Inside the Workers’ Comp Process in Pennsylvania

What you need to know when you’re hurt on the job

Although some of the nation’s most robust protections for injured workers are found here in NEPA and throughout the state of Pennsylvania, moving through the process can still be a challenge. You need to know your rights in order to get all the compensation you’re entitled to receive for your medical treatment and lost wages.

What’s covered by workers’ compensation in Pennsylvania

The Pennsylvania Workers’ Compensation Act requires every employer with at least one employee to participate in the workers’ compensation program. Every employee – part-time, full-time, or seasonal – is covered by workers’ comp, and there is no wait time for benefits; if you are injured on your first day of work, you’re covered. The only exceptions are certain specific professions that are covered under other programs, such as railroad workers and government employees. Note that workers’ compensation only covers employees, not independent contractors, freelancers, or consultants.

Workers’ compensation covers injuries that happen “in the course and scope” of employment. That’s not necessarily limited to injuries that occur on the employer’s premises; for instance, if you are hurt while on a business trip, performing work on a client’s premises, or out running an errand for your employer, that injury is also compensable. However, workers’ compensation does not cover your commute to and from work, except for whatever portion of your commute is on your employer’s premises (for instance, injuries in the company parking lot) as well as any portion of your commute when you are following specific instructions from your employer. For instance, if your employer tells you to park in a lot across the street from your actual workplace, and you are injured while crossing the street, that is a compensable injury.

According to O’Malley & Langan attorney Mary Anne Lucas, “Workers’ comp is a “no-fault” system, so your injuries should be covered even if your own carelessness caused them. The only requirement is that you were at work when the injury happened.” There are a few exceptions, though: you generally can’t get workers’ compensation if you intentionally injured yourself, were under the influence of drugs or alcohol when the injury happened or were injured in a fight or fooling around at work.

The process begins on the day of the injury

The first critical milestone in a workers’ compensation claim in Pennsylvania is the date of the injury itself. Whether you live in Scranton, Wilkes-Barre, or another city in our beautiful Commonwealth, you have 21 days from the date of the injury to report it to your employer without compromising your legal rights. After 21 days but within 120 days from the date of the injury, you can still report the injury and get workers’ comp from that point forward, but you lose your right to retroactive benefits for the time before you reported it. After 120 days, you can lose your right to workers’ compensation entirely unless the employer was already aware of the injury.

For injuries that happen at a specific moment in time – for instance, if you fell and broke your arm – the date of the injury is obvious. For injuries that occur over a period of time, like repetitive stress or cumulative trauma injuries (such as carpal tunnel syndrome), the date of the injury for workers’ compensation purposes is the date you became aware or should have become aware, the injury was work-related. However, where it can be established that ongoing work activities aggravated the condition, the last day of work or the last day on which the aggravation occurred (if employee switches to a light-duty job) is the date of injury.

“Practically speaking, it’s in your best interest to report the injury as soon as possible,” says O’Malley & Langan’s newest attorney Joseph Grady. “The longer you wait, the easier it is for your employer or their insurance company to dispute whether the injury was work-related.”

Legally, you can report the injury to your employer verbally or in writing. The only requirement is that you tell a supervisor, manager, human resources, or someone else in charge at your employer; merely telling a coworker doesn’t count. However, it’s in your interest to make sure you have a record of the report. However, it’s in your interest to report the injury in writing so that you have a record of the report.

How medical treatment works for on-the-job injuries

Under the PA Workers’ Compensation Act, employers can establish a list of designated healthcare providers. The requirements for this list include:

• There must be at least six providers on the list, at least three of whom must be physicians, and each provider’s name, address, telephone number, and specialty must be included on the list.
• The employer must provide a clearly written notice to the employee describing the employee’s rights and duties, and this notice must be signed by the employee at the time of hire, at any time when changes are made to the list of providers, and at the time of injury.
• The listed providers must be geographically accessible (i.e., within a reasonable distance of the place of employment) and must contain the appropriate specialties for anticipated work-related medical problems.

If the employer-provided list meets all the legal requirements, then you may only go to the providers on the list to get treatment for your work injury, for the first 90 days after the injury. You are free to choose whichever provider you like from the list (the employer cannot direct you to a specific provider), and you are free to switch from any provider on the list to any other provider on the list.

There are several circumstances in which you can go to a provider not on the list for treatment during the first 90 days:

• You can receive emergency treatment for your injury from any provider. In other words, in the immediate aftermath of an injury, you can go straight to the emergency room; you don’t have to check the list to make sure that emergency room is on it.
• If a provider on the list refers you to a provider not on the list, you can receive treatment from the referred provider.
• If a particular type of specialty care is reasonable and necessary for your work injury, and the list does not include a provider in that medical specialty, you can see a provider of your choice for that specialty care.
• If a provider on the list prescribes surgery, you can go to a provider of your choice for a second opinion. If the second opinion recommends a different course of treatment, you can choose either the originally prescribed surgery or the treatment prescribed in the second opinion. However, you can only go off the list for the second opinion itself; if you choose the treatment prescribed in the second opinion, you must receive that treatment from a provider on the list for 90 days after you saw the provider of the second opinion.

After the first 90 days, you are free to see the provider of your choice for any reasonable and necessary treatment for your work injury. However, you are required to notify your employer if you receive treatment from any provider who is not on the list within five days of the first visit to the provider.

Click here to download a printable version of the "Medical Treatment for a Pennsylvania Work Injury" infographic.

How the claims process moves forward in Pennsylvania

Once the employer receives notice of an injury, they must immediately report the injury to their workers’ compensation insurance carrier. In addition, they must file a First Report of Injury with the Pennsylvania Bureau of Worker’s Compensation.

Within 21 days of receiving notification, the insurance carrier must issue one of three notices:

• Notice of Compensation Payable: the carrier accepts liability for the injury and issues a notice to the injured worker.
• Agreement for Compensation: the carrier accepts liability for the injury and issues an agreement to the injured worker.
• Notice of Temporary Compensation Payable: the carrier extends the investigation period for 90 days and does not accept or deny full liability for the injury. After the investigation is complete, the carrier must issue either final approval or denial of the claim.
• Notice of Workers’ Compensation Denial: the carrier denies compensation and closes the claim. The injured worker’s recourse at this point is through the litigation system.

Calculating compensation for your lost wages

For as long as you are out of work due to the injury, workers’ comp generally pays two-thirds of your “average weekly wage;” that is, the amount of pay you were receiving prior to the injury. Your average weekly wage is based on your gross wages from all employers as of the time of the injury, including overtime, bonuses, tips, vacation pay, and payments for lodging if your job involved overnight travel. There is a state maximum based on the statewide average weekly wage, which is updated every year. There are also adjustments for low-paid employees.

In Pennsylvania, there is no specific end date for compensation for your lost wages if you are totally disabled. You can receive up to two-thirds of your pre-injury wages for the rest of your life if you are permanently unable to work. However, after two years (104 weeks) of compensation, you may be required to undergo a medical exam called an Impairment Rating Evaluation (IRE) to calculate your percentage of permanent impairment. The results of the IRE can sometimes limit you to no more than 500 weeks of future benefits.

If you are partially disabled because of a work injury and need to work reduced hours or take on lighter duties for lower pay, workers’ compensation will pay two-thirds of the difference between your current wages and pre-injury wages. These partial disability benefits last for a maximum of 500 weeks.

Specific loss benefits for permanent injuries

If a work injury causes the loss of a body part (for instance, amputation), or a substantial loss of function of a body part, the injured worker is eligible for specific loss benefits. Pennsylvania law sets both a “specific loss award” and a “healing period” for injuries to each body part, according to the following table:

Click here to download a printable version of the Specific Loss Benefits and Healing Period infographic.

Each week of benefits in a specific loss award is equal to 2/3 of your average weekly wage. If you sustain loss of use of multiple body parts, you get the combined specific loss weeks for both losses, but only the longer healing period applies. For instance, a worker who loses a thumb and index finger would get 150 weeks of specific loss benefits, but only a 10-week healing period (for the thumb) since that is the longer of the two healing periods.

While the healing period requires that you be out of work to heal, the specific loss benefits can be paid even if you don’t miss a single day of work.

Appealing a denied workers’ comp claim

“When a workers’ compensation claim is denied, the employee has three years from the date of the injury to file a claim petition to bring the case before a workers’ compensation judge. Injured workers can also reopen their claim within three years from the last day an indemnity payment (that is, payment for lost wages) was made on the claim,” says attorney Todd. J. O’Malley, founder of O’Malley & Langan and recipient of the prestigious Super Lawyer designation for his professional achievements.

After the claim petition is filed, the case is assigned to a workers’ compensation judge, typically located in the county where the employee lives, and a hearing is scheduled. At the hearing, the workers’ compensation judge hears evidence presented by both the claimant (the injured worker) and the defendant (the employer or insurance carrier). Depending on the complexity of the case, multiple hearings may be needed to hear all the witnesses and medical evidence.

Typically, the judge will schedule the case for mediation. The parties are also free to ask for an informal conference or settlement conference with a judge to resolve the claim. If a settlement is not reached via mediation or conference, the judge will render a decision, and the case is closed.

Either party can appeal the judge’s decision to the Workers’ Compensation Appeal Board within 20 days of the date the decision is circulated to the parties. The Appeal Board’s decision can be further appealed to the Commonwealth Court of Pennsylvania within 30 days, and the Commonwealth Court’s decision can be appealed to the Supreme Court of Pennsylvania within 30 days.

The value of strong legal representation in this process

Pennsylvania’s workers’ compensation process is complex, and there are numerous legal nuances that affect how much an injury is worth. Strict deadlines must be met, and every detail must be accounted for to ensure that you get the full compensation you’re entitled to receive by law. The workers’ compensation insurance company won’t make this easy. They have attorneys and adjusters working hard to minimize their costs. You need an experienced advocate on your side to protect your rights.

If you’ve been hurt on the job in Pennsylvania, contact O’Malley & Langan for a free consultation.

Ask all the questions you like and get answers regarding your legal rights and options. We’ll be happy to take the time to sit with you and talk things out. There’s absolutely no risk and zero obligation to hire us. Why not let us lend a hand and put your mind at ease? Contact us today.