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Why Workers’ Compensation Claims Get Denied

Every day, employees of all kinds in every field and industry are subject to injuries in the workplace. When these injuries are severe, they can make performing job duties and daily tasks difficult or impossible. Workers' compensation is in place to provide medical care and lost earnings for injured workers. Unfortunately, actually recovering workers' comp benefits can be difficult. Claims get delayed or denied, leaving workers facing uncertain futures.

In this blog, we will take a closer look at some of the workers' compensation denial reasons in Pennsylvania and what injured workers and their families can do to get the medical treatment and financial support they deserve.

Workers' Compensation in Pennsylvania: Who's Eligible?

Workers' compensation covers all on-the-job injuries on a no-fault basis. This means that an injured worker does not need to prove that someone else (the employer, co-worker, or another party) was to blame in order to recover benefits. The injury need only be work-related to qualify.

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, it is also important to consider the possibility of purchasing your own workers’ compensation insurance.

Workers' Comp Denial Reasons

Even if you're covered by workers' compensation, some employers and their insurance companies will try to do everything in their power to avoid paying benefits. They'll delay payment, offer unfairly low settlement amounts, or even deny claims outright.

The following are reasons a Pennsylvania workers' comp claim may be denied:

  • Absence of proof that the injury is work-related or that the injury has required medical treatment and resulted in missed work and lost earnings.
  • Claim time limits expired, meaning the worker did not report the injury to his or her employer in a timely manner. In Pennsylvania, work-related injuries and illnesses must be reported within 21 days of the incident or diagnosis. Waiting longer than 120 days may eliminate one's right to workers' comp benefits altogether.
  • Insufficient information provided in the claim or report to verify eligibility for workers' compensation.
  • Statutory exclusion, which 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.

Proving You're Entitled to Benefits

Even if your workers' compensation claim was denied, you have the right to appeal this. The U.S. Department of Labor defines “proof” with five essential components for a valid workers’ compensation claim. Reviewing these can help you understand whether you're eligible. You can also talk to an attorney to discuss your rights and options in appealing a denied claim for any reason.

The five 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 a maximum of 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.

How Workers' Comp Claims Are Denied

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 reason 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 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. Our team at Handler, Henning & Rosenberg LLC is happy to help.

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