Workers Comp Defense FAQs

Defense means protecting an employer's legal and financial interests when a claim is filed. That includes investigating whether the injury actually occurred, whether it happened at work, and whether the medical treatment and wage-loss amounts being claimed are accurate.

Defense attorneys work with employers, insurers, and third-party administrators to challenge claims that are invalid, inflated, or improperly documented.

Early involvement is key. Pulling time records, backing up surveillance footage, and interviewing staff and supervisors can really pay off later in the game.

Under the Pennsylvania Workers' Compensation Act, employers may raise several defenses, including:

• Intoxication: The employee was under the influence of drugs or alcohol at the time of the injury, and the injury was a result of that intoxication.
• Willful misconduct or horseplay: The injury resulted from deliberate violation of known safety rules or unauthorized conduct.
• Self-inflicted injury: The employee intentionally caused the harm.
• No causal connection: The injury is not work-related. It stems from a pre-existing condition, a personal activity, or an incident that did not occur in the course of employment, and has not been aggravated by work activities or a discreet incident.
• Failure to report: The employee did not give timely notice as required by Pennsylvania law. (within 120 days of the incident)

Contesting with the above reasons can be difficult to prove. As mentioned, early involvement is important.

Under Pennsylvania law, an injured employee must notify the employer within 21 days of the injury. Failure to report within 21 days may result in reduced or delayed benefits.

If the employee fails to report within 120 days, the claim is barred entirely. This is a hard cutoff. Employers should document the date they first received notice of any injury.

Disputing severity is one of the most common moves in a contested claim, often characterized as challenging the "nature and extent" of the injury or disability.

Two tools are commonly used:

• Independent Medical Examinations (IMEs): The employer can request that the employee be evaluated by a doctor the employer picks. If the IME physician concludes the injury is less serious than claimed or that the employee can return to work, or that the employee has fully recovered, that finding can be used to potentially reduce or terminate benefits.
• Modified duty / return-to-work offers: If a doctor clears the employee for light or restricted work, the employer can offer a modified position. If the employee refuses reasonable modified duty without good cause, wage-loss benefits can be reduced or suspended

An IME is not a second opinion but rather a formal evaluation.

The physician reviews all medical records, then conducts a physical examination. Their job is to provide context to the following questions:

1. Is the diagnosis consistent with the reported injury?
2. Has the treatment been reasonable and necessary?
3. Can the claimant return to work, and in what capacity?

Consistency matters as much as physical findings. A claimant who reports severe limitations but demonstrates normal strength and range of motion during the examination has a credibility problem. That inconsistency goes into the report.

If the IME finds that the claimant can return to work and the employer makes a valid job offer, a refusal may result in a petition to halt wage-loss benefits.

One practical note: Make every effort to choose a physician known for credible, well-reasoned reports. A one-sided IME can cause more harm than good at a hearing.

If the employee returns to their pre-injury wage, wage-loss benefits stop entirely. If they return at a reduced wage, benefits are recalculated accordingly.

The process requires a Notice of Ability to Return to Work issued by the treating or IME physician, followed by a job offer that falls within the employee's medical restrictions. If the employee refuses a valid, within-restriction offer without good cause, the employer can petition to suspend or modify benefits.

Documenting the offer properly, including the specific duties, hours, and wage, will help ensure that the petition succeeds. A vague job offer is easy to reject.

This is one of the most-contested areas in Pennsylvania workers' comp. An employer is not responsible for a pre-existing condition itself, but may be liable if work activities aggravated or accelerated that condition.

The key question is whether work was a substantial contributing cause of the current disability. Medical records, employment history, and IME testimony are all vital in these disputes. Judges will scrutinize competing opinions.

Surveillance is a legitimate and commonly used defense tool in Pennsylvania workers' compensation cases. Video footage showing a claimant doing activities inconsistent with their claimed limitations can directly undermine the credibility of their disability claim.

These could support a petition to modify or suspend benefits:

• lifting heavy objects
• engaging in physical recreation
• working another job

Surveillance must be conducted lawfully. Employers and their investigators may observe and record claimants in public places where there is no reasonable expectation of privacy. Entering private property or recording in areas where privacy is expected is not permitted and can expose the employer to separate legal liability.

Social media is equally relevant. Courts and workers' compensation judges have considered posts, photos, and videos that contradict a claimant's reported limitations. A claimant who posts photos of themselves hiking or playing sports while collecting total disability benefits has created significant evidence problems.

Employers should monitor publicly available social media activity in any claim where the extent of disability is in dispute.

Pennsylvania's workers' compensation system includes a medical fee review process. Providers can dispute the amount of reimbursement for individual bills by submitting a fee review request through the Bureau of Workers' Compensation. The deadline to file is 30 days following notification of a disputed bill or 90 days from the original billing date, whichever is later.

This process evaluates whether the charges comply with the established fee schedule. Employers can also challenge the need for ongoing treatment through utilization review. The review process has no fixed timeline, though it typically takes several weeks to a few months before a decision is issued.

Utilization review (UR) is a formal mechanism under Pennsylvania law that allows employers and insurers to challenge the reasonableness and necessity of ongoing medical treatment. A UR request triggers a review by a licensed healthcare provider in the same specialty as the treating physician.

If the reviewer determines the treatment is not medically necessary, the employer is no longer required to pay for it. UR is particularly useful when an employee is receiving extended treatment for an injury that appears to have resolved. It is also one of the most underused tools available to employers.

The UR process can also be used prospectively. This process is called prospective utilization review or review before treatment. PA's UR process under the Workers' Compensation Act is generally retrospective or concurrent in practice.

A Compromise and Release Agreement (C&R) is a full and final settlement of all or a portion of a workers' compensation claim. The claimant receives a lump-sum payment in exchange for releasing all future claims against the employer and insurer related to that injury.

C&Rs must be approved by a workers' compensation judge. For employers sitting on a claim that has dragged on for two or three years, a C&R is often the fastest path to capping their exposure and closing the file.

Speed and documentation often give you more options later. Employers should:

• Record the date and time the injury was reported.
• Conduct an incident investigation and preserve any physical evidence or surveillance footage.
• Notify the insurance carrier promptly.
• Document any witnesses and their accounts.
• Provide the injured worker with the required Panel of Physicians notice if one is in place.

Employers with a designated panel of physicians can direct employees to one of those providers for the first 90 days of treatment. That panel must be properly posted and communicated in advance.

Pennsylvania law allows employers to maintain a list of at least six designated physicians, including at least three who are not coordinated care organizations. If the panel is properly established and posted, the employer can direct the injured employee to one of those physicians for the first 90 days of treatment.

This potentially gives employers more control over early medical management. That means the first doctor to evaluate the injury, set restrictions, and recommend treatment is someone the employer selected, not someone the employee found on their own.

As early as possible. The decisions made in the first days and weeks after a claim is filed can determine the direction of the entire case.

Those decisions typically include how the claim is characterized, what documentation is preserved, and whether a panel physician program is properly invoked.

You should contact counsel immediately if a claim involves serious injury with significant wage-loss exposure, if there are red flags suggesting fraud or exaggeration, if the employee has retained their own attorney, or if you are considering a return-to-work offer or a Compromise and Release.