Understanding The Delay Tactics In Workers’ Compensation Health Insurance

Workers’ Compensation Health Insurance Delay Tactics

In Pennsylvania, employers with one or more employees are required to purchase workers’ compensation insurance. Many employers choose to self-insure, which means that an injured worker would file his or her claim directly with the employer, who would then conduct an investigation before making a decision. For the most part, however, employers choose to purchase coverage directly from a private sector insurance carrier who provides workers’ compensation coverage.

While many insurers respond quickly to claims and begin paying benefits immediately, it is not uncommon to see insurance companies dragging their feet when it comes to processing a workers’ compensation claim. This failure to address claims promptly can have serious consequences for injured employees who must struggle with paying expensive medical bills while not being paid. To ensure that your claim is resolved quickly, it is critical to retain an experienced workers’ compensation attorney who will aggressively represent your interests.

Processing Delays

Pennsylvania’s workers’ compensation laws require injured workers to notify their employers of an injury sustained while at work within four months of the date that it occurred. At this point, the employer submits the claim to its insurer who will conduct an investigation before providing benefits. Unfortunately, some insurers take months or even years to resolve claims, often as a result of:

  • Understaffing or overworked insurance adjusters with heavy caseloads;
  • A lack of training;
  • Clerical errors;
  • Negligence or a lack of procedural guidelines; and
  • An attempt to convince a claimant to accept a lower settlement.

Under Pennsylvania law, using processing delays as a tactic in negotiation is against the law. In fact, insurers face serious penalties if they do not complete a claim investigation within one month of notification. For instance, when insurance providers do not comply with these laws, injured workers can force them to demonstrate that their investigation could not have been completed before the deadline. Furthermore, once the first 30-day period has passed, insurers are required to provide claimants with a written explanation every 45 days after that. Courts can also penalize insurance companies for failing to approve or deny a claim within 21 days of receiving notification. In some cases, courts have ordered insurance companies to pay as much as 50% of the full amount of delayed benefits.

Whether the delay was caused by a clerical error or outdated procedures or is merely an attempt to convince an injured worker to settle, these kinds of delays leave injured workers with no safety net, as well as mounting medical bills and household expenses.

Requests for Additional Time

In many cases, once an insurer is notified of a claim, it may request more time to conduct an investigation or obtain the opinion of an independent physician. At this point, the insurer may also ask for additional information before proceeding with the claim. In fact, claims are often delayed because a claimant failed to submit the correct paperwork in the first place. These mistakes range from failing to fill out the appropriate form and forgetting to include medical records to missing an important deadline or submitting the claim to the wrong department.

Employer Delay

It is not always the fault of an injured worker or an insurer when a claim is delayed, as many late claims can be attributed to an employer’s failure to report the injury in a timely fashion. Common reasons for these delays include:

  • A failure to institute appropriate reporting procedures;
  • Negligent or reckless handling of a claim;
  • A failure to submit the correct claim form to the appropriate entity;
  • A lack of communication between supervisors, who may have received notice of the claim first, and employers;
  • Losing a claim form; and
  • Purposefully ignoring the claim in hopes that the injured worker will not follow through with filing.

Employers are required to provide their employees with workers’ compensation, and when they purposely impede the ability of injured employees to submit a claim, they are illegally interfering with that right. Fortunately, those who are represented by a work injury lawyer are at an advantage in these situations, as experienced attorneys who are well-versed in state filing requirements will have the means and knowledge to follow up on claims, hold employers and their insurers responsible for failing to process a claim on time, and appeal any unfair denials.

Call A Pennsylvania Workers’ Compensation Lawyer

Competent and passionate legal representation is key to the success of any workers’ compensation claim, especially when an insurer is dragging its feet. If you were hurt at work, contact Krasno Krasno & Onwudinjo at (866) 948-9088 to schedule an initial consultation with a dedicated member of our legal team.

This is the first part of a ten-part series on “are insurance companies dragging their feet?” Check out part 2 here: Why do Insurers drag their feet?