Free Case Review I Want to File an Appeal

Denied Workers’ Compensation and Appeals in Pennsylvania

t doesn’t matter if you’re the most dedicated employee in your company, never missing a day because of sickness, always reporting on time and glowing performance reports. Sometimes, even the best employees can get hurt. Regardless of the cause of the injury, Pennsylvania law entitles you to file a workers’ compensation claim if you get injured on the job. 

But what happens if your request for benefits is denied — by your employer or the insurance carrier? Let’s discuss the specifics of a denied claim and how to appeal a workers’ comp denial.

What Is a Workers’ Comp Claim Denial?

When you’re hurt on the job, you can submit a workers’ compensation claim. These are benefits covered by your employer’s workers’ comp insurance that provide assistance for financial losses such as medical expenses or lost wages. Once you complete the required paperwork, your employer will contact their insurance and officially file the claim. Then, an insurance adjuster reviews the evidence.

Not all workers’ compensation claims are approved. A denial occurs when your employer or the insurance adjuster rejects the claim for a job-related injury or illness, leaving you to recoup those financial losses on your own. 

If your claim for workers’ compensation is denied, contact an attorney specializing in Pennsylvania workers’ comp, like the team at Frommer D’Amico. We can walk you through each step so you know how to appeal the workers’ comp denial.

Reasons Workers’ Comp Claims Get Denied

The first thing you need to do is to determine why your workers’ compensation claim was denied. In Pennsylvania, you should receive a Notice of Workers’ Compensation Denial. This information will help your attorney advocate for your rights during the appeals process.

Some of the reasons that your claim may be denied include the following.

1. You Did Not Report Your Injury Promptly

Pennsylvania state law says you need to report your injury to your employer within 120 days of suffering that injury while on the job or when you first realize you were injured.

If you wait longer than 120 days to report your injury, you will not receive compensation. The moment you get injured or believe you have suffered a work-related injury, report it immediately.

2. Your Employer Disputes the Reason for Your Injury

Your employer may deny responsibility for your injury. Your employer could say your injury was the result of carelessness on your part, some form of horseplay on the job or that the accident that resulted in your injury happened outside of the workplace or regular work hours.

Employers who want to dispute your claim will try every excuse in the book to avoid paying you the compensation benefits to which you are legally entitled.

3. Your Employer Disputes the Severity of Your Injury

Another reason your workers’ compensation claim may get denied is that your employer, or the employer’s insurance company, claims that your injury was not as severe as you claim it was and that there was no reason for you to miss time on the job or to see a doctor.

4. Your Employer Claims You Engaged in Illegal Activities

Employers and their insurance companies frequently try to use the excuse that you were doing something illegal to persuade the workers’ compensation administrative law judges to deny your claim. For example, your employer may suggest that you were using drugs or intoxicated while on the job. Unfortunately, this is a popular excuse for employers and insurance companies to use.

If you go to the emergency room after your injury and your medical records indicate that you had illegal drugs present in your system, you will almost certainly get denied your workers’ compensation benefits.

5. Your Injury Does Not Fall Into the Category of Injuries That Qualify for Compensation

Another reason you may face a workers’ comp denial is that your injury doesn’t fall into the category of compensated injuries.

Sometimes, it can be challenging to prove that injuries, conditions or even diseases are job-related. For instance, a stress-related injury can be hard to prove. Your employer’s insurance company may also cite a preexisting condition or issue as the result of your injury to avoid liability.

6. You Did Not Receive Any Medical Treatment for Your Injury

You should see a doctor as soon as possible after sustaining your injury. Mention to your healthcare provider that this injury is job-related so the documentation for the workers’ comp appeal process can begin. You may need to select from an employer-approved list of doctors within 90 days after you receive your injury. Beyond these 90 days, you may go to your physician.

Sometimes, we don’t notice any pain until a few days after sustaining an injury. As soon as you begin to feel discomfort or pain, visit your doctor. Let your physician know about the injury you received at work and how it happened.

If you don’t receive medical attention, or if you delay the visit to your doctor, your employer’s insurance provider may fight your claim, arguing that you aren’t injured as badly as you are alleging.

7. A Lack of Evidence That the Injury Was Job-Related

It is not always clear that an accident happened at work or while doing work-related activities off the jobsite. For example, your employer may argue that your injury occurred during your lunch break.

If you don’t have any witnesses to your injury, your employer and their insurance company may also use this fact as a lack of evidence that your injury happened at work. In this case, inform your supervisor and co-workers about your injury as soon as possible and ensure you tell each person exactly the same thing about how you received your injury.

Again, if you’re injured, and it is job-related, make sure you see a doctor. It will help your claim.

Appealing a Workers’ Compensation Decision

Once your claim is denied, it’s up to you to take the necessary steps to pursue your rights. A certified workers’ compensation attorney like Frommer D’Amico can file your appeal and collect the evidence you need to present a solid case. Here’s a step-by-step breakdown of Pennsylvania’s workers’ compensation appeal process.

1. File a Claim Petition With the Workers’ Compensation Office of Adjudication (WCOA)

In Pennsylvania, disputed workers’ compensation cases are overseen by the WCOA. If denied for workers’ compensation, you have three years from the date of your injury to file a Claim Petition for Workers’ Compensation (form LIBC-362). 

The office will assign a Workers’ Compensation Judge (WCJ) who may attempt mediation. This voluntary, informal discussion may offer a favorable resolution between all parties. However, some cases proceed to the hearing stage without mediation.

2. Hearing Before the WCJ

During your hearing before the WCJ, you will present evidence to support your workers’ compensation claim. This may include medical reports, witness statements and any other relevant documentation. The judge will issue their ruling once all evidence has been submitted. If they continue to deny your claim, you can appeal this decision.

3. Appeal to the Workers’ Compensation Appeal Board​​​​

If your Claim Petition gets denied, you can appeal the judge’s decision to the Workers’ Compensation Appeal Board (WCAB) using Form LIBC-2526, Appeal from the Judge’s Finding of Fact and Conclusions of Law. You have 20 days from the letter’s postmark informing you of the judge’s decision to submit your appeal. 

Here are some more crucial things to know about this stage of the appeals process:

• Make sure you attach a copy of the judge’s denial of your worker’s compensation claim, also known as a circulation sheet.
• You need to complete the Proof of Service page on the form listed above. You must list all the names and addresses that appear on the copy of the judge’s decision you received, including the judge. You then need to mail a copy of your appeal to all these parties.
• Before you send in your appeal to the Workers’ Compensation Appeal Board or send copies to all of the appropriate parties, double-check your appeal to ensure all your data and facts are correct. That includes the type of petition — which will be on the judge’s decision letter — the date you received the judge’s decision, the claim number assigned to you by the Workers’ Compensation Board, the original date of your injuries, correct addresses and why you feel the judge was wrong in their decision.
• This last item is vital. You need to concisely summarize why you feel the judge made a mistake in denying your workers’ compensation claim. Here is where working with a workers’ comp lawyer is a good idea. An attorney can help you accurately articulate your reasons for disputing the workers’ compensation administrative law judge’s decision.

The Workers’ Compensation Appeal Board doesn’t overturn a judge’s decision very often. But if you can argue successfully that the judge overlooked a valuable piece of evidence or did not appropriately consider all the facts of the case, the Appeal Board can direct the judge to rehear the case.

4. Appealing to the Pennsylvania Commonwealth Court

If the WCAB denies your appeal, your next step is to file a workers’ compensation appeal with the Commonwealth Court. Either you or your employer has 30 days to appeal the Appeal Board’s decision to the Commonwealth Court.

The Commonwealth Court in Harrisburg is one of Pennsylvania’s two intermediate appellate courts. It is the job of the court to review your case and decide if someone has made a mistake or an error, and whether the evidence presented supported the judge’s ruling. The court will then issue a written decision.

Many workers’ compensation appeals do not go beyond the Commonwealth Court. However, there is one step left — to file an appeal with the Pennsylvania Supreme Court.

5. Appeal to the Pennsylvania Supreme Court

If the Commonwealth Court denies the appeal of your workers’ comp claim, you have 30 days to decide whether to take your case to Pennsylvania’s highest court. The Supreme Court may choose not to hear your case. If this happens, your appeals process comes to an end.

If they do, however, decide to hear your case, your lawyer and the lawyer for your employer will have one last opportunity to present your evidence. After the court issues its decision, the appeals process is over.

Denied PA Workers’ Compensation Appeal Process FAQs

Still curious about the workers’ compensation appeals process in Pennsylvania? The lawyers at Frommer D’Amico are dedicated to providing you with personalized attention to answer your concerns. In the meantime, here are some frequently asked questions.

How Long Does the Workers’ Comp Appeal Process Normally Take?

There is no set timeline for how long the workers’ comp appeal process for a workers’ compensation claim can last. Many factors can affect the timeliness of the decision, including:

• The workload of the judge or judges hearing the case or appeal
• How hard your employer fights your workers’ compensation claim
• How far you wish to take the appeals process

If your original claim gets denied and you decide to go through the appeals process, litigation may last more than a year. Fortunately, most workers’ compensation claims do not take this long to settle. One of the things that you may have in your favor is that your employer may not wish to spend a lot of money to fight your appeal, and it is easier for them to settle with you.

In any case, it’s essential to realize that fighting for your compensation benefits may take some time.

What Are My Chances of Winning a Workers’ Comp Appeal in Pennsylvania?

The further you go in the workers’ compensation appeal process, the better your chances that you will be successful. Your employer or their insurance provider may feel that continuing the appeals process is too time-consuming or costly, which can make them more inclined to negotiate a settlement.

Should I Hire a Lawyer to Help Me With My Denied Claim Appeal?

Hiring a lawyer is highly recommended. Pennsylvania’s workers’ compensation process is complex. It requires you to gather evidence that supports your claim, keep records of all your medical expenses and lost wages, perhaps get statements from witnesses who may have seen you be injured on the job, fill out a lot of forms and meet a lot of filing deadlines.

A workers’ comp lawyer’s job is to help you through this process. While you’re recovering, they are busy working for you:

• Preparing all the paperwork
• Gathering all the evidence
• Filing all the correct forms on time 
• Letting you know where and when you have to make an appearance to support your claim

Workers’ compensation lawyers have years of experience in helping people like you. And let’s face it — the lawyers for your employer’s insurance companies also have plenty of experience in using every trick in the book to deny you the compensation benefits to which the law entitles you. Working with a trusted workers’ comp lawyer is the best way you can stand up to the lawyers for the insurance company and win your initial claim or, if need be, your appeal.

Let the Experienced Lawyers at Frommer D’Amico Help You With Your Workers’ Comp Appeal

When you are looking for a trusted lawyer to help you with your workers’ compensation claim or appeal, contact Frommer D’Amico. We are a workers’ compensation firm in Pennsylvania with years of experience helping our clients recover the compensation benefits they deserve after a workplace injury.

Our firm has a group of highly experienced lawyers and paralegals who can provide the best in legal services to every one of our clients. We treat each case with the care and attention it deserves.

Contact us today for a free consultation to get the compensation owed to you. Leave us details about your case or call us at  717-400-1405. A member of our team will be in touch with you as soon as possible.