Adapted from Chapter 7 of The Wounded Worker: Inside the Pennsylvania Workers' Comp Maze:
Benefits if your workers’ comp claim is denied
If you have to file a claim petition, talk to your lawyer about how long he expects it will take for you to be paid your workers’ comp benefits. It is often difficult to estimate this before a claim petition is filed, but ask anyway. There may be benefits available to you if you have a claim that has been denied. Please call or email us and we will provide you a copy of our free book Battered and Broke: Making Ends Meet when your Workers' Compensation Claim is Denied.
How the hearing process works
Workers' compensation cases are heard in a series of hearings. Once you or the insurance company files a petition, the Bureau of Workers' Compensation assigns it to a judge in the county in which you live. The bureau will notify you and the insurance company of the identity of the judge. The bureau usually schedules a hearing within a few weeks, at which you will probably tell your story if you filed the petition. If the insurance company filed the petition, you ordinarily will not testify at a later time.
Workers' compensation cases are not decided in a single hearing. Usually there are about three, each spaced about 90 days apart. Judges will move the case faster in some circumstances, but in general the length of time is controlled by the scheduling of medical or fact depositions in your case. A deposition is a formal question and answer session during which lawyers ask doctors or other witnesses for sworn answers to questions about your injury. It may take a while to schedule depositions, particularly of doctors, who must clear time on their busy calendars.
Typical Types of Petitions
Claim and Reinstatement petitions
If your claim is denied, you must file a claim petition with the Pennsylvania Bureau of Workers’ Compensation. A claim petition contains a brief summary of the facts you must prove to win your case. Usually the company will deny the truth of the facts because their lawyer needs time to investigate and can’t do it in the time allotted. If you’re seeking benefits on a claim for which you previously received benefits, you must file a reinstatement petition. Typically injured workers file this petition if they return to work and their condition worsens or they get laid off from light duty jobs. For a discussion of the testimony you must give at such a hearing, click here.
If you file a petition, the insurance company has 45 days from the date of the first hearing to have you undergo an "Independent Medical Evaluation.” Their lawyer also has 90 days from the date that your doctor testifies to take a deposition of their doctor.
A second hearing on a claim or reinstatement petition will normally be scheduled 90 days after the date of the first hearing. At the second hearing, the lawyers may present testimony from non-expert witnesses. The deposition of your physician will be submitted at that time, and at the conclusion of the second hearing, the record will be left open for opposing counsel's medical expert deposition.
Your lawyer should push hard to obtain a decision as soon as possible, but during the course of the litigation, there may be delays. The insurance company may hire a private investigator to video your activities (more on that later), hire experts to look at your claim or present fact witnesses to rebut your story. Other facts may also come to light that require additional work and time.
Termination, Suspension and Modification petitions
In a termination petition, the insurance company claims you are fully recovered from your work injury and can resume normal activities without restrictions. In a suspension petition, the insurance company alleges that though you have not recovered, you are not entitled to wage loss checks. They may claim that you rejected an offer of a job you were capable of performing. Sometimes the insurance company files a suspension petition because you have returned to work but have not signed any documents permitting them to stop paying you benefits.
Insurance companies file modification petitions when you return to work at wages that are less than your pre-injury wages but you do not sign documents permitting them to pay you reduced wages that reflect the lower paying job that you are currently working. In general, however, modification petitions are filed when the insurance company uses a vocational expert to give an opinion about your earning power, which is discussed below.
If the insurance company has filed a petition to cut off or reduce your workers' compensation benefits, the lawyer for the insurance company will make a preliminary motion called a supersedeas request in which the insurance company asks that your benefits be cut off pending the final outcome of the case. Ordinarily you will not testify at the first hearing on a petition filed by the insurance company. Instead, you and your lawyer will prepare a sworn written statement called an affidavit and obtain a medical report for submission to the court. If you are still disabled, supersedeas requests are usually denied and the insurance company must continue paying benefits. At the same time, the judge will approve your lawyer's fee, which will soon be deducted from your compensation. You will probably testify at the last hearing. At the end of any case, including cases you file, the judge directs the parties to submit proposed findings and conclusions of law that summarize the evidence. Normally all parties file these findings within 90 days of the last hearing, after which the judge will issue a final decision.