Can your employer deny your workers’ compensation claim?
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Your employer can dispute your workers’ compensation claim, but it doesn’t get the final say. In Pennsylvania, the decision to accept or deny a claim is made by your employer’s workers’ compensation insurance company, or by the employer itself if it is self-insured, and any denial can be challenged before a Workers’ Compensation Judge. The judge, not your boss, decides whether benefits are owed.
Here is how that process actually works, what an employer can and can’t do, and what to do if your claim is denied.
Who decides your workers’ comp claim
Your employer. Your job is to report the injury, and your employer’s job is to pass the report along to its workers’ compensation insurer. Your employer can give the insurer its version of what happened, and it can investigate. It cannot refuse to let you report an injury or decide on its own that you don’t qualify.
The insurance company. Once the employer has notice or knowledge that a work injury has kept you from working, the insurer generally has 21 days to respond. It can accept the claim with a Notice of Compensation Payable, pay temporarily while it investigates with a Notice of Temporary Compensation Payable, or deny the claim with a Notice of Workers’ Compensation Denial that states its reason.
A Workers’ Compensation Judge. If the claim is denied, a judge decides the dispute after hearing testimony and reviewing medical evidence. The judge’s decision controls, whatever the employer or insurer concluded.
What your employer or its insurer can legitimately dispute
An employer or insurer can challenge whether the injury happened in the course of your employment, whether it was reported in time, whether you were really an employee, whether your medical condition is related to work, and whether the injury keeps you from working. It can also raise the narrow defenses the law allows, such as an injury that was intentionally self-inflicted or one that would not have happened but for intoxication. Our guide to common reasons workers’ comp claims are denied covers each of these in detail.
What company rules and investigations can’t do
An internal investigation, a finding that you broke the code of conduct or a missed step in the company’s own paperwork does not, by itself, decide whether you are covered. Pennsylvania workers’ compensation is a no-fault system. A mistake on the job, or violation of a company rule, does not automatically defeat a workers’ compensation claim. Whether the conduct takes the worker outside the course of employment depends on the particular activity, the rule involved and the facts of the accident.
What does matter is reporting the injury on time. Tell your supervisor as soon as you can. Notice within 21 days protects your benefits from the first day. Notice after 21 days but within 120 days generally means benefits start from the date you reported. After 120 days, the claim can be barred unless your employer already knew or you did not yet realize the injury was related to your work.
Your employer also cannot fire you for filing a workers’ compensation claim. The Pennsylvania Supreme Court held in Shick v. Shirey (1998) that firing an employee for pursuing workers’ comp benefits violates public policy.
What workers’ compensation actually pays
When a claim is accepted or awarded, Pennsylvania workers’ compensation benefits include:
- Reasonable and necessary medical treatment for the work injury
- Wage-loss benefits, generally about two-thirds of your average weekly wage up to a yearly maximum, if the injury keeps you from working or reduces what you can earn
- Specific loss benefits for the permanent loss of use of certain body parts or eyesight, qualifying hearing loss, or serious, permanent scarring of the head, neck or face
- Death benefits for eligible dependents if a work injury is fatal
Workers’ compensation does not pay for pain and suffering or loss of companionship. Those are damages in a personal injury lawsuit, which generally cannot be brought against your employer.
If your claim is denied
A denial from the insurance company is not a court decision, and you don’t “appeal” it. You challenge it by filing a Claim Petition, generally within three years of the injury. The case is assigned to a Workers’ Compensation Judge, who holds hearings where you can testify and present medical evidence. If either side disagrees with the judge’s decision, that decision can then be appealed to the Workers’ Compensation Appeal Board.
If your employer or its insurer has denied your claim, our denied claims lawyers can review the denial and tell you where you stand. Call 610-892-9300, text 610-255-7183 or contact us for a free consultation.