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Were Your Workers’ Compensation Benefits Denied?

If you were injured at your place of employment, learning that your workers’ compensation claim was denied can be devastating. Workers’ compensation is supposed to be a safety net for workers who suffer a serious injury that requires taking time away from work to recover. Unfortunately, some employers and insurance companies look for ways to avoid paying your workers’ comp benefits, which can leave you in a position with no means to pay your medical bills and other expenses. If you or a family member was denied workers’ comp after being injured, you need an experienced Philadelphia workers’ compensation attorney today. At Schmidt, Kirifides & Rassias, each and every one of our CERTIFIED WORKERS’ COMPENSATION SPECIALIST LAWYERS* has at least 28+ years of experience handling only workers compensation claims. IT’S WHAT WE DO! We will fight to get the benefits you need – and are entitled to.

Common Reasons For Workers’ Comp Denial

There are many reasons why an employer or insurance company may deny a claim for workers’ compensation. The very first steps after the injury are essential, and can set the claim up for acceptance – or denial. [See section on tips for a successful claim]. While the ‘true’ reason may only be known to the claims representative, the official form that must be filed with the Bureau of Workers Compensation lists 5 reasons why a claim may be denied.

1. The employee did not suffer a work-related injury. The definition of injury also includes aggravation of a pre-existing condition or disease contracted as a result of employment.
2. The injury was not within the scope of employment.
3. The employee was not employed by the defendant.
4. The employee did not give notice of his/her injury or disease to the employer within 120 days within the meaning of Sections 311-313 of the Workers’ Compensation Act.
5. Other good cause; please explain fully in the space below

  1. The employee did not suffer a work-related injury. This denial is generally used when the insurance carrier believes an injury to be minor, and not likely to result in disability, and possibly not even require medical treatment. It is also (often) used when an insurance company will retain their own doctor, and expect (after paying a generous fee to the doctor) that they will say there is no injury, or that a minor sprain or strain has already resolved.
  2. The injury was not within the scope of employment. Only injuries suffered while in the course of employment and related to the employment are covered by workers’ compensation. With some exceptions, commuting to and from work is not ‘part of the job’, and injuries coming to work and going home are not in the scope of employment. Injuries suffered during a break may or may not be in the course of employment, depending on where the person is, what they were doing, and how they were injured. Certain activities by the injured worker can remove them from the scope of employment, such as horseplay, a violation of law, intoxication, or directly disobeying an express work rule.
  3. The employee was not employed by the defendant. This denial is typically utilized for independent contractors, domestic workers and many delivery drivers (such as the food delivery companies separate from the restaurant you ordered the food). It is also used by temporary employers, who hire workers through a temporary staffing agency, where the agency is the actual ’employer’.
  4. The employee did not give notice of his/her injury. An injured worker must report the incident and injury to someone in a supervisory capacity (not a co-worker) within 21 days of the incident. [There are rules regarding late notice up to a maximum of 120 days.] Where Notice is timely, meaning within 21 days, but not until days or weeks after the incident, the insurance company may use the delay to contest whether it actually even happened at work, by checking boxes 1, 2 and/or 3. Always request a copy of the incident report, or send an email or text message with a delivery receipt – to prove you gave Notice timely.
  5. Other good cause; please explain fully in the space below. This is the ‘catch-all’ denial, when the insurance company suspects there is some reason to deny the claim, but does not quite know what their defense will be.

Un-Official reasons for Denial
Insurance companies can only ‘officially’ deny a claim by issuing the Notice of Workers’ Compensation Denial Form, and checking one of the boxes above. If none of the correct reasons apply, they will check box 5. Despite requiring an explanation, many times no explanation is stated. Some reasons may include: the insurance company has not received medical records confirming an injury occurred; the doctor (usually a ‘company doctor) has released claimant from care and a return to full duty; the claimant has had numerous past claims; the circumstances of the incident are ‘suspicious’, such as an injury just after receiving a bad performance review or threatened with firing. Some insurance companies simply deny claims, hoping the claimant will not know or pursue their rights.

Our Work Injury Lawyers Can Help You File A Claim For Benefits

If you or a family member was denied worker’s compensation benefits, contact Schmidt, Kirifides & Rassias, Delaware County’s Certified Work Injury Specialists to schedule a free legal consultation. Call us at 610-601-5399 or contact us online.