When the insurer denies your workers’ compensation claim, start with the notice it sent. Is it disputing that you were hurt at work, or has it accepted the injury but refused wage-loss payments? The answer determines what you need to challenge. A notice from the insurer also calls for a different response than a decision from a Workers’ Compensation Judge.
Badey, Sloan & DiGenova, P.C. helps injured workers review claim notices, identify needed evidence, and pursue contested benefits. Call (215) 790-1000 or request a free consultation to discuss the paperwork you received.
Start with the Actual Denial Notice
Save every page of the notice, including attachments. Keep the envelope or email that shows when you received it. If an adjuster explained the denial by phone, write down the date and what was said, but use the written notice when getting legal advice. A phone conversation with the adjuster does not replace a required filing.
Look for the reason given for the denial. A dispute over when you reported an injury calls for different proof than a dispute over what caused it. The insurer might agree you were injured but question whether you lost wages because of it. Focus on what it actually says rather than trying to answer every possible objection.
Earlier paperwork can help explain what changed. Bring any Notice of Compensation Payable, temporary-payment notice, agreement, or judge’s order you received before the denial. An insurer’s payment of medical bills does not necessarily mean it has accepted the same injury description your doctor uses or agreed to pay wage-loss benefits.
Understand Which Procedure Applies
An initial insurer denial may require a Claim Petition filed with Pennsylvania’s Workers’ Compensation Office of Adjudication. That puts the disputed claim before a Workers’ Compensation Judge, who considers the evidence and decides whether benefits are due. You can ask the adjuster to reconsider, but that request does not take the place of a required petition.
A judge’s decision follows a separate appeal process. An appeal to the Workers’ Compensation Appeal Board generally must be filed within 20 calendar days from the circulation date of the judge’s decision. This is not a 20-day deadline for every initial insurer denial, and it is not measured from whenever you happen to read the decision. Have the decision reviewed immediately.
If payments started and then stopped or decreased, show your lawyer the payment history as well as the latest notice. You may need a challenge, a reinstatement petition, a response to an employer’s petition, or another procedure. For example, a LIBC-751 notice about suspension or modification after a return to work has its own 20-day challenge period measured from receipt. Treating it as an initial claim denial could lead you to use the wrong procedure.
Check Notice and Filing Deadlines Promptly
Reporting your injury to your employer and filing a petition are separate requirements. Unless the employer already knows about the injury, waiting more than 21 days to provide notice can delay compensation. Notice generally must be given within 120 days. Special rules can affect when the notice period begins, including when the connection between a condition and your work wasn’t initially known.
A Claim Petition ordinarily must be filed within three years of the injury, subject to exceptions. Other documents can require a response much sooner, including a notice affecting current payments or a judge’s decision. Keep those deadlines separate, and don’t count on discussions with the insurer to extend them.
Your symptoms may have built up gradually, or you may not remember the date you first told a supervisor. Take the records you have to a lawyer rather than waiting to reconstruct everything. Earlier payments and the injury history may affect the deadline analysis.
Gather Evidence That Answers the Insurer’s Reason
Put the events in date order, starting with the accident or the first symptoms. Add when you notified your employer, sought treatment, and missed work. Use appointment records, messages, and pay records to check the dates. Mark anything you cannot remember instead of filling in a guess.
Match the records you gather to the reason the insurer gave:
- A disputed accident or workplace connection: Save incident reports, supervisor messages, witness names, and photographs taken safely and lawfully. Identify any cameras or equipment involved so an attorney can assess preservation needs.
- A disputed medical connection: Gather treatment records, test results, restrictions, and information about earlier conditions. Tell your provider what your job actually requires and how symptoms began or changed. A prior condition does not, by itself, rule out a work-related aggravation.
- A reporting dispute: Keep texts, emails, forms, and the names of people you notified. Record what you told them and when.
- A wage-loss dispute: Save pay stubs, schedules, attendance records, written restrictions, and job offers. Identify missed shifts or reduced earnings and why they occurred.
Tell your lawyer about earlier injuries and any facts that seem inconsistent with the claim. Address those issues now, not later when the insurer raises them. Your lawyer can assess whether the medical records explain the connection to work or whether you need further medical opinion evidence and testimony.
Keep Addressing Treatment and Work Restrictions
Let your medical providers know the claim is disputed and ask how they will handle billing while it is unresolved. Keep their bills with the insurer’s correspondence. Another insurance policy may have its own coverage limits, and a later workers’ compensation award may still leave billing issues to resolve. Continue seeking appropriate care rather than treating the denial as a medical decision.
Keep your treating provider up to date about your condition and any proposed return to work. If the employer offers a job, get the duties, hours, and pay in writing so the provider can compare them with your restrictions. Examination requests and hearing notices also need attention while the claim is disputed. Ask about anything you do not understand before a response is due.
Our overview of Pennsylvania workers’ compensation benefits explains the broader claim process. The response to a denial still needs to fit the specific notice and evidence in your case.
Prepare for a Claim Petition and Hearing
Filing a petition does not produce an immediate payment. You may need to testify about your work, the injury, and your medical history, while both sides submit evidence to the judge. Your lawyer can help you prepare an accurate account and explain what you must prove. How long the case takes depends in part on the disputed issues and the evidence needed to address them.
Before the consultation, write down the problem that needs attention first. It might be an unpaid treatment bill, a hearing date, or an instruction to return to work next week. Bring the denial with whatever earlier claim records you have. Once you have an attorney, forward new notices promptly, even if they look similar to something already in the file.
Talk with Badey, Sloan and DiGenova About a Denied Claim
At Badey, Sloan & DiGenova, P.C., we can start with the notice in front of you and explain what response it calls for. Bring your records and questions about the denial. You do not need to assemble a complete case file before asking us to review a deadline.
Call (215) 790-1000 or contact our Philadelphia office to request a free consultation. We explain fees and possible costs so you can understand the proposed representation.