Workers’ Comp Denial Playbook — PA, NJ, NY & MD

What To Do When Your Workers’ Compensation Claim Is Denied or Delayed

Workers’ comp insurers deny or delay valid claims as a matter of course. They count on you giving up. This playbook walks you through the response, in order, for PA, NJ, NY, and MD.

Step 1 — Get the Denial Letter in Writing

Every state requires the insurer to provide a written denial that lists the specific basis. If you only got a phone call or a text message saying “denied,” call the insurer and ask for the formal denial letter. You cannot appeal what you do not have on paper.

Step 2 — Read the Reason Carefully

Most denials fall into one of these categories:

• “Injury did not arise out of employment.” The insurer is saying the injury wasn’t caused by your work. Counter with witness statements, supervisor knowledge, and contemporaneous medical records.
• “Pre-existing condition.” Pre-existing conditions don’t bar recovery; aggravation by work injury is itself compensable.
• “Failure to give notice.” Each state has a notice deadline (PA: 21 days notice / 120 days outside limit; NJ: 90 days; NY: 30 days; MD: 30 days). Notice can sometimes be given orally to a supervisor.
• “Independent Medical Examination found you fit for duty.” The insurer’s IME doctor is hired by the insurer. Counter with your treating physician and, where available, an independent expert.

Step 3 — Calendar the Appeal Deadlines

Each state has a strict time window after a denial:

• Pennsylvania: File a Claim Petition with the Bureau of Workers’ Compensation. Statute of limitations runs 3 years from the date of injury.
• New Jersey: File a Claim Petition with the Division of Workers’ Compensation. Statute of limitations is 2 years from the last payment of compensation or the date of accident.
• New York: File a C-3 with the Workers’ Compensation Board within 2 years of the injury or the discovery of an occupational disease.
• Maryland: File a Claim Form with the Workers’ Compensation Commission within 60 days for accidental injury claims; longer windows apply for occupational disease.

Step 4 — Get Your Treating Doctor on Board

The treating physician’s notes are the single most important piece of evidence. Bring the denial letter to your next appointment and ask the doctor to specifically address (in writing) the issues the insurer raised. A “Functional Capacity Evaluation” or detailed restriction note often turns the case.

Step 5 — Document Everything

• Every conversation with the insurer (date, time, who, what was said)
• Every doctor’s appointment and what was said
• Every supervisor / HR conversation about the injury
• Every change in your work status, pay, or position
• Every form, letter, or email exchanged with the insurer

Step 6 — Watch for Surveillance

Workers’ comp insurers commonly hire investigators to photograph and video claimants. Anything you do while claiming injury may be filmed: yardwork, gym visits, social events, even normal daily activities. If your restrictions say no lifting over 10 lbs and there’s video of you carrying groceries, the case becomes much harder. Live within your restrictions in public, period.

Step 7 — Know When to Bring in a Lawyer

Workers’ comp lawyers in PA, NJ, NY, and MD work on a fee that’s set by statute and approved by the workers’ compensation judge — typically 20% of the back-due benefits the lawyer recovers. You don’t pay out of pocket. The fee is a percentage of what you would not have received without representation.

Special Issue — Third-Party Claims

If you were hurt on the job by something other than your direct employer — equipment that malfunctioned, a subcontractor’s negligence, a delivery truck that hit you while you were working — you may have a third-party claim ON TOP OF your workers’ comp claim. The third-party claim recovers pain and suffering and full lost wages, neither of which workers’ comp pays. Always evaluate.

Workers’ comp denied or delayed? Call us at (610) 255-7500. Free case review. We get you paid and keep you paid.