Appealing a Denied Claim

The workers’ compensation system exists to protect hardworking Americans who are injured in a work-related accident. However, insurance carriers routinely deny legitimate claims to cut costs. If you have had a claim denied for a work-related illness or injury, we understand how frustrated and powerless you may be feeling—and we are ready to fight on your behalf to get you the full benefits you deserve.

Reasons Why Your Claim May Have Been Denied

Insurance carriers may deny a claim for any number of reasons, but some of the more common causes of denial include:

  • Claim documents were incomplete or not filed within the proper time
  • Lack of evidence to support the workers’ account that the injury happened at work
  • Discrepancies between the petition for benefits, accident report, and/or medical records
  • Pre-existing condition
  • Initial diagnosis records indicate the worker may have been under the influence of illegal drugs or alcohol at the time of the accident

An experienced Philadelphia workers’ compensation lawyer will have seen common denial tactics before, and know how to respond. It is not uncommon for insurance carriers to deny claims, expecting that an injured employer will not push back and appeal the determination.

How to Appeal a Denied Claim

Injured workers who have had their claims denied can appeal the denial of benefits. In Pennsylvania, there are very specific steps that must be followed. Because the appeals process can be complex, you should retain the advice of a competent and experienced Philadelphia workers’ compensation attorney.

The first step in appealing a denial is to file a petition with the Workers’ Compensation Office of Adjudications, also called WCOA. You must also serve a copy of the petition on the insurance carrier who denied your claim so that they have notice of the appeal. Appeals must be filed within three years of the denial in Pennsylvania. After that period of time, you may be barred from filing an appeal. Once the WCOA receives your petition, someone will contact you to schedule your case for mediation.

During mediation, you will meet with the Judge and a representative from the insurance company. The Judge will attempt to facilitate a settlement. Having a seasoned Philadelphia workers’ compensation lawyer representing you in these negotiations may help you leverage a better settlement, because they will understand the strength of your claim and know how to present that information to the insurance carrier and the Judge.

If you are unable to come to an agreement with the insurance company during mediation, your case will proceed to a hearing—which is very much like a trial. The judge will review evidence and take testimony, then issue a written decision. Because medical experts typically testify at these hearings, it is extremely helpful to be represented by competent counsel.

If the Judge denies your claim, you can appeal to the Workers Compensation Appeal Board (WCAB) within twenty days. The procedure can be complex, with specific rules detailing who you must serve with the appeal and how, what documents to attach, and how many copies you need to send to each mandatory recipient. You also need to file a proof of service.

At this stage, the parties submit legal briefs on the legal issues, and the WCAB issues a decision. You then have another opportunity to appeal, if your claim is still denied. You can appeal the WCAB’s decision to the Pennsylvania Commonwealth Court within 30 days. The Commonwealth Court’s decision can then be appealed to the Pennsylvania Supreme Court, which can decide whether or not to hear the case. The Pennsylvania Supreme Court’s decision is final.

Philadelphia Workers’ Compensation Lawyers at Freedman & Lorry, P.C. Rigorously Appeal Denied Claims

At Freedman & Lorry, P.C., we believe in the workers’ compensation system, and fight tirelessly for the rights of hardworking people who have been hurt on the job. If you suffer from an occupational illness or work injury and have had your claim denied, we understand your frustration and are ready to fight for you and your family. Contact one of our seasoned Philadelphia workers’ compensation lawyers today at 888-999-1962 to begin fighting back. You can also contact us online.