over the injury’s connection to your job. A successful appeal begins with pinpointing the exact reason for the denial. Facing an insurance company and employer alone can be difficult. At Luxenberg Garbett Kelly & George P.C., our team of Western Pennsylvania workers’ compensation attorneys has a deep familiarity with Pennsylvania’s workers’ compensation system. We can help you challenge the denial and focus on maximizing your compensation claim to secure the full benefits you need.
Call us today to discuss your case at (724) 658-8535.
Why Was My Workers’ Compensation Denied?
Workers’ compensation claims in Western Pennsylvania are often denied due to missed deadlines, insufficient medical evidence, lack of employer notification, or disputes about whether the injury is work-related. Insurance companies may also deny claims if the injury occurred off-site or involved misconduct such as intoxication or fighting.
The Injury Was Not at Work
One of the most common reasons for denying a claim is an assertion that your injury did not occur at work. The insurance company may argue that your injury happened at home or during your commute. Do not be deterred. It is possible to appeal most of these claims and obtain the benefits you deserve.
The Injury Was Not Work-Related
A claim may also be denied if your employer believes you were injured while not performing your job duties. If an employer has reason to think an employee was engaging in roughhousing, horseplay, or was under the influence of alcohol or drugs, they may use this as grounds for a denial.
There Was No Injury
An employer or an insurance company may try to deter you by claiming you were not injured or that your injury was not serious enough to prevent you from working. This tactic questions the legitimacy of your pain and limitations. Rest assured, you can appeal this type of denial with proper medical evidence.
Failing to Report the Injury to Your Employer or File a Claim Before the Deadline
There is a strict timeline for telling your employer that you have been injured and filing a claim. In the state of Pennsylvania, you have 21 days from the injury, or you may not be able to benefit from filing a claim. This deadline is strict. This is why it is critical that you report your claim as soon as possible after an injury.
Failing to Seek Medical Treatment
If you do not seek prompt medical treatment for your injury, it may invalidate your claim. An insurance company could get the impression that your injury is not serious or that it will not keep you from performing your job. Seeking immediate medical treatment benefits your health and gives your situation more credibility.
You Went to the Wrong Doctor for Treatment
You might be more comfortable going to your own doctor if you are injured. However, in Pennsylvania, a company can require you to see a list of panel medical providers, doctors of their choosing, to evaluate and treat you for the first 90 days following an injury. If your doctor is not approved, getting medical treatment from him or her might disqualify you from receiving benefits. Make sure to check with your company’s requirements before seeking help to avoid going to the wrong doctor.
Work injuries can be serious and prohibit you from being able to work and support yourself or your family. You have the right to be compensated if you were injured. If your claim was unfairly denied, talk to a workers’ compensation attorney about your options.
Can A Claim Be Denied If I Am Classified As An Independent Contractor?
A claim can be denied if you are classified as an independent contractor in Western Pennsylvania because independent contractors are generally not covered by workers’ compensation laws. Only employees are typically eligible for such benefits under Pennsylvania law.
How Do I Appeal a Denied Workers’ Comp Claim in PA?
If your Pennsylvania workers’ compensation claim is denied, you have the right to challenge that decision through a formal appeals process. The first and most critical step is filing a Claim Petition with the Bureau of Workers’ Compensation. This must be done within three years of your injury date, as missing this deadline can permanently prevent you from receiving benefits. Once filed, your case is assigned to a Workers’ Compensation Judge, who will typically schedule a mandatory mediation session to see if a settlement can be reached.
Should mediation fail to produce an agreement, your case will advance to formal hearings. During these proceedings, you will present evidence, such as medical records and proof of lost wages, and provide testimony to support your claim. After reviewing all the evidence, the judge will issue a written decision. If this decision is not in your favor, the appeals process is not over. You have 20 days from the date on the decision letter to file an appeal with the Workers’ Compensation Appeal Board (WCAB).
The WCAB does not rehear the case or accept new evidence; instead, it reviews the existing record for legal errors or to ensure the judge’s findings were supported by the evidence. If the WCAB appeal is unsuccessful, you have 30 days from their decision to petition the Commonwealth Court of Pennsylvania. As a final resort, an appeal can be made to the Pennsylvania Supreme Court, also within a 30-day timeframe. However, the Supreme Court has discretion over which cases it hears and is not obligated to review every appeal.
Navigating this multi-layered system requires careful attention to detail and strict adherence to every deadline. Each step has its own procedural requirements, and a misstep at any stage can jeopardize your claim. To meet strict deadlines, it is essential for injured workers to act promptly and be fully prepared for each phase of the appeals process.
| Reason for Denial | Description |
|---|---|
| Injury Not at Work | Claim denied if the insurer argues the injury occurred outside the workplace, such as at home or during commuting. |
| Injury Not Work-Related | Denial if the injury happened while not performing job duties or involved misconduct like horseplay or intoxication. |
| No Actual Injury | Employer may claim the injury doesn’t exist or isn’t severe enough to impact work ability, disputing medical validity. |
| Missed Deadlines | Failing to report the injury within 21 days or to file the claim in time may result in ineligibility for benefits. |
| No Medical Treatment | Not seeking timely care may suggest the injury is minor or unrelated to work, weakening the claim. |
| Wrong Doctor | Visiting a non-approved physician during the first 90 days may lead to denial under Pennsylvania’s panel provider rule. |
Protect Your Rights with a Western Pennsylvania Workers’ Compensation Attorney
Serious work injuries can prevent you from working and supporting your family. You have the right to be compensated if you were injured on the job. A claim denial can feel overwhelming, but it is not the final word. The appeals process is detailed and has strict deadlines, and a misstep at any stage can jeopardize your claim.
At Luxenberg Garbett Kelly & George P.C., we can create a legal strategy focused on securing your compensation. Our Western Pennsylvania workers’ compensation attorneys can review your denial, explain your options in plain language, and manage every stage of your appeal so you can focus on your recovery.
Contact us today at (724) 658-8535 to schedule a consultation.
