Appealing a Denied Workers’ Compensation Claim in Pennsylvania

An injured or ill worker in Pennsylvania is entitled to workers’ compensation benefits if they can show that the cause of their injury or illness was work-related. Workers’ compensation benefits in Pennsylvania may include payment of medical bills, wage loss compensation, and other related expenses if the injured worker is unable to return to work while they are recovering. Not all workers’ compensation claims are approved, however, and many workers are frustrated when their workers’ compensation claims are denied. If you have a denied workers’ compensation claim in Pennsylvania, here are some steps that you can take to appeal that denial.

Understanding Workers’ Compensation in Pennsylvania

Before getting into the appeals process, let’s take a brief look at Pennsylvania’s workers’ compensation law, which provides benefits to an employee who is injured or becomes ill as a result of their employment. Specifically for Pennsylvania employees injured on the job, benefits can include:

• Medical Benefits: Payment for all medically-necessary treatment related to the work injury.
• Wage‑Loss Benefits: The return of money that a worker has lost as a result of a work‑related injury or illness that prevents the worker from returning to his/her job. 
• Specific Loss Benefits: Payments for the loss of a body part or the use of a body part, disfigurement, or scarring.
• Death Benefits: Payments to survivors of a worker who died as the result of a work-related injury or illness. 

Common Reasons for Claim Denials

There are several potential reasons why workers’ compensation claims can be denied. Identifying why your claim was denied can better prepare you to advocate for yourself during the appeals process. Some of the more common reasons for claim denials include:

• Insufficient Medical Evidence: The insurer can contend there is insufficient medical basis or no medical proof that the particular injury or illness is linked to the job.
• Late Reporting: Pennsylvania employees have 120 days to report their injuries, after which the claim can be denied.
• Differences between the worker’s accident report and the medical reports: If there is a difference between the worker’s description of the accident and the observed injuries to his body, this could indicate that they’re lying.
• Pre-Existing Condition: Your injury was not a result of a work-related incident; it was a pre-existing condition.
• Delay in Seeking Medical Attention: Early medical treatment is seen as indicative of the seriousness of the injury.

Steps to Appeal a Denied Claim

If your workers’ compensation claim is denied, you may appeal the decision. The appeals process includes a series of steps. 

1. File a Claim Petition

The first step in appealing a denied claim is to file a Claim Petition with the Pennsylvania Bureau of Workers’ Compensation within three years from the date of injury. The claimant (the person whose claim is denied) can file a Claim Petition (LIBC-362) on the Pennsylvania Department of Labor and Industry website.

2. Mediation

After the Claim Petition is filed, the case will be assigned to a Workers’ Compensation Judge (WCJ) and may be scheduled for mediation. Mediation is an informal discussion between the parties, facilitated by a neutral mediator, to attempt an agreeable resolution. Some cases proceed to the hearing stage without mediation, and some do not go to hearing at all after mediation. Mediation is voluntary. However, mediation is an opportunity for the parties to come to a resolution and avoid the costs and time associated with a formal hearing.

3. Hearings

If mediation is unsuccessful, the case will proceed to a hearing before the WCJ, at which point both parties will present evidence such as medical records, witness statements, and other relevant documentation. Having a skilled Lancaster workers’ compensation attorney by your side is highly advisable, as workers’ compensation law can be confusing.

4. Decision by the Workers’ Compensation Judge

Following the hearing (or hearings), the WCJ will issue a written decision containing findings of fact and conclusions of law that will be considered a determination of whether or not the claim is approved or denied. If the decision is not in your favor, you can appeal to the Workers’ Compensation Appeal Board (WCAB).

5. Appeal to the Workers’ Compensation Appeal Board

If you do not agree with the WCJ’s decision, you can appeal to the WCAB within 20 days from the date of the judge’s decision. The Board will look at the record from the judge’s hearing to determine if the law was correctly applied. The Board will not hear the case again and will not accept new evidence.

6. Appeal to the Commonwealth Court

If the WCAB denies your claim, you can get a review of the denial through the Commonwealth Court of Pennsylvania, but you must do so within 30 days from the date of the WCAB’s decision and order. The Commonwealth Court will only review the case to make sure that the correct law was applied without reassessing whether there were any factual errors made by the WCAB.

7. Appeal to the Pennsylvania Supreme Court

The final stop is the Pennsylvania Supreme Court, but note that the court decides on its own which cases to hear and often chooses ones with broader legal questions and public interest.

What is Needed to Increase Your Chance of Having a Successful Appeal?

Hire an Experienced Lancaster Workers’ Compensation Attorney

Without a knowledgeable lawyer, the appeals process can be complicated. A seasoned workers’ compensation attorney can help you navigate the process and represent your interests in Lancaster and elsewhere in Pennsylvania.

Gather Strong Medical Evidence

Get detailed medical reports linking the injury or illness to your work. The more detailed and consistent the documentation, the better.

Ensure All Deadlines are Met

Ensure that all forms and appeals are filed within the specified time limits. Missing a deadline can jeopardize your chances of a successful appeal.

Prepare for Hearings

Cooperation with your lawyer entails preparation for hearings. This includes obtaining evidence, preparing witnesses to testify, and understanding the legal arguments that will be made. 

Speak to a Knowledgeable Lancaster Workers’ Compensation Attorney Today

Appealing a denied workers’ compensation claim in Pennsylvania is not an easy or enjoyable process. However, once you understand the process and the procedural steps you will have to take to get your benefits, you can better prepare yourself for what lies ahead. Get the help you need after a claim denial — contact our office today for immediate assistance.