Pennsylvania Workers Compensation Insurance Claims Guide

When an Employee Is Injured: Immediate Steps

1. Ensure the employee receives medical attention immediately. Workers' comp provides no-deductible medical coverage from the first dollar. Get the employee treated — do not delay due to coverage questions.
2. Direct them to an employer-designated medical provider (for the first 90 days). Pennsylvania allows employers to designate a panel of healthcare providers for the first 90 days of treatment. After 90 days, the employee may choose their own provider. Maintain a posted list of designated providers (LIBC-9 form) in your workplace.
3. Report the injury to your insurer immediately. Most carriers require notice within 10 days. Delayed reporting can complicate the claim. Note: As an employer, you have 21 days to file a First Report of Injury (FROI) with the Bureau of Workers' Compensation for injuries resulting in more than 7 days of lost time.
4. Implement your return-to-work program. Get the employee back to work in a modified or light-duty capacity as soon as medically cleared. This reduces wage replacement costs — the largest driver of claims expenses and your future EMR.

What Benefits Are Available to Injured Workers in PA

• Medical benefits: All reasonable and necessary medical treatment related to the work injury, with no deductible or copay for the employee. Includes hospitalization, surgery, physical therapy, medications, and medical equipment.
• Temporary total disability (TTD): If the employee cannot work at all, they receive 2/3 of their average weekly wage (AWW), up to the state maximum (approximately $1,273/week for 2026). Benefits continue until the employee returns to work, reaches maximum medical improvement, or the claim resolves.
• Temporary partial disability (TPD): If the employee returns to light duty at reduced wages, they may receive up to 500 weeks of partial benefits covering 2/3 of the wage difference.
• Specific loss benefits: Fixed statutory payments for permanent loss of specific body parts or functions (loss of a hand, loss of hearing, permanent vision loss, etc.).
• Death benefits: If a work injury results in death, the worker's dependents receive weekly wage replacement benefits and funeral expenses up to $3,000.

How Claims Affect Your Future Premium (The EMR Impact)

Every claim you file becomes part of your loss history. After 3 years of coverage, the PCRB calculates your Experience Modification Rate (EMR) by comparing your actual claims losses to the expected losses for businesses your size and type.

The math: a business with $10,000 base annual premium and an EMR of 1.30 pays $13,000. An EMR of 0.80 pays $8,000. A $5,000 injury today can cost $3,000/year in premium increases for the next 3 years — potentially $9,000+ in total impact.

This is why proactive claims management and return-to-work programs have a high ROI beyond just the immediate claim cost.

Disputed Claims

If your carrier disputes a claim (challenging whether the injury is work-related, the extent of disability, or the treatment plan), the claim enters a formal dispute process:

• The carrier issues a Notice of Compensation Denial (NCD) or Notice of Temporary Compensation Payable
• The employee may file a Claim Petition with the Bureau of Workers' Compensation
• The petition is heard by a Workers' Compensation Judge (WCJ)
• Appeals go to the Workers' Compensation Appeal Board, then the Commonwealth Court

Disputed claims significantly increase costs — both legal fees and the potential for larger awards if improperly denied. Work with your carrier's claims team and provide full documentation to support the claim or denial decision.

How to Reduce the Impact of Claims

• Designate medical providers — Using your panel providers for the first 90 days gives you more control over the treatment direction and timeline
• Return-to-work program — Light duty saves wage replacement costs immediately and limits EMR impact
• Proactive communication — Stay in contact with the injured worker throughout their recovery
• Safety investment — The only way to permanently reduce claim frequency and cost
• EMR appeal — If your EMR calculation appears incorrect, you can petition the PCRB for a review