The Workers’ Compensation Appeals Process: Why Your Claim Was Denied & How to Appeal

Seeking workers’ compensation benefits may be difficult, especially if your case has been denied. But it is your right to appeal that decision.

Getting through the full workers’ compensation appeal process must be done without mistakes and shortcuts. This will be a lot easier if you have an experienced workers’ compensation lawyer by your side.

Workers’ Compensation Claim Denied? Talk to Our Lawyers

If you’re running into issues getting your workers’ comp claim approved, talk to our lawyers today. Our attorneys have decades of expertise when it comes to the Pennsylvania Workers’ Compensation process. We can help you advance your claim past the PA Workers’ Compensation Appeals Board and can get you the workers’ comp benefits you deserve while you recover.

To get started, use our site’s live chat or call us at toll-free at (844) 243-4932 to see how we can help advance your claim.

Common Reasons for a Workers’ Compensation Claim Denial

These are some of the most common reasons for your claim to get denied:

  • Employer contention that the injury occurred outside the “course and scope of employment”
  • Inaccurate information on the accident report or in claim forms
  • Unlawful conduct such as the use of illicit drugs by the employee
  • Failure to comply with the 120-day filing deadline
  • Challenges regarding the severity or validity of injury

Although you are not required to retain a lawyer, a Pennsylvania workers’ compensation lawyer will help you navigate the process of appealing a denial. The first step of any appeal begins with filing a Claim Petition with the Bureau of Worker’s Compensation. The case will then be deliberated upon by a Worker’s compensation Judge. When appealing a denial, you must face a challenging procedural, substantive law and evidentiary issues. If your claim is denied, you ought to contact an experienced workers’ compensation to help tip the scales of justice in your favor.

Many workers who get injured because of their job or get some other occupational illness recognize that they have the right to workers’ compensation benefits and the rewards therein. However, these same workers often assume that they will just simply receive these workers’ compensation benefits, after recording their accident and reporting it to their employer.

Your employer’s workers’ compensation insurer will often drag their feet and attempt to wriggle out of the responsibility of paying these benefits, even if your entire workers’ comp case is legitimate. When injuries occur on the job, the injured workers need to know how to proceed when receiving a Notice of Workers’ Compensation Denial or Notice Stopping Temporary Compensation.

When submitting an application for workers’ compensation benefits, your employer and their insurance company will often make an initial determination regarding whether or not they ought to extend benefits. The workers’ compensation insurance carrier will advise your employer on whether to extend these benefits.

Why It’s Difficult to Get a Workers’ Comp Claim Approved

The actual hearing for your workers’ compensation claim can be one of the most frustrating aspects of the workers’ compensation system. The workers’ compensation judge may limit the evidence you could bring or the subject matters you could talk about. Witnesses for your employer may have come and offered untrue testimony or statements. You may have lost your case and had your benefits cut off, even though you are still unable to return to your job and your pre-injury earnings.

Alternatively, you may have settled a claim in the past and have now experienced a significant worsening of your condition. In all of these instances, you may have the right to bring a workers’ compensation appeal.

Because the rules that govern how and when an appeal can be brought are highly technical and contain strict time deadlines, it is important to consult an experienced workers’ compensation attorney as soon as possible.

An experienced workers’ compensation attorney will review your settlement or the decision from your workers’ compensation trial and advise you as to whether an appeal will improve the unfavorable situation or decision.

Pennsylvania’s Workers’ Comp Appeals Process

Follow these steps to navigate the workers’ compensation appeal process in Pennsylvania if your case was ruled against you, in part or in whole, by a workers’ compensation judge.

Step 1: File a Claim With the Pennsylvania Workers’ Compensation Appeal Board

The first step in the Pennsylvania worker’s compensation appeals is to file with the Workers’ Compensation appeal board within 20 days from the date of the written decision. After the appeal board reviews your case, they will either affirm or overrule the original judge’s decision. Occasionally the case will send the case back to the Workers’ Comp Judge.

Step 2: Appeal to the Pennsylvania Commonwealth Court

If the Worker’s Compensation Appeal Board does not rule in your favor, the next step in the process is to submit an appeal to the Pennsylvania Commonwealth Court. From the date of the decision by the appeals board the deadline to submit an appeal to the Pennsylvania Commonwealth Court is 30 days. When reviewing cases to submit to the Pennsylvania Commonwealth court, our attorneys will identify all of the errors made by the appeal board and evaluate if there is substantial enough evidence to reverse the decision. The court will issue a written decision upholding or overturning the decision of the appeals board.

Step 3: Appeal to the Pennsylvania Supreme Court

Although most workers’ compensation denials only reach the Pennsylvania Commonwealth Court, a claimant who loses in that court can appeal to the Pennsylvania Supreme Court. This appeal must be filed within 30 days of the date that Commonwealth Court issued their decision. The State’s supreme court can elect whether or not to hear the case.

If they were to decline, or rules that the denial was proper, this means that the decision is final and there are no other avenues to appeal. If a claim were to reach this stage, the injured worker will generally need to file a length written appellate brief with exhibits and appear at a hearing to argue the merits of the claim.

This happened recently when the Pennsylvania Supreme Court offered to hear a case on the rights of people employed by franchises.

About the Workers’ Compensation Appeals Process

In most states, the workers’ compensation system is founded on administrative law. That means that there is some administrative agency, operating under the executive authority of the governor in your state, which oversees the worker’s compensation laws created by the state legislature.

Under an administrative law system, administrative law judges conduct trial-type hearings. Your workers’ compensation trial was probably an administrative law hearing before a specially trained workers’ compensation administrative law judge.

If you are unhappy with the decision from the administrative law hearing that was held to determine some aspect of your workers’ compensation claim, there are procedures to appeal an unfavorable result.

In some states, your first appeal must be made to a workers’ compensation court of appeals.

A workers’ compensation court of appeals is also an administrative law panel. Once the workers’ compensation appeals have made its ruling, or if no such administrative law appeals court exists, a judicial appellate review can usually be commenced if you are still unsatisfied with the results of your workers’ compensation case.

Judicial appellate review happens when a court, outside the workers’ compensation administrative law system, examines the decision of the administrative law judge.

Usually, the court examining or reviewing the workers’ compensation decision will be the state supreme court or the state court of appeals. Regardless of which court actually considers the appeal, the judicial appellate system calls for a review of the law, the record of events that happened at the hearing, and the actions of the trial court.

In many states, workers’ compensation review is limited to questions of law. If the worker’s compensation judge made a mistake using or applying the worker’s compensation law or rules, the reviewing court can change the judge’s decision as it sees fit. Fact questions and decisions the worker’s compensation judge made about the evidence are harder to get changed on appeal.

If there is substantial or significant evidence in the record from the hearing to support the decisions made by the workers’ compensation judge about the facts of the case, the appeals court will usually not change those factual decisions or any final ruling that comes from those factual decisions. Accordingly, decisions made about things like the character or believability of witnesses, what evidence to allow in and what evidence is most believable, can usually not be changed by a judicial appellate review.

However, in some states, if a workers’ compensation judge totally ignored rules of evidence, a judicial appellate review may change the judge’s decision because it relied too heavily on evidence that is not acceptable to the judicial appellate court.

In some states, you may also be able to get a judicial appellate review of the settlement of your worker’s compensation claim. Change in disability status, fraud or mutual mistake are all reasons why a judicial appellate court may review or reopen a previously settled claim.

Each state has different requirements that must be met before an earlier settlement will be re-opened by a judicial appellate review.

Rules for Appealing a Workers’ Comp Decision After Denied Claim

All workers’ compensation appeals are governed by specific, technical rules. These rules dictate the amount of time after the workers’ compensation decision is made in which an appeal must be filed, who must receive copies of the appeal, what documents need to accompany the appeal, and what the appeal itself must look like.

The requirements for an appeal differ significantly from state to state. Because of the complexities associated with appealing a workers’ compensation decision, it is extremely important to work with an attorney who knows the worker’s compensation laws in your states.

A knowledgeable, experienced workers’ compensation lawyer will review the decision from your hearing and determine if there is a good basis for appealing your claim.

Thoughts on Appealing a Workers’ Compensation Decision

Appealing a bad decision from a workers’ compensation hearing can be very difficult. You must meet formal requirements regarding mistakes made by the workers’ compensation judge in order to convince the reviewing court that good reasons exist to change the decision.

You must also comply with specific rules that govern the time of the appeal and how the actual appeal papers look. Choosing an attorney who understands workers’ compensation and the appeals process can provide you with a way to meet the challenges raised when you have to bring an appeal of a workers’ compensation decision.

An experienced workers’ compensation attorney will take all possible steps to review your decision and let an appeals court know that you are entitled to a different, better result.

Was Your Workers’ Comp Claim Denied? Contact Our Lawyers

Our experienced Pennsylvania workers’ compensation law firm of Krasno, Krasno & Onwudinjo diligently protect our clients’ interest while navigating procedural hurdles, preparing complex documents, and providing persuasive advocacy. We invite you to call us at toll-free at (844) 243-4932 to learn how we can help.

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