How to Appeal a Denied Workers’ Compensation Claim
February 14, 2025
The workers’ compensation system was designed to help injured workers quickly get the medical care and financial help they need without having to go through the process of a personal injury lawsuit. Ideally, you’ll receive a workers’ comp settlement soon after filing your claim. However, denied workers’ comp claims are more common than many realize. The good news is that if your claim is denied, you still have options. Here’s a closer look at how to appeal workers’ compensation denials.
If your workers’ compensation claim is denied, the best way to increase your chances of approval is to work with an experienced workers’ compensation attorney. Your lawyer can identify potential weaknesses in your claim and help you put together a strong appeal.
An Overview of the Pennsylvania Workers’ Compensation Claim and Appeals Process
The workers’ compensation claim process is fairly similar from state to state, but states often vary when it comes to deadlines and appeal procedures. Here’s a general overview of the process in Pennsylvania.
1. Injury and Initial Report
If you suffer a work injury, you must notify your employer within 21 days. Your employer then notifies the insurer. The insurer investigates the injury to determine whether it will cover the cost.
2. Initial Decision
Once you notify your employer of the injury, the insurance company has 21 days to make a decision. If the insurer denies the claim, it will issue you a Notice of Workers’ Compensation Denial (LIBC-496) form.
3. Starting the Appeal
To appeal the denial, you must file a claim petition (form LIBC-362). You generally have three years from the date of the initial injury to do so. Once you file the petition, your case will be assigned a workers’ compensation judge, and a hearing will be scheduled.
4. The Hearing
At the hearing, both you and your employer’s insurance company can present evidence and argue your case. In some instances, there may be multiple hearings, especially if your case involves significant evidence.
5. Mediation
After the hearing or hearings, the appeal must go to mediation. However, the judge may waive this requirement if they believe mediation efforts would be futile.
6. Decision
If the case does not go to mediation or the mediation doesn’t result in a settlement, the judge will issue a decision.
7. Further Appeal Options
All parties have 20 days from the judge’s decision to file an appeal with the Workers’ Compensation Appeal Board. There are two other levels of potential appeals:
- All parties have 30 days from the appeal board’s decision to file another appeal with the Commonwealth Court.
- All parties have 30 days from the Commonwealth Court’s decision to file an appeal with the Pennsylvania Supreme Court.
To maximize your chances of success, you should reach out to a workers’ compensation lawyer before you make your first appeal. However, unless you have completely exhausted the appeals process, consulting with an attorney at any point is well worth it.
Common Reasons for Workers’ Compensation Claim Denials
If your workers’ compensation claim is denied, don’t immediately rush into an appeal. Taking the time to understand why your claim was denied is essential — this information will help guide you as you craft an appeal.
Your notice should outline the reason for the denial, and your lawyer can help shed additional light on why your claim wasn’t approved the first time around. However, it may be helpful to have a general understanding of some of the common reasons workers’ compensation claims are denied.
Has your workers’ comp claim been denied? Call Wapner Newman now at (215) 569-0900 for a free consultation.
You Didn’t Immediately Seek Medical Treatment
Workers’ compensation insurance companies want to pay out on claims only for injuries severe enough to limit your ability to work. If you reported your injury, kept working, and didn’t seek medical treatment for days or weeks, that may make it seem like the injury isn’t as severe as you claim.
You Have a Pre-Existing Condition
Usually, if you have a pre-existing condition that your job may aggravate, you can’t collect workers’ compensation benefits. However, some workers’ compensation insurance companies go so far as to deny any claim that seems related to a pre-existing condition.
For instance, suppose that you have a pre-existing ruptured disc and you suffer a vertebral fracture at work. An unscrupulous insurance company may try to deny your claim because you had a pre-existing back injury, even though ruptured discs and vertebral fractures are very different injuries.
Your Employer Claims the Injury Wasn’t Work-Related
Sometimes, insurers will try to deny even legitimate claims by asserting that your injury did not happen at work. In this case, medical records and statements from your doctors may bolster your appeal.
How a Lawyer Can Help
You Need an Advocate Through the Appeals Process
When you appeal a workers’ compensation claim, the stakes are high. If your appeals are all denied, you will be responsible for all of your medical care. You also will not receive any compensation for lost wages from your employer.
You aren’t obligated to have a lawyer when you file an appeal. However, the right legal representation can dramatically increase your chances of success. Your employer’s insurance provider will be represented by experienced attorneys, so if you don’t have a lawyer, you’ll be at a significant disadvantage. Here’s how an attorney can help you through the appeals process:
Understanding Reasons for Denial
Before building your appeal, your attorney will thoroughly investigate the reasons your claim was denied. They will use this knowledge to create a strategy that meets your needs.
Gathering Evidence
The right evidence can often convince an appeal board to approve a claim. Often, workers’ compensation attorneys gather evidence like this:
- Your medical records
- Statements from your doctors
- Expert opinions
- Statements from witnesses
- Communication with your employer.
The exact evidence you need depends on the reason for the denial. For example, if the insurer denied your claim because it determined your injury was not work-related, your lawyer may ask for a statement from your doctor clearly connecting your injuries to your duties at work.
Filing the Appeal
Workers’ compensation attorneys are very familiar with the paperwork and the deadlines involved in the appeals process. Once they have gathered all evidence, your lawyer can ensure the appeal is filed correctly and on time.
Arguing Your Case
Workers’ compensation appeals don’t just involve written evidence — they also require each side to present the case before the Workers’ Compensation Appeal Board, Commonwealth Court, or Pennsylvania Supreme Court. Attorneys know how to effectively argue a case, and your lawyer can make sure all evidence is presented clearly and effectively.
Can You Sue Your Employer If You Get Hurt at Work?
You might wonder if you can file a personal injury lawsuit against your employer if your workers’ compensation appeal is unsuccessful. In nearly every case, you cannot. The Pennsylvania Workers’ Compensation Act includes something known as an “exclusive remedy provision.” This means that the workers’ compensation process is the only legal remedy for work injuries due to employer negligence.
However, there are two notable exceptions:
- Intentional Acts: You may sue your employer if they intentionally caused your injury.
- Failure to Insure: You may sue your employer if they don’t have workers’ compensation insurance.
Suing your employer is a legally complex process, and it may not always be advisable. A workers’ compensation attorney can help you determine whether you’re eligible to file a lawsuit and whether it’s in your best interests to do so.
Has Your Workers’ Compensation Claim Been Denied?
We Put Our Experience to Work for You
It’s easy to panic if you receive a notice that your workers’ compensation claim has been denied. However, you should remember that you have a second chance through the appeals process — and we’re here to help you make the most of that second chance.
At Wapner Newman, we have more than 40 years of experience helping workers like you recover the benefits they deserve. When you work with us, you can expect regular case updates, a direct line to our attorneys, and a case that’s fully tailored to your needs.
Has your workers’ comp claim been denied? Call Wapner Newman at (215) 569-0900 to schedule your free consultation.