What to Do if Your Workers’ Comp Case is Denied in Pennsylvania

When you file a Workers’ Comp claim with your employer, they are usually the ones making the initial decision. Convincing them – or, more likely, their insurance carrier – to pay your claim outright will be difficult. Many claims are denied initially, but there are steps to take afterward.

Once your case is denied, our lawyers can get involved. We will file a Claim Petition in court, then fight before a Workers’ Compensation Judge to appeal the claim. We can also settle during this process, potentially getting your benefits paid in a lump sum.

For a free evaluation of your case, call Cardamone Law’s Certified Pennsylvania Workers’ Compensation Lawyers at (267) 651-7945.

Can I Sue if Workers’ Comp Denies My Claim?

When you file through Workers’ Comp, your employer is the one who decides your initial claim. If they deny you, you can take your case to a Workers’ Comp Judge and file your case there. This whole system is separate from any lawsuits you can file in open court, and you can appeal further denials.

You usually cannot sue your employer for injuries at work, but you can still sue third parties. Technically, you do not need to wait for a denial, either; these lawsuits are separate from Workers’ Comp claims.

Cases can be complicated if you get paid through both a lawsuit and Workers’ Comp. The insurance company might claw back damages they already paid you if you got paid twice. Otherwise, lawsuits are analyzed separately.

How Do I Know if My Claim Was Denied?

Your employer has to mail you a notice saying whether they accept or deny the claim by filing one of these:

• Notice of Compensation Payable
• Notice of Workers’ Compensation Denial.

If they do not contact you within 20 days from your initial notice of injury (including a few days for mail delays), they may have forgotten about or ignored your claim, and you should get a lawyer involved immediately.

The Process After a Workers’ Comp Claim is Denied in Pennsylvania

Do not be afraid that your case is over just because your employer denied your Work Comp claim. This is incredibly common and is just the beginning of the court battle.

Filing Claim Petition

After a denial, your petition must be filed within 3 years of injury or the claim is forever barred. Your employer gets 20 days to respond, either by filing an answer or a Yellow Freight Motion. If they do not, they can be penalized.

Claim Petitions are not filed in open court like a lawsuit. Instead, our Philadelphia Workers’ Comp lawyers file them into a separate system for Workers’ Comp claims. This means you are not competing for court time against other types of cases; Workers’ Comp cases are handled through a system just for Workers’ Comp.

Assignment Notice

This notice tells the parties who the judge will be. Workers’ Compensation Judges (WCJs) are special judges that only hear Workers’ Comp cases.

Hearing Notice

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 essentially pre-trial hearings for the attorneys to present information and arguments to the judge.

If the judge holds a full hearing later, you may have to attend that and testify. However, by the time we get to that hearing, we will likely have a lot of evidence and records collected and depositions taken so the judge can review those instead of needing in-court testimony.

Litigation

The parties have 180 days in most cases to secure evidence – 90 days for each party – and there may be 1 to 3 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

If the case doesn’t settle, the lawyers write their briefs/written arguments to the judge, outlining the applicable law, facts, and why or why they didn’t meet the burdens of proof. The judges will often grant the lawyers between 30 and 60 days from the close of the record to submit their briefs.

Judge’s Decision

This usually occurs about 45 days or so after the last brief is submitted, a written decision will arrive. Note that it can take longer; 45 days is just an average.

Can You Appeal Denials After a Workers’ Comp Hearing?

The WCJ’s decision is legally binding, but it is not the final say. WCJ decisions can be appealed to the Workers’ Comp Appeal Board (WCAB).

This is a board under the Department of Labor and Industry that hears appeals and reviews the judge’s determinations. There are multiple types of petitions you can file before the WCAB, but the goal is usually to overturn the WCJ’s decision.

Appeal petitions need to be filed within 20 days of the WCJ’s final decision and order.

If the WCAB still rules against you, we can appeal further. Often, this occurs when the WCJ and the WCAB got the law wrong, and it needs to go before a court to potentially make a broader ruling about how Workers’ Comp laws should be applied.

These further appeals first go to the Commonwealth Court, a statewide court that hears regulatory and Workers’ Comp appeals. From there, you can appeal again to the Pennsylvania Supreme Court, but they do not have to accept the appeal and can leave the lower court ruling in place.

Common Reasons for Workers’ Comp Denials

Your employer will deny your initial case for any reason they can point to, but it should usually be a legal reason. Employers sometimes deny motions for unreasonable causes or discriminatory causes, which can get them in trouble later when the case goes before a judge. This can even result in penalties, potentially ordering them to cover your attorney’s fees.

However, legal, rational denials are often based on one of these claims about your case:

Injury Not Work-Related

If your injury happened outside of work or while you were performing non-work-related tasks, your employer doesn’t have to cover it. However, employers often expand this rule too far and try to claim accidents or mistakes were against company policy and thus outside the scope of your work.

This is often legally incorrect and can be overturned.

Injury Not Disabling

If your injury does not disable you or keep you from working, then your employer will argue you can go back to work and should not get wage-loss benefits. This is where they might file a Yellow Freight Motion and argue over the facts of your disability.

Notice Not Given

An employer cannot grant a claim if they do not have it. You should always keep track of and get some sort of confirmation or receipt when you give notice of your injury so that your employer cannot turn around and say they never received it.

Employment Status

Employers only cover employee injuries. If they claim you are an independent contractor, they might deny your claim on that basis. We can fight misclassification and try to get your case covered under Workers’ Comp.

What is a Yellow Freight Motion?

A Yellow Freight motion is a procedural request filed by an employer or their insurance provider in a Pennsylvania Workers’ Compensation case. It is used to require an injured worker to appear for an Independent Medical Examination (IME), as permitted under § 314 of the Pennsylvania Workers’ Compensation Act.

This motion seeks to compel the employee to go to a scheduled IME by having the Workers’ Comp Judge order them to appear. This request can also temporarily pause wage-loss benefits if they fail to appear.

In order for the motion to succeed, the employer has to show the medical exam is crucial in determining their disability status, especially when parties disagree on the extent of disability or treatment plan.

Sometimes we can fight the motion, but more often, you will have to attend the exam to keep your benefits. However, we can seek out exams from other doctors to counter any negative evidence if the doctor’s exam was wrong.

Contact Our Workers’ Comp Lawyers for Help Today

If your claim was denied, get our Northeast Philadelphia Workers’ Comp lawyers on your side. Call Cardamone Law at (267) 651-7945 right away.