Workers’ Comp is there to cover your injuries, but when your employer or the insurance company they work with denies your claim, it can feel like no one is there for you. Our attorneys work to help injured workers get denials overturned and avoid denials in the first place.
Employers and insurance carriers have plenty of technicalities they can point to to throw out even strong Workers’ Comp claims, and sometimes they go beyond good-faith excuses. If your initial claim was denied, we can file a Claim Petition to get your case before a Workers’ Comp Judge.
For a free case evaluation, call our Certified Pennsylvania Workers’ Compensation Lawyers at Cardamone Law today at (267) 651-7945.
What to Do if Your Workers’ Comp Claim was Denied
It can be hard to know what to do next, but start with these steps:
Do Not Panic
Medical bills can be incredibly high, and if you cannot work right now, you may be looking at your expenses and beginning to lose your cool. A denial is not the end of your case, and it does not mean that everything is over or lost.
Do Not Pay
You may have already gotten medical bills for the care you received, but this care is supposed to be covered under your employer’s Workers’ Comp coverage. Do not start paying everything out of pocket or using your own health insurance to cover these bills.
Simply save all of the bills you get and bring them to us.
Call Our Lawyers
Once you have all of your ducks in a row, call our attorneys. We can help you collect missing information, but more importantly, we can negotiate with insurance and file the formal claims needed.
File a Claim Petition
Your initial claim goes through your employer and their insurance carrier. When they deny your case, we can take it to a formal claim through the Workers’ Comp Office of Adjudication.
We file a Claim Petition within 3 years of the initial accident, and it gets assigned to a Workers’ Comp Judge (WCJ). The WCJ will then hear the case according to the steps and stages discussed below.
The Process After a Workers’ Comp Claim is Denied in Pennsylvania
Filing a Claim Petition
Our lawyers must file your Claim Petition within 3 years of injury, or the claim is forever barred. We also have to properly serve copies of the Petition on the employer.
Employer’s Answer
Your employer’s Answer must be filed within 20 days, or else we can file a Yellow Freight Motion to get the WCJ to accept all of our assertions in the Claim Petition as true.
Assignment Notice Arrives
This notice tells the parties who the judge in the case will be. The Judge in a Workers’ Comp Case is a Workers’ Comp Judge, not a normal Court of Common Pleas Judge that hears lawsuits. These are specialized judges who work under the Department of Labor and Industry to hear Work Comp cases and decide them, typically after years of experience working as Workers’ Comp lawyers themselves.
Hearing Notice Arrives
This notice notifies the parties when the first hearing is. The injured worker may or may not need to attend, depending on the judge. Many initial hearings are just “pre-trials” for the attorneys.
Talk with your attorney about what is needed from you. In some hearings, you may need to attend and explain what happened to the judge in person. If your testimony will be needed, we can prepare you for the hearing ahead of time.
Litigation Takes Place
The parties have 180 days in most cases to secure evidence – 90 days for each party – and there may be one to three more hearings depending on the case and judge. Parties will likely attend mediation – either mandatory or voluntary – where we try to settle the case.
Briefing Period
If the case doesn’t settle, the lawyers write their briefs/written arguments to the WCJ, outlining the applicable law, facts, and why they didn’t meet the burdens of proof. Judges will often grant the lawyers between 30 and 60 days from the close of the record to submit their briefs.
A Decision is Rendered
This usually occurs about 45 days or so after the last brief is submitted. This is handed down as a written decision. Note that it can take longer than this, and 45 days is just an average.
Appeals
Any party can appeal to the Appeal Board within 20 days. If that appeal fails, then another appeal can be taken to the Commonwealth Court or the Pennsylvania Supreme Court if a party doesn’t agree with the Commonwealth Court.
Not every appeal will be heard by the Pennsylvania Supreme Court. They typically only hear appeals when there is something about the way the case was decided that compels them to clarify laws or rules.
Understanding Reasons for Workers’ Comp Denials in Pennsylvania
Workers’ Comp claims are denied for various reasons. Understanding the excuses and processes behind the denial will help us understand what needs to be done to overcome the denial legally, but it will also help us understand the thought process behind the insurance carrier’s denial and ways we might be able to simply get them to change their minds.
Injury Not “Work-Related”
If the insurance carrier says that the injury was not work-related, then the way to get them to change their mind is usually by providing more evidence. In many cases, insurance carriers say an injury is not work-related because they simply do not have enough proof.
Injury Not “Disabling”
Sometimes, the insurance carrier accepts that they have to pay your medical bills, but they do not think that you are “disabled enough” going forward that they should pay you ongoing wage-loss benefits. In these cases, it is often harder to supply evidence of your disability without medical examinations.
Disability Deemed “Partial”
Insurance carriers might not want to cover you for the full value of your lost work. If they believe you can still work, you would receive 2/3 of the difference in pre- and post-injury average weekly wages (AWW) instead of 2/3 of the full pre-injury wage.
If you receive a Notice of Ability to Return to Work, but you cannot actually do it, it could hurt your case or stop your benefits.
Exaggerating Your Condition
Never do this. Many injured workers are quite anxious to explain how serious everything they have been through is to the Judge or a doctor, but exaggerating can really harm your case.
Failing to Communicate with Your Attorney
Communication is really important as there are many potholes in these cases that can be avoided with good communication.
Failing to Follow Through with Care
Do not ignore the recommendations from your doctor. Do not skip appointments, and be diligent in following through on what your doctor recommends.
Failing to Give an Accurate History to Your Doctor
It is important to give your doctor accurate information concerning prior injuries or accidents. Do your best to really think back about pre-work injury accidents or injuries because they will be relevant to all kinds of decisions and assessments your doctor and your employer’s doctor are going to make about your case and your benefits.
Failing to Follow Your Employer’s Procedures
You have to stick to your employer’s procedures and Workers’ Comp procedures for
- Reporting your injury on time (typically within 21 days)
- Calling out of work
- Following up on good-faith job offers
- Seeking employment after you get a Notice of Ability to Return to Work
- Obeying your doctor’s instructions for limitations or light-duty restrictions.
What Our Lawyers Do After a Workers’ Comp Denial
At this point, it might be hard to see what your case looks like and what our Philadelphia Workers’ Compensation Lawyers will do for you.
Obtaining Evidence and Documents
For one, we will file the necessary documents and fight to get your claim granted by taking it through all of the stages discussed below.
In the immediate next few days or weeks, we will also seek out as much evidence as we can collect to help build the case: your medical records, any documents you have, etc. We may even contact the insurance carrier to let them know we are serious about getting you your benefits and that we are preparing a Claim Petition.
Filing a Claim Petition
Sometimes filing a Petition gets a settlement handled early, but often we need to go through the whole Claim Petition process. This is a complex process, and you should never try to file without a lawyer.
Negotiating Settlements
If we are able to convince your employer to pay your benefits, we can work to draw up settlement paperwork and end the case sooner. However, you should always review settlement structures and any questions you have with us.
The WCJ will want to make sure you have already done all of this and that you understand your settlement before the WCJ can sign off on it.
FAQs for What to Do After a Workers’ Comp Denial in Pennsylvania
Can I Talk About My Case?
Generally avoid talking about your case to others or venting on social media about your denial. Providing inconsistent information can hurt your case if coworkers are called to testify or if your inconsistent social media statements are presented as evidence against you.
Your employer can also still fire you for unrelated causes, such as badmouthing them on social media, but they cannot fire you as retaliation for filing the claim.
Can I Appeal My Employer’s Denial of Workers’ Comp Benefits?
“Appeals” actually happen far later in a Workers’ Comp claim. Your employer’s or their insurance carrier’s initial denial is not a full and final denial, and it is really only the start of your claim. Your case will progress by filing a Claim Petition with a Workers’ Comp Judge, and only once they deny your case do we need to consider actually “appealing” the claim.
If your case does get to that stage without being accepted, we can indeed appeal the decisions.
What is a Supersedeas Denial?
Supersedeas is a petition your employer files to try to get your wage-loss checks stopped immediately. Having Supersedeas denied is actually a good thing for your case and means you can keep getting your wage-loss checks.
If Supersedeas is granted, your checks will stop. In either case, you need an experienced Pennsylvania Workers’ Comp lawyer to assist you and to maximize your settlement.
What is a Yellow Freight Motion?
A Yellow Freight Motion alleges that the employer’s lawyers did not file their Answer to your Claim Petition on time. This essentially asks the WCJ to accept that everything we said in our Claim Petition is true, since they didn’t bother to refute any of it on time.
The Answer to a Claim Petition is due within 20 days from the assignment to a Workers’ Compensation Judge. If the Judge finds there is no good cause for the late Answer, our facts are assumed to be true.
Can I Settle a Denied Claim?
Within 21 days of when you initially gave your employer notice of your injury, they should return to you with four possible outcomes:
- They can accept the claim.
- They can deny the claim.
- They can offer a settlement.
- They can temporarily accept the claim and continue investigating for 90 days.
If they deny the claim at that time, that doesn’t mean a settlement is off the table forever. After we file a Claim Petition, many cases can be settled, getting you all the benefits you need.
Can You Get Penalties for Unreasonable Denials?
All denials must be based on good, reasonable grounds, or else the employer can face penalties. We can request penalties with a Penalty Petition.
One possible penalty is making the employer pay your legal fees.
What if My Employer Never Responded to My Claim?
Employers get 21 days from the date you submitted your notice of injury to decide the case. This gives them time to talk to their insurance carrier, investigate, and make a decision.
If they ignore your claim and do not get back to you within 21 days at all, we can treat that as a denial. When we file your Claim Petition, we may also be able to file a Penalty Petition, as giving no reason for the denial counts the same as failing to give a good reason.
Call Our Pennsylvania Workers’ Compensation Lawyers for Denials Today
Call Cardamone Law at (267) 651-7945 for a free case review with our Pennsylvania Workers’ Compensation lawyers.
