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 serious injuries requiring 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-plus 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 Denial of Benefits

There are many reasons why an employer or insurance company may deny workers’ compensation claims. The first steps after the injury are essential and can set the claim up for acceptance or denial. 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. This denial is generally used when the insurance carrier believes an injury to be minor, 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. Workers ‘ compensation covers only injuries suffered during and related to employment. With some exceptions, commuting to and from work is not ‘part of the job’ and 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 defendant did not employ the employee. This denial is typically utilized for independent contractors, domestic workers, and many delivery drivers (such as the food delivery companies separate from the restaurant where 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 the notice in a timely manner.
5. Other good cause. 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.

Unofficial Reasons for Denial

Insurance companies can only ‘officially’ deny a claim by issuing the Workers’ Compensation Denial Form notice 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 not receiving medical records confirming an injury occurred; the doctor (usually a ‘company doctor’) has released the claimant from care and returned 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 deny claims, hoping the claimant will not know or pursue their rights.

Our Workers’ Compensation Lawyers Help if You Are Denied 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 610-892-9300 or contact us online.