DEPARTMENT OF LABOR & INDUSTRY
BUREAU OF WORKERS’ COMPENSATION
WORKERS’ COMPENSATION
AND THE INJURED WORKER
www.dli.pa.gov
This brochure is a general guide for injured workers on the Pennsylvania Workers’ Compensaon Act for work injuries and illnesses occurring on or aer
June 24, 1996. This is general informaon only and does not represent ocial interpretaons of the law. Injured workers are encouraged to discuss
quesons and concerns regarding the workers’ compensaon law and the addional opons with legal counsel.
What is workers’ compensaon?
If you sustain a job injury or a work-related illness, the Pennsylvania
Workers’ Compensaon Act, or Act provides payment for your
medical expenses and, in the event you are unable to work, wage-loss
compensaon benets unl you’re able to go back to work. Addionally,
death benets for work-related deaths are paid to your dependent
survivors.
Benets are paid by private insurance companies (also includes third-
party administrators) or the State Workers’ Insurance Fund (a state-run
workers’ compensaon insurance carrier) or by self-insured employers.
Are you covered?
Nearly every Pennsylvania worker is covered by the Act. Employers must
provide workers’ compensaon coverage for all of their employees,
including seasonal and part-me workers. Nonprot corporaons,
unincorporated businesses and even employers with only one employee
must comply with the Act’s requirements.
Some employees are covered by other compensaon laws, including
federal civilian employees, railroad workers, longshoremen, shipyard
and harbor workers. Others who may not be covered include volunteer
workers, agricultural laborers, casual employees, domescs and
employees who have been granted a personal religious exempon from
the Act. Certain types of execuve ocers of corporaons may elect
exempon from the Act. A worker should seek further informaon if
there is any doubt as to coverage.
If you learn that your employer does not have insurance or is not self-
insured for workers’ compensaon, you may be eligible for benets from
the Uninsured Employer Guaranty Fund. For details, see our website
(www.dli.pa.gov) or call the Bureau of Workers’ Compensaon, toll free,
at 800-482-2383 or locally and outside Pennsylvania at 717-772-4447.
What is covered?
If your work causes an injury, illness or disease, you may be entled
to WC. No compensaon shall be paid when an injury or death is
intenonally self-inicted, or is caused by an employee’s violaon of the
law including, but not limited to, the illegal use of drugs. An injury or
death caused by intoxicaon also may not be covered.
When am I covered?
Coverage begins on the date of hire. Medical benets are payable from
the rst day of injury; payment of lost wages is addressed on Page 3.
How do I get the benets?
Prompt reporng is the key. Report any injury or work-related illness to
your employer or supervisor immediately. You must tell your employer
that you were injured in the course of employment and inform your
employer of the date and place of injury. Failure to nofy the employer
can result in the delay or denial of benets. Once you have lost a day,
shi or turn of work, your employer is required to report your injury to
the Bureau of Workers’ Compensaon by ling a rst report of injury.
The employer may choose to either accept or deny the claim. If your
claim is denied, you have the right to le a claim peon with the bureau
for a hearing before a WC judge.
What are the benets?
The law provides several types of workers’ compensaon benets:
Payments For Lost Wages
Wage-loss benets are available if it is determined that you are totally
disabled and unable to work or parally disabled and receiving wages less
than your pre-injury earnings. Please see the Total and Paral Disability
Benets Status secon for further informaon as to disability status.
Death Benets
If the injury results in death, surviving dependents may be entled to
benets.
Specic Loss Benets
If you have lost the permanent use of all or part of your thumb, nger,
hand, arm, leg, foot, toe, sight, hearing or have a serious and permanent
disgurement on your head, face or neck, you may be entled to a
specic loss award.
Medical Care
Employers are responsible for advising workers of their rights and dues
under Secon 306(f.1)(1)(i) of the Act. The wrien noce of these rights
and dues is to be provided to the employee at the me of injury or as
soon aer the injury as is praccable.
In the event of a work-related illness or injury, you are entled, if covered
under the Act, to the payment of related reasonable surgical and medical
services rendered by a physician or other health care provider.
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Medicine, supplies, hospital treatment and services, orthopedic appliances
and prostheses are also covered for as long as they are needed. (To assure
payment of medical services, see the Choice of Doctor secon.) Even if you
have lost no me from work, health care costs for a work-related injury or
illness are payable at the fee schedule rate. However, an employee may not
be charged the dierence between the health care provider’s charge and
the amount paid by the employer or its insurance carrier. In other words,
there can be no balance billing to you.
If you seek medical treatment outside Pennsylvania, you may be subject to
the risk of balance billing by the medical provider. You should discuss this
with your medical provider prior to iniang treatment.
Choice of Health Care Provider
You are free to choose your own health care provider to treat your work
injury unless the employer accepts your claim and has posted in your
workplace a list of six or more physicians or health care providers. You
are required to visit a provider on the list for inial treatment. You are to
connue treatment with that provider or another on the list for a period of
90 days following the rst visit. You may see any provider on the list; your
employer may not require or direct you to any specic provider on the list.
If a listed provider prescribes invasive surgery, you are entled to a
second opinion that will be paid for by your employer/insurer. Treatment
recommended as a result of the second opinion must be provided by a
listed provider for 90 days.
If during the 90-day period you visit a provider(s) not on the list, your
employer or your employer’s insurance carrier may refuse to pay for such
treatment. Aer the 90 days, and in situaons where your employer has no
posted list or an improper list, you may seek treatment with any physician
or other health care provider you select. You must nofy your employer
of the provider you have selected. During treatment, the employer or the
employer’s insurance carrier is entled to receive monthly reports from
your physician or provider.
Injured workers should be advised that your health care providers may
need informaon concerning your claim. Some of this informaon may
be contained in correspondence you receive from your insurance carrier,
and you may want to provide copies of leers or forms to your health care
provider.
Once you begin receiving WC benets, the employer/insurer has the right
to ask you to see a doctor of their choice for examinaon. If you refuse, the
employer is entled to request an order from the WC judge requiring you
to aend an examinaon. Failure to then aend may result in a suspension
of your benets.
Occupaonal Disease
Occupaonal diseases under the Act are covered if caused by or aggravated
by employment. Your disability must occur within 300 weeks of your last
employment in an occupaon where you were exposed to the hazard.
For certain lung diseases, you must have worked in an occupaon with a
silica, coal or asbestos hazard for at least two years in Pennsylvania during
the 10 years prior to your disability.
Total and Paral Disability Benets Status
Total Disability Benets Status
Applies to injured workers for a period during which they are considered
totally disabled and unable to work. Aer 104 weeks of such status, the
employer/insurer can require a medical examinaon to determine if the
employee is at least 35 percent impaired based upon his/her work injury
according to American Medical Associaon standards. If the 35 percent
threshold is not met, the employee’s status can change to paral disability.
Paral Disability Benets Status
This benet status is for a maximum of 500 weeks. If, while on paral
disability status, you obtain a qualied impairment-rang physician’s
determinaon of impairment that is equal to or greater than 35 percent,
you may le a peon for reinstatement of total disability status.
Paral disability of up to 500 weeks of benets are paid if you can, or do,
return to work at a lower paying job within work-related restricons or you
are found not totally disabled.
How much are the payments for lost wages?
Wage-loss benets are equal to approximately two-thirds of your average
weekly wage, up to a weekly maximum. WC wage-loss benets can be
oset for 50 percent of Social Security (old age) benets, the employer-
paid poron of a rerement pension, severance pay, unemployment
compensaon or other earnings the employee receives. The law does not
allow for a cost-of-living increase.
There are several dierent ways to calculate the average weekly wage
under the Act. The minimum compensaon rate is the lower of 90 percent
of the workers’ average weekly wage or 50 percent of the statewide
average weekly wage.
Reporng Wages and Other Benets Received
Under the Act, any worker who has led a peon for total or paral
disability benets or who is receiving such benets is required to report,
in wring to the insurer, any informaon that is relevant in determining
entlement to, or amount of, compensaon including, but not limited to,
informaon regarding the receipt of wages from another employer or from
self-employment. The worker is obligated to cooperate with the carrier
in an invesgaon of employment, self-employment, wages and physical
condion.
Workers’ Compensaon & the Injured Worker is published by the Dept. of Labor & Industry,
Bureau of Workers’ Compensaon, 651 Boas Street, 8th Floor, Harrisburg, Pa 17121-0750
Employer Informaon
Services
717.772.3702
Claims Informaon Services
toll-free inside PA: 800.482.2383
local & outside PA: 717.772.4447
Hearing Impaired
PA Relay 7-1-1
Email
ra-li-bw[email protected]
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Insurance Fraud is a Crime
The above-menoned reports and other WC forms must be honestly
completed to avoid violang PA fraud provisions.
When are wage-loss payments made?
You must be disabled more than seven calendar days (including weekends)
before WC payments for disability are payable. Benets for me lost from
work are payable on the eighth day aer injury. Once you have been o
work 14 days, you receive retroacve payment for the rst seven days.
If you report the injury promptly, miss more than seven days of work and
your claim is accepted by the insurance carrier, you should receive your
rst compensaon check within 21 days of your absence from work. Aer
that, you will receive a check on a regular basis.
Payments of temporary compensaon may be made by your employer or
the insurance carrier for up to 90 days, even if your claim is not accepted by
your employer or its insurance carrier. If your employer or the company’s
insurance carrier advises you that it will not connue your temporary
compensaon checks past 90 days, or if they deny your claim, you have the
right to le a claim peon with the Oce of Adjudicaon for a hearing if
you believe you are entled to benets.
Oer of Employment
If, aer you begin to receive benets, your employer has evidence to prove
that employment is available to you, within your medical restricons and in
your local area, you may receive an oer of employment.
If you decline the job oer, the employer may then peon a WC judge
to either reduce or stop your wage-loss benets based upon that job. The
insurer/employer must connue to pay benets during the hearing process
unless the judge orders otherwise.
In open hearings, the judge will hear and receive medical evidence, both
from you and your insurer/employer, on the availability of the work and
your ability to do it, before rendering a decision.
When Wage-Loss Payments Stop
Wage-loss benets can be stopped by an employer/ insurer that has
evidence that you have returned to work at wages equal to or more than
your earnings level prior to the injury and aer providing a mely noce of
that fact. If you are receiving temporary compensaon benets during the
90 days following the report of injury, the insurance carrier/employer may
nofy you they are stopping benets because they are not accepng the
claim of a work-related injury.
Other reasons that benets may be stopped include, but are not limited to:
a WC judge stopped benets aer a hearing; the employee signs either a
supplemental agreement or an agreement to stop workers’ compensaon
(commonly referred to as a nal receipt); the 500-week
period of paral disability status expires.
What if there is a problem?
If you think you haven’t received benets that you are due, contact
your employer or your employer’s insurance carrier. The insurance carrier
is allowed 21 days from your noce to the employer of your disability to
decide to accept or deny your claim or to make payments of temporary
compensaon for up to 90 days.
Cooperave communicaon with your insurance carrier and employer
is recommended. If the problem is not resolved, it may be necessary for
you to le a peon with the Oce of Adjudicaon. Forms can either
be obtained online at www.dli.pa.gov or through the Claims Informaon
Helplineat 800-482-2383. The Oce of Adjudicaon is responsible for
resolving disputes by assigning peons to WC judges who decide each
case aer holding hearings on the issues.
Time Limits
Unless an employer has knowledge of the injury or the employee gives
noce to the employer within 21 days of the injury, no compensaon is
due unl noce is given. Noce must be given no later than 120 days aer
the injury for compensaon to be allowed. If your request for WC benets
is denied by your employer or your employer’s insurance carrier, you have
three years from the date of injury to le a claim peon.
In occupaonal disease cases, injury/disability must occur within 300
weeks from the date of last employment in an occupaon in which you had
exposure to a hazard, and a peon must be led no later than three years
from the date of injury/disability.
Failure to le a peon on a mely basis may result in forfeiture of your
right to benets.
If your benets were terminated, you may le a peon to reinstate WC
benets within three years aer the date of your most recent WC check.
If your benets were suspended, you may le a peon to have benets
reinstated. This peon must be led within 500 weeks from the date of
suspension.
Payment of medical benets by your employer does not mean that your
claim has been accepted or reopened.
Alternave Dispute Resoluon
In alternave dispute resoluon, a WC judge helps the pares sele the
case by talking through their dierences. Alternave dispute resoluon
may take the form of mediaon, selement conference or informal
conference.
If either you or your employer les a peon with the Oce of
Adjudicaon, the WC judge will schedule mediaon unless a judge
determines it would be fule. If the case does not sele at this mediaon,
the pares may resume mediaon or a selement conference later in
the proceedings. The pares may also request mediaon or a selement
conference later in the proceedings if the judge had previously found
mediaon to be fule.
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You may also request an informal conference to try to resolve your issues.
If you are not represented by an aorney at an informal conference, your
employer is not entled to be represented either. Informal conference
forms are available online at www.dli.pa.gov or through the Bureau of
Workers’ Compensaon Claims Informaon Helpline at 800-482-2383.
Do I need an aorney?
You may represent yourself in WC proceedings, but a non-aorney
cannot represent you. However, you should be aware that WC ligaon is
complex, and your employer or your employer’s insurance carrier will be
represented by an experienced aorney. If you hire an aorney, you should
discuss fee and cost arrangements. The fee agreement must be approved
by a WC judge or the Workers’ Compensaon Appeal Board. Your local bar
associaon, or the Pennsylvania Bar Associaon’s Lawyer Referral Service
at 800-692-7375, can help you nd an aorney.
Appeals
WC judge decisions can be appealed to the Workers’ Compensaon Appeal
Board and then to Commonwealth Court. You will be informed of appeal
rights upon receiving the WC judge’s decision.
Other Benets
If the injury is a very serious one where you won’t be able to work for a
year or more you may be eligible for addional disability benets from
Social Security. For informaon, visit the Social Security Administraon’s
website at www.socialsecurity.gov or contact your nearest Social Security
Administraon oce.
General Informaon
If you require a special accommodaon to parcipate in a hearing due to a
physical impairment, or need a sign language interpreter or an interpreter
for your own language other than English, without cost, request one
online at www.dli.pa.gov or contact the Bureau of Workers’ Compensaon
Helpline and describe the accommodaon:
Email: [email protected]
Helpline voice telephone numbers:
toll free in Pennsylvania: 800-482-2383
local and outside Pennsylvania: 717-772-4447
Only people with hearing loss:
PA Relay 7-1-1
You may also ask your employer or supervisor for informaon on WC or
contact your employer’s WC insurance carrier, your union or an aorney.
The WC Act is available on the department website at www.dli.pa.gov.
Auxiliary aids and services are available upon request to individuals with disabilies.
Equal Opportunity Employer/Program
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