Pennsylvania Workers Comp Claims: Eligibility, Filing and Appeals

How workers' comp works in the state of Pennsylvania.

Worker’s compensation in Pennsylvania is governed by the Pennsylvania Workers’ Compensation Act, and administered by the state Department of Labor and Industries.  Workers’ compensation is responsible for providing benefits to workers that sustain an injury on the job or an illness related to their work.

Benefits are paid in one of three ways: by private insurance companies that provide workers’ compensation insurance, by the State Workers’ Insurance Fund (the state’s insurance), or by the employer if the employer is self-insured.

Covered Employees  

The first question to answer when determining whether you have a Pennsylvania workers’ compensation claim is whether you are an employee covered by the Workers’ Compensation Act in the state. Federal employees, railroad workers, longshoremen, and harbor workers are not covered by the state’s workers’ compensation system, and are instead covered by their own federal systems. Other non-covered workers include volunteers, independent contractors, and domestic workers, since these workers are not considered employees.

Seasonal and part-time workers, though, are covered under workers’ compensation. Similarly, non-profit corporations and unincorporated business must provide workers’ compensation coverage. Employers with as few as one employee must follow the Act’s requirements for providing coverage.

Covered Injuries and Diseases

The next question to answer regarding whether you have a Pennsylvania workers’ compensation claim is whether your injury or disease qualifies for a workers’ compensation claim. It is important to note that Pennsylvania, like most states, covers both workplace injuries as well as diseases arising from occupational conditions.

To be covered, the injury or disease must be sufficiently severe that you require medical treatment beyond simple first aid.  The injury or disease must also arise during the course and scope of your employment. And an occupational disease must have been proximately caused by, or aggravated by, the conditions of your work.

Filing a Workers’ Compensation Claim

You should notify your employer of your injury or disease as soon as possible. You must tell your employer that you were involved in a workplace injury, and describe the injury, place of injury, and the date it happened.  Your employer should then complete the required forms to report your workers’ compensation claim to the Bureau of Workers’ Compensation.

Pennsylvania Workers’ Comp Benefits

If your claim is allowed, you will be eligible for workers’ compensation benefits.  This includes medical benefits, lost wages, permanent partial disability benefits or permanent total disability benefits, and even death benefits for your survivors.

Medical Benefits

Your employer is responsible for covering necessary medical treatment for medical conditions related to your workplace injury or occupational disease. This includes doctor visits, surgery, physical therapy, and appliances such as hearing aids.

When you visit a doctor, inform your doctor that you are seeking treatment for a work-related injury or illness. Your doctor will then bill your employer or your employer’s workers’ compensation insurance carrier.

Wage Loss Benefits for Total Disability  

You may be eligible for compensation for lost wages if you are unable to work due to your workplace injury or illness. Wage loss benefits for total disability are 66.67% of your average weekly wage. However, your weekly benefit cannot exceed a maximum set by state law. As of January 1, 2017, the maximum benefit is $995 per week.

You will be entitled to these lost wage benefits if you are physically unable to work for at least seven calendar days following your date of injury. Provided that you promptly report your injury, and your claim is accepted by your employer or their insurance carrier, you should receive wage-loss benefits within 21 days of your first missed day of work.

After 104 weeks of wage loss benefits are paid, you will typically undergo a medical examination. In the rare case that a doctor assigns you a permanent disability rating of 50% or higher, you will continue to receive wage loss benefits for life. If you receive a disability rating of less than 50%, you will be switched to partial disability status.

Wage Loss Benefits for Partial Disability

Wage loss benefits for partial disability are paid if you are working but earning less due to your injuries, or if you have received a disability rating of less than 50%. These benefits are two-thirds of the difference in your wages, subject to the same maximum as wage loss benefits for total disability. Wage loss benefits cannot continue past 500 weeks (approximately nine years), including payments received for total disability.  

Specific Loss Awards  

If you are permanently disabled as a result of your work-related injury or occupational disease, you may be entitled to a specific loss award. These are monetary lump sum payments to compensate you for permanent impairment to certain body parts, such as a finger, hand, arm, leg, or foot. The benefit is calculated by multiplying two-thirds of your average weekly wage by the number of weeks assigned to the body part in a state schedule.  

Appeals

If you disagree with a decision from your employer or its workers’ compensation insurance carrier, such as a claim denial decision, you may file a petition with the Workers’ Compensation Bureau.    A workers’ compensation judge will conduct a hearing and review your case. You may appeal the decision to the Workers’ Compensation Appeal Board, and you may appeal the Board’s decision to the Commonwealth court.

To learn more, see our article on  Appealing a Denied Pennsylvania Workers Compensation Claim.

For any appeals, you should seriously consider hiring an attorney. The appellate process is legally complex and an attorney can help you navigate the system and advocate on your behalf.

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