Why Workers’ Compensation Claims Get Denied

Everyday employees are subject to injuries in the work place, and this can lead to complications in their lives because performing their duties becomes difficult or impossible. Getting workers’ compensation relief is a difficult endeavor—nevertheless, it is important to know that all Pennsylvania employees are entitled to workers’ compensation, unless they fall into one or more of the following categories:

  • Federal Workers
  • Longshoremen
  • Railroad Workers
  • Sole Proprietors
  • Domestic Based Workers
  • Volunteers
  • Agriculture Laborers
  • Casual Laborers

However, these employees might be subject to other forms of benefits such as the Federal Employees Compensation Act (FECA). If you are a domestic worker than it is also important to consider the possibility of purchasing your own workers’ compensation insurance.

Grounds for Denial of Workers’ Comp

Regardless of your employment situation many insurance companies will also pick any number of reasons when denying your right to workers’ compensation.

Workers’ compensation (WC) may be denied for several reasons, including but not limited to:

  • Absence of proof
  • Claim time limits
  • Insufficient information
  • Statutory exclusion

Statutory exclusion is defined as purposefully causing injury to oneself, purposefully causing injury to another, not performing duties as outlined in the employer’s safety guidelines, and/or intoxication. The U.S. Department of Labor defines “proof” with 5 essential components for a valid workers’ compensation claim.

The 5 components of workers’ compensation eligibility are:

  • The claim was filed within the first 120 days
  • The injury or fatality occurred to an employee as defined in §8101 of FECA
  • There is an official medical diagnosis showing an injury occurred
  • Medical proof correlates to the reported injury
  • There is proof that the employee was doing his job duties during the time of injury or death

Regarding the timeline above, an employee has 120 days to inform his employer of the injury that occurred while on the job and the employer is obligated to reply in the first 21 days of notification. It is important to note that in Pennsylvania under Chapter 121 §121.13 General Provisions, an employer can decide to file a Notice of Workers’ Compensation Denial Form (LIBC-496). This form disputes an employee’s claim for worker’s compensation for any of the reasons listed above, or an unspecified reasoning that can be written in.

Fighting a workers’ compensation denial, even on the above grounds, is not impossible. Our Pennsylvania workers’ compensation attorneys have successfully appealed hundreds of workers’ compensation denials, helping obtain tens of millions in relief for our clients. For advice and help with your case, call (888) 498-3023 for a free consultation. Handler, Henning & Rosenberg is happy to help.

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