Workers’ Comp Fraud Much Lower Than Industry Estimates

April 25th, 2024

Personal Injury Attorney

By Dean I Weitzman, Esq.


For years, the insurance industry has carefully created an image of workers taking advantage of the workers’ compensation system by faking their workplace injuries or making them out to be much worse than they really are. They have blamed injured workers for taking taxpayer money and putting a financial strain on employers who must continue to pay ever-increasing workers’ comp insurance premiums to cover the fraudulent claims.

The truth, however, is that the vast majority of workers’ comp claims are filed by honest, hard-working people who sustained legitimate on-the-job injuries. Rather than trying to take advantage of the system and taxpayers, these people are trying to recover the only benefits they have available to them to help pay for their medical bills and lost wages – expenses they would not have incurred had they not suffered a workplace injury.

While the insurance industry continues to perpetuate the myth that the majority of workers’ comp claims are fraudulent, studies have shown that only 1 to 2 percent of all claims are fraudulent. Studies also have shown that those most likely to commit workers’ compensation fraud are not injured workers, but employers and insurers.

The Pennsylvania Workers’ Compensation Act

Under the Pennsylvania Workers’ Compensation Act, nearly all employers are required to carry workers’ compensation coverage for their workers. This coverage may come from the state workers’ insurance fund, a private insurer or the employer may self-insure. Workers are entitled to workers’ comp benefits for any on-the-job injury, even if the injury was caused by the worker. All types of employees, including full-time, part-time, temporary and seasonal employees, must be covered by the employer’s policy.

Workers’ compensation is generally the only remedy available to workers who are hurt at work. In exchange for providing this coverage, workers are not usually allowed to file legal claims against their employers or other employees to recover additional compensation for their injuries.

Two of the most important types of benefits provided by workers’ compensation are medical benefits and wage-loss benefits:

  • Medical benefits: provide coverage for all reasonable medical expenses related to the work injury, including hospitalization, doctor visits, physical therapy, medications and supplies. Medical benefits are available immediately after the injury and workers do not need to miss any time from work in order to be eligible.
  • Wage-loss benefits: replace some of the income lost by workers who cannot return to work temporarily or permanently due to a workplace injury. Wage-loss benefits only are available to workers who are unable to work for more than seven calendar days as a result of their injuries. These benefits are paid at a rate of two-thirds of the worker’s weekly wages up to the maximum state average weekly wage ($858 for 2011). In general, those who suffer a partial disability only are allowed to collect wage-loss benefits for a maximum of 500 weeks.

Other workers’ comp benefits include:

  • Specific loss benefits for the loss of a specific body part or function, like hearing, vision or use of a limb
  • Disfigurement benefits for serious, permanent disfigurement of the worker’s head, face or neck
  • Subsequent injury benefits for workers who suffered a specific loss injury and then sustained a second specific loss injury, making them totally disabled
  • Death benefits for the family of a worker who dies as a result of a workplace injury

Filing a Claim for Workers’ Comp Benefits

To be eligible for workers’ comp benefits, workers should report their injury to their employers as soon as possible. If a worker fails to report an injury within 120 days of its occurrence, then the worker will be ineligible for benefits.

Once a worker notifies his or her employer of an on-the-job injury, the employer then is required to notify its insurance carrier. In most cases, the employer has seven days to give this notification, except in cases of death when the employer must notify the insurer within 48 hours. Under state law, the insurance carrier is given 21 days from the date of injury to notify the worker whether his or her claim will be accepted or denied.

If the claim is denied, then the worker has the option of filing a claim petition to request a hearing before a workers’ compensation judge (WCJ). The claim must be filed within three years of the date of injury. During the hearing, the WCJ will hear testimony from both sides prior to determining whether the claim for benefits should be granted or denied.

If the WCJ denies the claim for workers’ comp benefits, the worker can appeal the decision to the Workers’ Compensation Appeals Board (WCAB). If the claim is denied by the WCAB, then the worker can file a claim against his or her employer in a Commonwealth Court. The last step in the appeals process is filing a petition with the Pennsylvania Supreme Court.

Third Party Liability for Workplace Injuries

While the workers’ compensation system precludes injured workers from taking legal action against their employers in most situations, it does not prevent them from filing a legal claim against third parties who also may be responsible for their injuries.

Some examples of third party liability claims that may be available after an on-the-job injury include:

  • Product liability claim against a manufacturer, distributer or seller of a defective product
  • Claims against the property owner where the accident occurred
  • Claims against non-employees who were working at the job site, like contractors, sub-contractors

Additionally, there are limited circumstances when injured workers may be able to bring a legal claim against their employers, including in cases when the employer failed to carry worker’s comp insurance or when the employer acted intentionally or criminally. Injured workers also may bring a claim against their employers if they retaliate against them for filing the workers’ comp claim.

Get Help for Your Workers’ Comp Claim

The Pennsylvania workers’ comp system can be difficult to navigate on your own. Some employers and insurance companies can make it very difficult for injured workers to get the benefits they need, forcing them to go through the lengthy appeals process.

An experienced workers’ compensation attorney can help from the initial request for benefits to the final appeal. A workers’ comp lawyer also can determine whether any third parties may share liability for your injuries and file a civil claim against them to recover compensation. For more information on how a Pennsylvania attorney can help you, contact a knowledgeable workers’ compensation lawyer today.

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