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What Should I Do if Insurance Denies My Injury Claim at Work?

Posted on June 17, 2022

There are times when legitimate workers’ compensation claims are denied. While this can be extremely frustrating, fortunately, you still have options. Speak to a Philadelphia work injury attorney as soon as possible, and they can help you navigate the process for obtaining the benefits you deserve. 

What Are Common Reasons An Insurance Claim Can Get Denied?

Some of the most common reasons why an insurance company will deny a claim for a work injury in Pennsylvania include: 

Failure to Report Injury by Deadline

In Pennsylvania, workers must report an injury to their employer within 21 days to receive benefits from the date of the injury. If notice is given past 120 days, they can lose their right to seek workers’ compensation benefits. 

Injury Is Not Severe

The insurer may view your medical records and see no evidence of an injury that would cause you to miss work. 

Intoxicated on the Job

If your injury occurred while you were under the influence of alcohol or drugs, insurers will often deny a workers’ comp claim. 

Injury is Non-Work Related

If you weren’t at work or acting on behalf of your employer when you suffered an injury, you will not be eligible for benefits. 

Failed to See Doctor

There must be proof of medical treatment before your claim is approved. 

How Do I Appeal a Workers’ Compensation Denial?

Here are the steps to take if your workers’ compensation claim is denied. 

  1. Speak to a Philadelphia Work Injury Attorney. A work injury lawyer will understand the workers’ compensation appeals process and complex laws related to your claim. They can guide you and help ensure you receive the benefits you are entitled to.                    
  2. File a Formal Claim. It is up to you or your attorney to pursue an appeal. The first step in appealing a workers’ compensation denial is to file a claim petition with the Workers’ Compensation Bureau within three years. 
  3. Request a Hearing. When you file an appeal, you will request a hearing to appear before a workers’ compensation judge. The judge, chosen by the Workers’ Compensation Bureau, will notify you, your lawyer, your employer, and their insurer of the hearing date. 
  4. The Hearing. All relevant parties will be present at the hearing. The judge may attempt to settle the matter through mediation. However, if it fails, the judge will hear evidence and then issue a ruling. 
  5. Appeal the Judge’s Ruling. If you disagree with the judge’s decision, you have 20 days to file an appeal with the Workers’ Compensation Appeal Board using form LICB – 25/26. Oftentimes, a judge’s decision is not overturned, but the Appeals Board will order the judge to rehear a claim in some cases. On the other hand, if the Appeal Board upholds the judge’s ruling, you have 30 days to file a claim with the Commonwealth Court. Appeals typically do not go past the Commonwealth Court, but if your appeal is denied, you can file an appeal to the Pennsylvania Supreme Court within 30 days. Each lawyer will then submit a brief, and the parties may have to make their arguments in front of the court. After which, the Supreme Court will issue a final ruling. 

If you believe your workers’ compensation claim was wrongfully denied, contact Rosenbaum & Associates. We offer free consultations; call (215) 569-0200 or contact us online today.