A workers’ compensation claim can seem straightforward at first. You report the injury, see a doctor, and expect the claim to move forward. Then a letter arrives saying the claim has been denied.
The reason isn’t always obvious. Questions may come up about how the injury happened, when it was reported, what appears in the medical records, or whether the injury is related to your job. In other cases, only part of the claim may be disputed.
This article explains why workers’ compensation claims may be denied in Wilkes-Barre, where problems can develop during the claim process, and what to do if your workers’ compensation claim is denied.
Reviewed by: Timothy P. Belt, Certified Specialist in Pennsylvania Workers’ Compensation Law.
Attorney Belt is certified as a specialist in Pennsylvania Workers’ Compensation Law by the Pennsylvania Bar Association’s Section on Workers’ Compensation Law as authorized by the Pennsylvania Supreme Court.
Understanding A Workers' Compensation Denial
Nothing may seem unusual while your claim is being reviewed. You may be going to medical appointments and receiving paperwork while your employer and the insurance company gather information about the injury.
Problems sometimes surface during that review. An accident report may describe the injury differently than the first medical record, or there may be questions about when your employer was notified. These issues can matter when the insurance company decides whether to accept or deny the claim.
Not every workplace injury comes from one obvious accident. Maybe the pain started while you were lifting something, or it developed while you were doing the same work you do every day. Either way, the details matter when the insurance company decides whether workers’ compensation covers the injury.
An injury can happen during the workday and still lead to questions about what caused it. This can happen if you already had pain in the same area, symptoms developed over time, or no single accident caused the injury.
The issue then becomes whether the job caused the injury or worsened a preexisting condition, or whether the condition is unrelated to the employment. This distinction can become a major point of disagreement in a workers’ compensation claim.
You may not think much of an injury when it first happens, especially if you expect the soreness to go away on its own. When it doesn’t, several days may have passed before you report the injury or see a doctor. That delay can make it harder to establish when the injury occurred and whether the condition being treated is connected to what happened at work.
If you’re still early in the process, knowing what to do after a work injury in Wilkes-Barre can help you avoid problems before they develop.
Medical records do more than show that you received treatment. They also document what you told the doctor about your injury, when your symptoms began, what the doctor found during the examination, and how the condition was diagnosed.
When a workers’ compensation claim is reviewed, those records may be compared with other information about the injury. If something important doesn’t line up, it can create a dispute over whether the medical evidence supports the claim.
The first medical record becomes part of the story of your injury. It documents what you told the doctor about getting hurt at work, along with the doctor’s findings from that visit.
We’ve seen cases become more difficult when the connection to work wasn’t documented during the first medical visit. That’s one reason it’s important to tell your doctor from the beginning that you were injured on the job.
What appears in your medical history may not always fit neatly with what was reported after the injury. An old complaint may show up in your records, or a doctor’s notes may describe when your symptoms started differently than you remember.
A difference in the records doesn’t mean the injury wasn’t work-related. It can become important, however, when your medical history is considered as part of the claim.
A previous injury can become part of the discussion when the insurance company reviews your medical history. If you’ve had treatment for the same part of your body before, the insurer may question whether your current condition is connected to the workplace injury or something that was already there.
The question may then turn to what changed after the workplace injury. In Pennsylvania, a work injury can include an aggravation of a preexisting condition, so a prior medical problem by itself doesn’t necessarily rule out workers’ compensation benefits.
A workers’ compensation claim can involve more than the question of whether you were hurt at work. Even when everyone agrees that you were injured at work, there can still be disagreements about the claim. The insurance company might recognize the injury but take a different position on what you’re entitled to because of it.
That means one part of your claim may be accepted while another remains disputed. Understanding what the insurance company has accepted—and what it hasn’t—can make a big difference in deciding what to do next.
An insurance company doesn’t always take the same position on every part of a claim. It may recognize one injury while questioning another condition that you believe came from the same accident.
This can leave you with an accepted workers’ compensation claim while still having a disagreement over what that claim covers.
A dispute can come up after treatment is already underway. You might be attending appointments or physical therapy when you learn someone is challenging the need for additional care.
At that point, the disagreement isn’t necessarily about whether you were hurt on the job. It may center on the care being recommended for your recovery.
Being unable to work doesn’t always mean there will be agreement about wage-loss benefits. Your employer or its insurance carrier may take the position that you can return to work or that your injury isn’t keeping you from earning your regular wages.
This creates a different issue from whether the workplace injury itself was accepted. You can have an accepted injury and still face a disagreement over the benefits you’re receiving while you’re out of work.
A denial changes where the claim goes from there, but it doesn’t necessarily end everything. Pennsylvania gives injured workers a process for challenging the insurance carrier’s decision.
What happens next depends on why the claim was denied and what evidence supports the injury. The notice you receive is an important place to start because it tells you the insurance carrier’s position.
If your claim is denied, you may receive a Notice of Workers’ Compensation Denial (LIBC-496) explaining the insurance carrier’s position. The explanation matters because it can help you understand what part of the claim is being challenged.
Keep the notice with your records. You’ll want to know exactly what the carrier said when you’re deciding how to respond.
A denial is the insurance carrier’s decision, but it does not necessarily settle the matter. If you believe the injury should be covered, Pennsylvania workers’ compensation law provides a process for bringing the dispute before a Workers’ Compensation Judge.
This is where the claim can move from an insurance decision into a formal legal proceeding.
Once a claim is disputed, the information gathered early on can take on greater importance. Medical records, details about the accident, and information from your employer may all become part of determining whether the injury should be covered.
The reason for the denial will shape what you need to address. A dispute over how the injury happened may require different evidence than one involving a prior medical condition or the extent of your disability.
A denied claim can leave you with questions about your benefits and what comes next. The answers below cover common issues that come up after an insurance carrier denies a workers’ compensation claim in Pennsylvania.
No. A denial means the insurance carrier has decided not to accept all or part of the claim. It does not prevent you from challenging that decision through Pennsylvania’s workers’ compensation system.
What happens from there depends on what was denied and the reason the carrier gave for its decision.
In Pennsylvania, the insurance carrier generally has 21 days after receiving notice of the injury to accept or deny the claim or begin paying temporary compensation.
That doesn’t mean every claim is completely resolved within 21 days. If you’re unsure what the carrier has decided, review any notices you’ve received and pay attention to how the claim is being handled.
Yes. An insurance carrier may accept one part of your injury while taking a different position on another. You could also have a disagreement over benefits even though the underlying workplace injury has been accepted.
This is why it’s important to understand exactly what the carrier has agreed to cover. An accepted claim doesn’t always mean every injury, treatment, or benefit connected to it has been accepted.
A preexisting condition can lead to a dispute, but having one does not automatically prevent you from receiving workers’ compensation benefits. The question is often whether your work caused a new injury or aggravated a condition you already had.
Your medical history can become especially important in these cases because it helps show what changed after the workplace injury.
Your employer can disagree with your account of the injury, but that disagreement alone does not determine whether you have a workers’ compensation claim. A dispute may develop over where you were, what you were doing, or whether your job had anything to do with the condition.
Evidence from the time of the injury can become important when the two sides don’t agree about what happened.
A denied claim shouldn’t be left sitting. In Pennsylvania, if an injured worker has provided proper notice of the injury to the employer within 120 days of the injury, they generally have three years from the date of the injury to file a Claim Petition seeking workers’ compensation benefits.
That deadline is different from the time allowed to appeal a decision made by a Workers’ Compensation Judge. If your claim has been denied, knowing which deadline applies to your situation is important.
You don’t have to wait for a dispute to arise before talking with a lawyer. If your claim has been denied or you’re unsure why certain benefits aren’t being paid, getting legal guidance early can help you understand what the insurance carrier is challenging and what options you have.
A Wilkes-Barre workers’ compensation lawyer can review the denial, explain the Pennsylvania claims process, and help determine what may be needed to challenge the carrier’s decision.
If your workers’ compensation claim has been denied or you’re having trouble getting the benefits you expected, you don’t have to wait for the problem to get worse before seeking legal guidance. Belt Law can discuss your situation and explain the options that may be available under Pennsylvania law.
We help injured workers in Wilkes-Barre, Pittston, Hazleton, Kingston, Edwardsville, Nanticoke, Mountain Top, and throughout Luzerne County.
Why Injured Workers Choose Belt Law
Contact The Belt Law Firm, P.C. today at (570) 714-3343 to schedule your free consultation.
Report the injury to your employer as soon as possible and obtain any necessary medical treatment.
If the injury is not reported within 120 days, you will lose the right to file for compensation. You cannot legally be fired for reporting a work injury.
The employer reports your injury to their workers’ compensation insurer. If the insurance carrier accepts your claim, they will calculate any compensation owed and make payment. If your claim has not been accepted within 21 days of providing notice of the injury to your employer, your claim is likely denied.
If you receive a notice of denial, you can file a Claim Petition with the Pennsylvania Workers’ Compensation Bureau. Your Petition will be assigned to a Workers’ Compensation Judge. The Judge will schedule hearings, and both sides will be provided the opportunity to present evidence. If the claim is not voluntarily resolved, the judge will issue a Decision.
In most cases you have up to three years from the date of injury to file a Claim Petition.
Workers’ compensation insurance covers all medical expenses stemming from your work injury. Workers’ comp pays wage loss benefits until you are able to go back to work. If you suffer an amputation or disfigurement to your face or neck, you may be entitled to additional disability benefits (even if you are still able to work).
Taking a lump-sum settlement may or may not make sense for your situation. You should get legal counsel before agreeing to a settlement.
There is no upfront or out-of-pocket cost to you. We provide a free initial consultation. You do not pay any legal fees unless and until we recover benefits for you.
Do you have a work-related injury? Please give us a call in Kingston at 570-714-3343, in Hazleton at 570-535-3343 or contact us online. Belt Law Firm, P.C., serves injured workers in Luzerne County and the surrounding communities of northeast Pennsylvania.
Many aspects of a successful workers’ compensation claim or unemployment compensation benefits case are complex.
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