If a Pennsylvania Work Comp claim is denied, the insurance company is supposed to issue a Notice of Workers' Compensation Denial within 21 days of the notice of injury. Your employer or the insurance company is supposed to state the reasons why it is declining to pay workers' compensation benefits. Those reasons may include the following:
1. The employee did not suffer a work related injury, including an aggravation of a pre existing condition or disease.
2. The injury was not within the scope of employment.
3. The employer did not employ the claimant.
4. The employee has not suffered a loss of wages as a result of an already accepted injury.
5. 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.
There is also a catchall provision that requires the insurance company to explain why the claim was denied.
Keep in mind that the insurance company does not always issue a Notice of Workers' Compensation Denial, despite the fact that they are legally required to do so if they do not pay a claim. The insurance company is supposed to pay you your first compensation check within 21 days of the date your disability began. In the alternative, they are supposed to send you a denial. If they do not do so within 21 days, you may need to take further action, including hiring a lawyer.
For more detailed answers to your questions, consult the Frequently Asked Questions bar to the left or download a copy of The Consumer’s Guide to Pennsylvania Workers’ Compensation. For the definitive guide to making your way through the Pennsylvania workers’ compensation system, order a free paper copy of The Wounded Worker: Inside the Pennsylvania Workers’ Comp Maze by calling 877-959-1811 or download a free e-copy by clicking here.