Pennsylvania Workers’ Comp Denial Notice: What Each Reason Means
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When a Pennsylvania workers’ compensation insurer denies a claim, it can’t just say no. It must send you a Notice of Workers’ Compensation Denial (Form LIBC-496), generally within 21 days after your employer has notice or knowledge of your disability, and it must check the reason for the denial. The Pennsylvania Department of Labor and Industry lists the possible reasons right on the Notice of Workers’ Compensation Denial form.
Knowing which reason was checked tells you what the insurer is disputing, and what evidence you will need to prove your claim.
Disputes over the injury
Two of the reasons on the form challenge the injury itself: that you did not suffer a work-related injury, or that the injury was not within the scope of your employment.
Insurance companies want to know that you sustained an actual workplace injury. This means you got hurt because of your work activities and that the injury happened in the course of your employment. Injuries on breaks, in parking lots, while traveling for work or without witnesses are common targets for this kind of denial.
Your work activities could also have aggravated an existing injury or condition. The denial form itself notes that the definition of injury includes the aggravation of a pre-existing condition and a disease contracted as a result of employment. An aggravation does not have to leave you unable to work to be covered; medical treatment for it can be covered even if you never miss a day.
Denial due to non-employment
Your employment status could come into question as you pursue your workers’ comp claim. In some cases, insurance companies turn down a claim on the grounds that the worker did not actually work for the business covered by the insurer, for example because the worker was treated as an independent contractor. A “contractor” label or a 1099 does not decide that question. What matters is the real working relationship, including who controlled your work.
No wage loss from an accepted injury
Sometimes the insurer agrees that an injury happened but denies that it caused you to lose wages. That leaves your medical treatment at issue separately from your wage-loss benefits. Medical records showing your restrictions, and proof that your employer did not offer work within them, are usually the key evidence.
Not meeting timelines
State workers’ comp law establishes timelines you must meet to protect your claim. The reason on the denial form is that notice was not given within 120 days, not 21. Here is how the two deadlines work:
- Within 21 days: notice to your employer protects your benefits from the start.
- Between 21 and 120 days: the claim can still be valid, but benefits generally start from the date you gave notice.
- After 120 days: the claim can be barred, unless your employer already knew about the injury or you did not yet know the injury or illness was related to your work.
If you reported your injury after 21 days, don’t assume your claim is lost.
“Other good cause”
The form also lets the insurer deny for “other good cause,” but it must explain the reason in writing. This is where insurers raise things like a lack of medical evidence or one of the narrow statutory defenses, such as an injury that was intentionally self-inflicted or one that would not have happened but for intoxication. The employer has to prove those defenses.
What to do after a denial
A denial is the insurer’s decision, not a judge’s. The denial form itself tells you that you have the right to contest it by filing a petition. In Pennsylvania, that is a Claim Petition, which generally must be filed within three years of the injury. A Workers’ Compensation Judge will hold hearings where you can testify and present medical evidence, and the judge decides whether benefits are owed. An appeal to the Workers’ Compensation Appeal Board only comes after the judge’s decision. Our guide to common reasons for workers’ compensation denials explains the Claim Petition process in more detail.
If your workers’ compensation claim has been denied, you don’t have to go it alone. Our denied claims lawyers offer a free, no-obligation consultation. Reach us online, call 610-892-9300 or text 610-255-7183.