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What Should You Do If Your Workers’ Compensation Claim Is Rejected?

Consider this scenario: you’re having another routine day on the job and everything is going well. But as you’re walking through the warehouse, you slip on a wet spot and break your wrist, leaving you unable to work for an extended period of time. You file a timely and properly documented workers’ compensation claim in an effort to replace your lost wages, only to have it rejected by your employer and its workers’ comp insurance carrier. Without any money coming in, you and your family will have to struggle to pay the bills and even put food on the table during your recovery. What can you do?

Unfortunately, this type of situation occurs more frequently than you might think. Employers and their insurance providers often go to great lengths to avoid paying workers’ compensation benefits. They may attempt to state that your injury was not work-related or even that it occurred while participating in some form of inappropriate activity.

 

You Have Important Rights If Your Claim Is Denied

In Pennsylvania, employers have 21 days from the date of your claim notice to decide whether to accept or deny your claim for WC benefits, or agree to pay temporary benefits for a period of 90 days. If your employer makes the decision to reject your claim, you have multiple important rights under PA workers’ compensation law.

If you receive a notice of rejection, you have the right to submit a “Claim Petition” with the Pennsylvania Bureau of Workers’ Compensation. An administrative law judge will then hear your case and decide whether you are entitled to receive benefits. If the judge rules against you, you have 20 days to appeal his or her decision, which can be accomplished by submitting an appeal to the Workers’ Compensation Appeals Board for review.

If you disagree with the board’s decision, you have 30 days to file an appeal through the Pennsylvania Commonwealth Court.

 

Why Was My Workers’ Com Claim Denied?

The good news is that if your workers’ compensation claim is denied, you will receive a letter stating so. It is important to read this letter fully, because it will also explain why the claim was denied. Once you have read and understand the letter, you can request an appeal.

To prevent your claim from being denied a second time, you will need to submit evidence to address whatever issues your letter outlined. For example, if you receive a letter stating you do not qualify for workers’ compensation because you are a contractor, you may need to submit evidence of your work status. You may want to submit:

  • Your employment agreement
  • Any contracts you signed with your employer, outlining your status
  • Your official job description or the job you replied to when you applied for the position
  • Testimony from an expert witness, outlining why you do not fit the definition of a contractor

In some cases, you may be informed you are not eligible for benefits because your injuries do not match certain qualifications for workers’ compensation. In these situations, you may not be sure how to prove your injuries. You may require a medical consultant or expert, especially if the doctor approved by your employer or employer’s insurer has concluded you are not qualified. If this happens to you, working with a qualified workers’ compensation attorney can help.

An experienced workers’ compensation attorney can review the correspondence you receive about your claim and understand how to prove your injury and your eligibility for coverage. Since an attorney understands the rules and the standards for proof, they can submit the documentation required to strengthen your claim. If you are confused as to why your workers’ compensation claim was denied, contact a workers’ compensation attorney in your community to review the reasons and your options.

 

Common Reasons Workers’ Comp Claims Are Denied and Rejected

Worker’s compensation claims are rejected for many reasons, but some of the most common explanations given for rejections are:

  • The claim was not filed on time. It is important to file for a claim immediately and to report the injury at once. Failure to do so can hurt your ability to secure benefits.
  • The injury does not qualify for workers’ compensation because it did not occur as part of work-related duties. If an adjuster believes you became injured on your own time or on your commute but alleged the injury occurred at work, your claim may be denied. Reporting your injury to your supervisor promptly and gathering evidence can help you avoid this situation.
  • The worker is not covered because they are a contractor. Sometimes, workers are misclassified. If you are employed in such a way that your work duties are similar to those of an employee, you should receive workers’ compensation coverage, no matter how your job position is officially classified. Even if your work contract states you are a freelancer or contractor in Pennsylvania, for example, you may qualify for coverage if you work on an employer’s premises, are essential to the business and have your duties controlled by your employer.
  • The insurer alleges a condition or injury was pre-existing. If you had a leg injury before, for example, and a workplace injury reinjured the area, you should qualify for workers’ compensation. However, insurance adjusters may claim your injury was caused by the previous condition, not the on-the-job incident.
  • There is not enough evidence or documentation of your injuries or how they happened.
  • There are discrepancies in your statements or in the facts of the case.
  • The insurer alleges the worker was doing something illegal at the time of the accident. Under workers’ compensation laws, an employee may not qualify for benefits if they were drinking on the job, taking illegal drugs or were otherwise doing something illegal.
  • A difference of opinion between a worker and an approved medical practitioner. Sometimes, a worker will experience pain or other symptoms, but an approved medical professional will not be able to find anything wrong. It could be a simple misdiagnosis or another issue, but getting medical proof of injury is essential to securing benefits.

 

Workers’ Comp Claim Tips

If you want to avoid getting a letter telling you your workers’ compensation claim has been rejected, follow these tips for filing your claim correctly:

  • Report and file immediately. As soon as your injury happens, contact your employer, manager and supervisor. Report the injury, take photos of the injury and injury scene and note who witnessed the injury. You don’t want any doubt about where and when the injury took place. In addition, file for benefits right away, even if you’re not sure you need them.
  • Document everything. You can never document too much. Keep receipts of everything, keep a record of your symptoms and take photos of your injuries.
  • Consider staying off social media for a while. If you post an innocent picture of yourself having a good day, you don’t want that to be used against you. Be careful what you write, say and do once you file a claim. Even simple statements or photos can be cast in an unflattering light when it comes to your claim.
  • Work with a workers’ compensation attorney. As soon as you notice any potential for delay or denial, call a workers’ compensation attorney. Far too many eligible workers are denied their rightful benefits, and there is no reason you should have to suffer financially just because of a mistake made on your application or a difference of opinion about your injuries. An attorney protects your interests and your right to benefits.
  • Cooperate with the process. The insurance system is based on rules, so if you refuse to submit to medical exams or fail to complete forms as required, your claim will likely be denied.
  • Get serious about your medical condition. Avoid skipping medical appointments, since it can make your injuries seem less serious to some adjusters. Always follow doctors’ directions very carefully, and keep records of medical suggestions as well as your adherence to them. This can help show your injuries are serious and you are taking care to treat your medical condition.

 

Consult With a Knowledgeable Workers’ Compensation Claims Attorney

The process of seeking remedy for a rejected workers’ compensation claim is extremely complex. That’s why contacting a knowledgeable PA workers’ comp lawyer is a highly advisable course of action. Your workers’ compensation lawyer may be able to help you with the various phases of the appeal process, so you can avoid the missteps that could reduce your chances of a favorable outcome.

 

Contact the Pennsylvania Law Office of Lisa M. Ritacco

Workers’ compensation lawyer Lisa M. Ritacco represents individuals who have had their claims for benefits rejected. If you need an attorney to claim workers’ compensation in Philadelphia, Harrisburg or Lancaster, PA or the surrounding areas, our attorney will take the time to listen and talk with you. She will help you understand your rights under the law, including the complex appeals process. Contact us today to schedule a consultation as soon as you receive your notice of rejection.

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