Denied Workers’ Compensation Claims in Pennsylvania

A workers’ compensation denial can leave you with medical bills, missing paychecks and questions about what happens next. An employer or insurance company’s denial does not necessarily end your claim. In Pennsylvania, you may challenge a disputed work injury by filing a Claim Petition and presenting your case to a workers’ compensation judge.

The first step is to identify exactly what was denied and which notice you received. A denial from an insurer, an order from a judge and a notice that existing payments are stopping can require different responses. Keep every page of the paperwork and get advice promptly rather than assuming the same deadline applies to all three.

Larry Pitt & Associates helps injured workers evaluate denials and pursue disputed benefits. Learn more about our workers’ compensation representation.

Read the reason on your denial notice

A Notice of Workers’ Compensation Denial, commonly identified as form LIBC-496, records the employer or insurer’s position. Read both sides, including the stated reason and any explanation. Check the injury date, body parts, employer and claim number against your records.

Disputes may concern whether:

• Your injury or illness is related to your work.
• You were acting within the scope of your employment.
• You were employed by the company named in the claim.
• Your employer received timely notice of the injury.
• Another stated reason supports the denial.

A disagreement about one of these issues needs to be evaluated against the facts and medical evidence. For example, having a pre-existing condition does not automatically rule out a claim. Pennsylvania recognizes work-related aggravation of an existing condition, as well as some injuries that develop through repetitive work. An injury also does not always have to occur on the employer’s premises to be covered.

A Claim Petition is different from an appeal of a judge’s decision

When an employer or insurer denies a claim, an injured worker may file a Claim Petition with the Pennsylvania Workers’ Compensation Office of Adjudication. The petition asks a judge to decide whether the worker is entitled to benefits. It should identify the injury and provide relevant wage and lost-income information. Pennsylvania’s WCAIS system provides an electronic filing route.

The parties then have an opportunity to present evidence. This can include testimony about the work and injury, relevant witnesses, and medical evidence. The particular evidence needed depends on the issues in dispute. Filing a petition does not guarantee that benefits will be awarded.

If a workers’ compensation judge has already issued a decision, the next step may instead be an appeal to the Workers’ Compensation Appeal Board. That is a separate proceeding with a much shorter deadline. Bring the actual decision and all notices to your attorney, not just a summary of a phone call with the adjuster.

Know which deadline applies

After an insurer’s denial: a Claim Petition generally must be filed within three years of the injury date. That does not mean three years from the date of the denial letter. Exceptions and other rules may affect an individual case, so do not wait to have the dates checked.

After a judge’s decision: an appeal to the Workers’ Compensation Appeal Board generally must be filed within 20 calendar days of the decision’s circulation date. Calendar days are not business days. Ask an attorney to review the decision immediately.

Notice to your employer: the injury-reporting rules are separate from petition and appeal deadlines. Notice is generally required within 120 days, and reporting after 21 days can affect when compensation begins unless the employer already knows of the injury. Different timing rules can apply when the relationship between a condition and work is not immediately known.

Do not assume that talking with an adjuster, sending another medical record or requesting a consultation preserves a filing deadline.

Gather the records that explain the dispute

You do not need a perfectly organized file before asking for help. Start with what you have:

• The denial notice, all other claim notices and any judge’s decision, including every page.
• Your written injury report, related emails or messages, and the date and person you told.
• A short timeline of the work activity, symptoms, medical visits and missed work.
• The names and contact information of people who saw the incident or knew about the report.
• Medical records, work restrictions, prescriptions and unpaid bills you have received.
• Pay stubs, work schedules and records of missed hours or reduced earnings.
• Any temporary-payment records, return-to-work offers or requests to attend a medical examination.

Keep original documents and give accurate information about prior injuries or symptoms. Do not guess at dates or leave out a prior condition because you are worried it could affect the claim. Tell your attorney what is missing so the relevant records can be identified.

What if payments started and then stopped

Temporary compensation may be paid while an insurer investigates without finally accepting the claim. A later notice stopping those payments needs prompt review. Changes to benefits in an accepted claim can involve different procedures and deadlines. The notice, prior agreements and payment history help determine which response is appropriate.

Save the notice and the envelope or electronic delivery record, and record when you received it. If treatment bills are also unpaid, bring those separately so the medical-payment issue can be reviewed along with any lost-wage dispute.