So, you are a carpenter, a good one, and during your lunch break, you recently stepped down out of a new construction house with temporary stairs. The stairs gave way and you tore your ACL, MCL, meniscus, and your Achilles tendon on your right leg. Your company does the right thing, and you begin to receive Workers’ Comp Benefits at about 2/3 of your pay for the last month. You are getting paid, you are pretty sure the insurance company paid for the surgery you needed on your knee and your ankle. The recovery is going really slowly, but you are starting to see progress.
A few weeks after your surgery, you get a notification, via email, from your pharmacy, that your pain medications are not being refilled because your claim is still being investigated. “Wait a minute” you think, they are already paying me, and they paid for my surgery and all the other treatment I needed? Your pain medication is about to run out and now suddenly an insurance company is telling you that they are not going to pay for the medication that your surgeon recommended? Frustrated, you bill your regular health insurance instead of workers’ comp for the pain medication, and pay the co-pay. “I don’t know how much the copay will be, but I am not waiting around any longer, in pain!” you think. The next email tells you that the surgery on your knee and Achilles has now been deemed not related to your work injury. You think, “I just fell down some steps that were supposed to be secure, and my employer’s workers’ comp carrier just decided that my surgery was not related to the work injury?”
The hospital has already billed your health insurance for the surgery, and you now receive a co-pay notification that you owe around $12,000 for the surgery you just had. Two days later you get a letter in the mail from the workers’ comp insurance carrier. The letter inside looks like it is from Harrisburg. The top reads “Notice of Denial,” and you think, what the heck does that mean? My incredibly obvious injury has been denied? You turn the form over and see box 1 checked off — at the bottom of that paragraph there is a sentence. “Knee and ankle strain injury denied because of pre-existing injury.” However, you never hurt your knee or ankle before. You have never even had any knee or ankle pain before. You have never seen a doctor for your knee or ankle. What could this insurance carrier possibly be talking about?
You have never been through a worker’s comp case. You have never been injured at work. You have never been sitting at home wondering how you are going to pay your mortgage, but after you receive the denial, the checks that you were receiving stop. The workers’ comp carrier has refused to pay for any of your medical bills.
Your employer just cancelled your health benefits because you have been out of work for over 30 days, and that’s their policy. So, you now have a denied workers’ comp claim and no health insurance, and you are sitting in a recliner in a cast and boot. Oh, and let’s not forget, your pain medication has run out so, odds are, you will not be sleeping tonight.
You think, “how can an insurance company do this? Why is my claim being denied?” You call your employer. You ask for the manager of the plant and are told he is busy and will call you back. You wait a few days and no call back. So, you call again, and again, and again. No call backs and no explanation. Finally, you ask a now “former” co-worker, hey what did you hear about my injury? Do you know why my claim was denied? “We heard that you crashed you motorcycle a few days before your so-called work accident!” “Who told you that?” you say. Then your co-worker gets nervous and tells you he can’t talk about it.
A few days later you are notified by your employer that your position is no longer available. “Wait, I’m fired? Can they do that?”
So, you have not crashed your motorcycle. It’s in mint condition in your garage. You couldn’t possibly ride it because you still can barely walk. Where did this story about my crash come from? Can an insurance company just hear a story and deny a claim? Don’t I have rights? I can barely walk, and I don’t even know my options. Do I have short term disability benefits through work? Did those benefits stop when my employer cancelled my health insurance? If they didn’t, is it a good idea for me to receive short term disability benefits when I know the injury was work related?
The questions continue to pop up. You received workers’ comp benefits for four weeks and then they were shut off. Did the insurance company admit liability when they started paying me and paying for my medical treatment? It wasn’t my fault that I fell on the steps, so shouldn’t I be able to sue my employer and its workers’ comp carrier for pain and suffering? And by the way, who built the steps that caused my fall — wasn’t it that other company? Did the insurance company deny my claim because they felt the accident was my fault? Does it matter if it was my fault or the employer’s fault?
Is there a way that I can rectify all these things?
Well, the clear answer is “yes.” The workers’ comp system is a strange part of the law and there are very specific attorneys that can guide you through this process. The questions above just scratch the surface compared to the number of questions that can be relevant to a workers’ compensation case. The above example of what might happen after a work injury has happened in my practice. You might have started to get checks, and a few appointments might have paid for, but inside of the first 90 days, your benefits could stop without any Judge’s order. “What is the relevance of 90 days?” you ask. “Do I still have to see their doctors now that my claim has been denied?”
Every person’s case is different, but we could write a book filled just with all of the questions that we have heard during our many years of practice in the workers’ comp system. We encourage any injured worker out there to consult with an attorney who has been certified as a specialist in workers’ compensation law by the Pennsylvania Supreme Court before trying to navigate the workers’ comp system on your own. Get expert help today.