After an accident, you expect your insurer or the at-fault party’s carrier to cover your medical bills, lost wages, and other expenses. In Pennsylvania, though, carriers may delay paying claims or even deny them outright. They may claim a missing form, contest the severity of your injuries, or invoke a policy exclusion.
At Wilk Law Personal Injury & Car Accident Lawyers, we can ensure you have the resources to challenge an unfair denial. Our skilled West Chester personal injury lawyers can look into your medical records, collect witness statements, and build a clear case that holds insurers accountable. Contact us today to schedule a free case review.
Top Reasons Why Personal Injury Claims Get Denied in Pennsylvania
Understanding the common grounds for denial can help you navigate the complex personal injury landscape in Pennsylvania more effectively. Take a closer look at some of the most common reasons why personal injury claims get denied in Pennsylvania:
Missed Deadlines and Statutory Limitations
Missing a deadline under Pennsylvania law can end your claim before it even starts. You usually have two years from the date of your accident to file a personal injury lawsuit. If you file after that window closes, the court may refuse to hear your case.
On top of the state deadline, your insurance policy may also include notice requirements you must meet sooner. If your policy asks you to report your injury or seek treatment within a specific period, you’ll need to follow those rules to keep your claim valid.
It’s also important to note that claims against state or local agencies generally follow a six-month notice rule. You need to send written notice of your intent to seek damages within six months of the incident. If you miss that deadline, your claim can be dismissed, even when you have a valid case.
That is why it is vital to keep a close eye on all timelines. You can consider marking your calendar for the statute of limitations and any policy notice deadlines. This way, you can avoid a denial based on timing and keep your path to recovery open.
Fault Determination and Comparative Negligence
If you’re assigned significant fault, insurers can turn down your case, which is a key reason why personal injury claims get denied in Pennsylvania. In Pennsylvania, a court assigns each party a percentage of fault. Your award then generally drops by that share.
So if you’re deemed 25% responsible for $100,000 in damages, you might receive $75,000. If your fault exceeds 50%, though, you could lose the right to recover any compensation. This means proving the other side’s liability — and keeping your own percentage of fault low — is essential to preserving your claim.
Disputed Accident Fault
Insurance companies frequently deny claims by disputing fault attribution. If they decide you share most of the blame, they can deny your claim outright.
That conclusion may clash with your recollection or with video, photos, and witness reports. In those disputes, a lawyer can gather the right evidence, challenge the insurer’s decision, and help keep your claim on track.
Assumption of Risk
If you knew about a hazard or it was deemed “open and obvious,” you may have taken on that risk yourself. Pennsylvania courts tend to apply this rule most often in slip and fall incidents or accidents involving recreational activities. When a judge finds you voluntarily faced a known danger, your claim can be dismissed.
Insurance Coverage Complications
The structure and limitations of insurance policies create numerous opportunities for claim denials in Pennsylvania.
Limited Tort vs. Full Tort Election
Limited tort keeps your premium lower but narrows your legal avenues. With limited tort, you rely on your own policy for minor injuries and give up the right to sue another driver unless you suffer a “serious injury.” That can leave you covering medical bills and other costs out of pocket.
Full tort costs more up front. But it preserves your right to pursue the at-fault driver for compensation for things like pain and suffering, lost wages, and medical expenses that exceed your policy’s basic benefits.
Policy Exclusions and Fine Print
Your policy may hide limits in a stack of fine print. Some contracts may rule out certain crash types or injuries, while others cap payouts at set levels. Insurers may comb through those pages looking for applicable exclusions that might justify denial.
You’ll want to scan your exclusions before you file. Note any clauses that might apply and gather proof showing your accident and injuries fit under your coverage.
If your insurer still pins a denial on a buried clause, consider bringing in a public adjuster or an injury claim denial lawyer. They can challenge misapplied exclusions and keep your claim moving forward.
Insufficient or Lapsed Coverage
When your policy doesn’t include the right protection or has lapsed due to nonpayment, your insurer cannot be compelled to compensate you. Instead, you may get a direct denial if your coverage is inactive.
In such cases, you may have to pursue other avenues of compensation for your loss, such as filing a claim against the party at fault or seeking a court order. Always ensure your policy is up to date and review your coverage limits before disaster hits.
Failure to Follow Proper Medical Protocols
How and when injured parties seek medical care can significantly impact claim outcomes in Pennsylvania.
Delayed Medical Treatment
Insurers may check how soon you sought care after an accident. If you wait to see a doctor, they may doubt whether your injuries really stem from that incident. They can claim you didn’t take steps to limit your harm and use that as a reason to deny your claim.
Gaps in Your Treatment
Insurance adjusters may review your medical records for any breaks in care. If you skip follow-up visits or don’t complete prescribed therapy, they may question how serious your injuries really are. That can lead to a reduced payout or even a denial.
Keeping every appointment and logging each treatment step shows the true extent of your harm and keeps your claim strong.
Certain Legal Doctrines
Some Pennsylvania rules can block or limit your claim — even when you’ve been injured.
Limits on Suing Government Agencies
If you file a claim against a state or local agency, immunity rules can bar your case if it doesn’t meet a strict exception. These rules dictate which types of harm you can pursue.
Even when your claim goes forward, recoveries cap out at $250,000 per person and $1,000,000 per incident. Those limits can leave you covering any costs that exceed the cap.
The “Open and Obvious” Hazard Rule
If a danger is clear to anyone who walks by, you may have limited options to recover. For instance, if you slip on a puddle of water or a broken step in plain view, courts may say you accepted that risk.
When a hazard is obvious, insurers can use this rule to deny your claim. To counter this, point to lighting issues, distractions, or objects that masked the danger.
Document the scene right away. Photos and eyewitness accounts could show that you couldn’t reasonably avoid the hazard. That evidence can make it harder for an insurer to lean on this doctrine and leave you without compensation.
What to Do if Your Insurance Claim Is Denied
A denial isn’t the end of the road. You still have routes to pursue the compensation you deserve.
Start by asking your insurer to send you a written explanation for the denial. Review it thoroughly to spot missing forms, overlooked receipts, or other paperwork gaps. If an error led to the denial, correct the situation promptly and request reconsideration.
Second, ensure your claim has been well-examined. If your insurer overlooked critical steps, like assessing structural damage or examining medical reports, you can push for a more detailed examination.
Also, make sure to carefully check for any notices or filing deadlines. Your policy may require you to report an accident within a few days or weeks, even though the state statute provides a longer period. Missing these shorter deadlines may result in a denial under the policy’s fine print. If you are approaching a cutoff, it is advisable to file a protective appeal to preserve your right to file.
Finally, consider talking with an injury claim denial lawyer who handles insurance disputes. A lawyer experienced in insurance disputes can spot when a carrier lacks valid grounds. They can guide you through each step, including filing a formal appeal, requesting mediation, or taking the matter to court if needed.
Pennsylvania Personal Injury Claim Denial Lawyers
In Pennsylvania, personal injury claims can encounter numerous obstacles, from strict filing deadlines and disputes over fault to coverage caps and rules that often favor insurers.
At Wilk Law Personal Injury & Car Accident Lawyers, our skilled team can handle the heavy lifting for you by going over your accident information, gathering witness statements and records, and negotiating with insurers and liable parties for fair compensation. Contact us today.