PENNSYLVANIA WORKERS’ COMPENSATION
CASE SUMMARIES
3/1/2026 – 3/31/2026
NOTICE
CLAIMANT IS THE EMPLOYER
Erie Ins. v. David Heater (WCAB)
Supreme Court of Pennsylvania – Published Opinion
Decided: March 26, 2026
Issue:
Whether Section 311 requires an injured employee who is a sole proprietor to notify his insurer of his work-related injury within 120 days of the injury?
Background:
Insurer appealed decision of the Workers’ Compensation Appeal Board, which affirmed workers’ compensation judge’s determination that claimant, who owned sole proprietorship and was his own employer, was entitled to disability benefits. The Commonwealth Court reversed. Claimant filed petition for allowance of appeal, which was granted. The Supreme Court held that the Workers’ Compensation Act’s notice provision does not require an injured claimant who is the sole employee and owner of a business to notify his insurer of his work-related injury within 120 days in order to be eligible for compensation. Specifically, Heater was the sole owner and employee of a general contracting business. Appellant applied for workers’ compensation insurance. On the application, Heater identified “David W. Heater” as the insured business. Erie issued a Policy. Appellant allegedly fell from a ladder and fractured his neck, requiring immediate surgery. Appellant sought workers’ compensation benefits under the Policy. Erie, maintained that it did not receive timely notice of Appellant’s injury because Appellant did not give notice of his injury or disease to the employer within 120 days. Appellant filed a claim petition. The Commonwealth Court reversed the Board’s decision, holding that, because Appellant did not provide timely notice to Erie pursuant to Section 311, he forfeited his right to compensation. Having determined that Section 311 is ambiguous, the Commonwealth Court turned to the Statutory Construction Act to ascertain the legislature’s intent.
Holding:
Pursuant to Section 311 of the Act an employee who suffers a work-related injury must give notice to his employer within 120 days of the injury; if such notice is not provided, compensation is disallowed. The Workers’ Compensation Act’s notice provision does not require an injured claimant who is the sole employee and owner of a business to notify his insurer of his work-related injury within 120 days in order to be eligible for compensation. When statutory language is not explicit, but, rather, is susceptible to two or more reasonable interpretations, the statute is deemed to be ambiguous. The Act contains two distinct definitions of the term “employer” – one in Section 401, which includes an insurer, and one in Section 103, which does not include an insurer. However, Section 311 does not expressly indicate which definition of employer applies. In its unanimous opinion, the high court said that if the plain language of the statute creates a problem, that is for the legislature to remedy, not the courts. After an exhaustive review of precedent, the Supreme Court concluded that Section 311 does not require an injured claimant who is the sole employee and owner of a business to notify his insurer of his work-related injury within 120 days in order to be eligible for compensation. The Commonwealth Court incorrectly interpreted “employer” in Section 311 to include insurance companies.
Reversed and Remanded.
FEE REVIEW
WHO IS A PROVIDER
Scomed Supply v. Hartford Accident & Indemnity, et al
Commonwealth Court of Pennsylvania – Published Opinion
Decided: March 16, 2026
Issues:
1. Whether Section 306(f.1)(5) reveals an ambiguity in the definition of “health care provider?” 2. Whether the case law was misapplied? 3. Whether the decision contravenes the Act’s objectives because it leaves Scomed without recourse to challenge payment disputes?
Background:
Scomed dispensed goods to Claimant which included electrodes, batteries, lead wires, moisturizer, and alcohol wipes, all of which are necessary for the use of a transcutaneous electrical nerve stimulation (TENS) unit that had been prescribed by Claimant’s physician for the treatment of a work injury. Scomed dispensed the goods on ten occasions between July 21, 2023, and April 21, 2024, and sent an invoice to Insurer. Insurer rendered payment for less than the full amount billed, and Scomed filed Applications for Fee Review. The Medical Fee Review Section found that no payment was due to Scomed beyond the amount already submitted by Insurer. Scomed filed its Hearing Requests and these were assigned to Hearing Officer Pickens. Insurer contended that Scomed lacked recourse to the Medical Fee Review Section because it was not a health care provider or “anything more than a middleman.” Offered a chance to respond, Scomed declined. The threshold issue of whether Scomed is a health care provider was bifurcated from issue of whether additional payment was due. Hearing Officer Pickens denied the Hearing Requests on the ground that Scomed was not a health care provider as defined by Section 109. This appeal followed.
Holding:
Under Section 306(f.1)(5) of the Act, health care providers who have properly submitted bills and who dispute the amount or timeliness of the payment from the employer or insurer shall file an application for fee review with the department no more than 30 days following notification of a disputed treatment or 90 days following the original billing date of treatment. “Health care provider” is defined in Section 109 of the Act. Under Armour Pharmacy it is within a Hearing Officer’s jurisdiction as to who is a ‘provider’ within the meaning of the Act. First, while the definitions of “health care provider” in Section 109 of the Act and Section 127.3 of the MCC Regulations are not identical, both encompass entities “licensed … by the Commonwealth to provide health care services[.]” Per the PA Supreme Court’s decision in Schmidt, Section 109 defines the term “health care provider … plainly and unambiguously.” Therefore, the Court declined Scomed’s request to expand the definition. Next, however impeccable may be the credentials authorizing Scomed to dispense durable medical equipment, they do not change the fact that such equipment comprises goods, rather than services; thus, such credentials do not transform the business dispensing them into a “health care provider” under Section 109. Next, the Court disagreed with Scomed’s argument that the recent decision in “Schmidt” supports its proposed interpretation of “health care provider.” The Schmidt Court only briefly discussed Section 109’s definition of “health care provider” to establish that a claimant “is not a ‘provider’ as that term is plainly and unambiguously defined under the Act. Finally, the Court disagreed with Scomed’s public policy argument. The statutory language is clear and unambiguous, and the Court cannot redefine definitions or disregard the letter of the statute under the pretext of pursuing its spirit.
Affirmed.
FEE REVIEW
TRAUMA CHARGES
American Select Insurance Company v. York Hosp. , et al (W. C. Fee Review Hearing Off.)
Commonwealth Court of Pennsylvania – Unpublished Memorandum Opinion
Decided: March 27, 2026
Issues:
Whether section 306(f.1)(10) is an unconstitutional delegation of the legislature’s authority? Whether the Hearing Officer erroneously ordered Insurer to pay Provider’s usual and customary charge rather than the usual and customary charge, in general? Whether the Hearing Officer erred when she credited testimony that pharmacy charges are found in a separate formulary rather than a hospital chargemaster?
Background:
Claimant was on the premises of her employer, when she fell down a flight of 13 steps and landed headfirst on a concrete floor. Claimant was immediately taken to Provider’s trauma bay. Claimant underwent an emergency right-sided decompressive craniotomy; duraplasty; evacuations of two, large hematomas, and a temporal lobectomy. Claimant’s condition continued to deteriorate following the surgery until she died as a result of her injuries. Provider sent Insurer a bill for the treatment and services rendered to Claimant from July 8, 2022, until July 10, 2022, requesting payment of $142,460.54. Provider had stamped the word “trauma” in capital letters. In an Explanation of Review, $98,407.61 in reductions were identified based upon other payer data. In response, Provider submitted an Application for Fee Review. Following an investigation, the Medical Fee Review section determined that the amount due to Provider was $98,967.61, plus 10% yearly interest. Insurer then submitted its Request to the Bureau, explaining that the “amount originally paid to Provider was consistent with Provider’s usual and customary charges for the services provided.” In addition, Insurer contended that Section 306(f.1)(10) of the Act as well as Section 127.128(a) of the Act’s Medical Cost Containment (MCC) Regulations unconstitutionally delegated the legislature’s authority. The Hearing Officer directed Insurer to pay the remaining $98,967.61 requested by Provider, plus 10% yearly interest. The Hearing Officer also found that $1,992.72 for anesthesia was still owed to Provider. The Hearing Officer preserved Insurer’s constitutional arguments for further appeal to this Court.
Holding:
Under Section 306(f.1)(10) of the Act, an exception arises when a Level I or Level II trauma center provides “acute care … in an acute care facility to a patient with an immediately life threatening or urgent injury. In turn, Section 109 of the Act provides that life-threatening injury “shall be as defined by the American College of Surgeons’ triage guidelines regarding use of trauma centers for the region where the services are provided.” In such instances, “the amount of payment shall be the usual and customary charge” rather than the Medicare reimbursement rate. As to its first issue, Insurer has failed to establish standing to challenge the trauma exception’s constitutionality in this case. As to the second issue, Insurer’s argument that the Hearing Officer erred by ordering payment of “Provider’s usual and customary charge rather than ‘the’ usual and customary charge.” was rejected. It was Insurer’s burden to establish that its payment amount was proper. Insurer attempted to do so with the cost transparency data, Provider’s Medicare cost report, and a document from Hershey’s chargemaster. The first two categories were found insufficient based on credited testimony that Medicare data cannot be used to “reverse engineer” the charges in a particular case, and the Hearing Officer found that Medicare data are “irrelevant” to the issue of trauma care charges, which are expressly exempt from Medicare price caps. Finally, Insurer never submitted Hershey’s actual chargemaster as an exhibit but only offered testimony that she had obtained Hershey’s chargemaster figures from its website. However, the Hearing Officer declined to credit that testimony. As to the third issue, Insurer’s argument that the Hearing Officer erred by ordering payment of the full amount billed for Provider’s pharmacy charges has no merit. The burden of proof was on the Insurer, not the provider. The Hearing Officer found that Insurer failed to prove that the $3,600.00 for anesthesia services was anything other than the usual and customary charge for such services. The Hearing Officer’s factual findings have adequate support in the record, there was no basis for disturbing them.
Affirmed.
JUDICIAL DISCRETION
NFI Industries v. Fritz Raymond, Jr. (WCAB)
Commonwealth Court of Pennsylvania – Unpublished Memorandum Decision
Decided: March 19, 2026
Issue:
Whether the WCJ and Board erred by relying on medical reports where Claimant’s counsel expressly disclaimed using them to establish an elbow injury?
Background:
Claimant was working as a forklift driver for Employer when he injured a finger on his left hand. Claimant returned to regular-duty work, when he injured his finger again. An urgent care facility treated Claimant’s wound and cleared Claimant for light-duty work that did not require using his left hand for grasping. Claimant was offered light-duty work, which Claimant acknowledged. Because the parties disputed the details of the offer for light-duty work, the parties introduced their respective medical records to establish Claimant’s injury. At the WCJ hearing, the parties discussed the admission of certain medical reports mentioning an elbow injury, and Claimant’s counsel explained that he was offering the report “to show the consistency between” the reports of the treating doctor and the IME and that there counsel was not trying to add the elbow. Employer’s counsel was concerned that Claimant would use the report to establish that he could no longer perform the offered light-duty work that would require use of both hands. Claimant’s counsel stated “That is not the reason we were offering those reports.” The WCJ then admitted the report subject to counsels’ agreement. The WCJ’s decision did not honor counsels’ agreement. The WCJ held that Claimant’s work injury now included his elbow pain and no evidence existed that Employer provided work appropriate to Claimant’s revised injury. The Board affirmed in relevant part.
Hearing:
When parties agree to limit use of the evidence to a single stated purpose, the tribunal may not make findings outside the scope of that agreement. Where (1) the parties agree that certain evidence may be used only for a limited purpose and (2) the opposing party relies on that limitation in presenting its case, then (3) the tribunal may not thereafter disregard the parties’ agreement or consider the evidence beyond the scope of that agreement. The WCJ erred by using evidence beyond the stated purpose of the parties’ agreement. Evidence offered for a limited purpose cannot support findings beyond that purpose. Employer, reasonably relied on the limited purpose for admitting the report and had no opportunity to present evidence on an issue the parties agreed was not before the WCJ. The Board compounded the error by characterizing the reports as “admitted without objection” without acknowledging the conditional basis for that non-objection. Claimant cannot benefit from the WCJ’s disregard of the parties’ agreement. The Court vacated the Board’s adjudication and remanded with instructions that it remand to the WCJ for the issuance of new findings of fact and conclusions of law. On remand, the WCJ was instructed to resolve the claim petition in light of the parties’ agreement limiting the use of the report.
Vacate and Remanded
PENALTY AWARDS
JUDICIAL DISCRETION
Save A Lot v. Sonia Morales (WCAB)
Commonwealth Court of Pennsylvania – Unpublished Memorandum Opinion
Decided: March 12, 2026
Issue:
Whether the Board erred by affirming the WCJ’s award of a penalty and unreasonable contest attorney’s fees as the matter should have been resolved through the Act’s fee review process under Section 306(f.1)(5) of the Act?
Background:
Employer appealed the WCJ’s order which granted Claimant’s Penalty Petition and awarded attorney’s fees against Employer pursuant to Section 435(d) of the Act. The violation was the failure to pay Claimant’s work-related medical expenses. Claimant sustained a work-related injury while working for Employer, for which she received WC benefits. Later a WCJ approved a C&R that resolved indemnity only. Employer remained liable for related, reasonable and necessary medical expenses. Thereafter, Claimant filed the Penalty Petition, therein alleging that Employer violated the Act by failing to timely pay some of the medical bills related to Claimant’s work injury, and seeking penalties and unreasonable contest attorney’s fees. After hearings and presentation of evidence, the WCJ determined that the Claimant met her burden of proof on the Penalty Petition. Based upon the “substantial delay” a 50% penalty on the unpaid bills was awarded. The WCJ further held that the Employer presented a reasonable contest and ordered that an amount equal to 20% of the penalties be paid to Claimant’s counsel as a fee. Employer appealed and the Board affirmed.
Holding:
The WCJ did not lack jurisdiction because the provider failed to avail himself of the Act’s fee review process. Unless an employer disputes the reasonableness or necessity of the treatment provided, all payments to providers are required to be made within 30 days of an employer’s receipt of a provider’s bill. Where an employer fails to pay the bill in its entirety or fails to timely pay the bill, the provider shall file an application for fee review. Notwithstanding, the employer may be subject to penalties to the claimant for unreasonable delays in paying compensation. The fee review provision does not mention employees or claimants at all. There is no language in the fee review provision which limits or conditions an employee’s right to pursue a penalty petition under Section 435 of the Act as a result of a late payment of medical bills. The Court distinguished the holding in Enterprise Rent-A-Car from the holding in Hough because Enterprise Rent-A-Car involved a dispute over the amount due to the provider from the employer and Hough involved a dispute as to the timeliness of the employer’s payment to the provider. Because Employer did not seek utilization review and failed to timely pay the amounts due under the C&R, it violated the Act, and the WCJ had jurisdiction to grant the Penalty Petition related thereto.
Affirmed.
PENNSYLVANIA LEGISLATIVE REVIEW
House Bill 183 is now Senate Bill 1094.
A few months ago, the Commonwealth of Pennsylvania, House L&I Committee, voted on what was then designated as HB 183. This Bill expands access to workers’ compensation disfigurement benefits by increasing the duration of eligibility from up to 275 weeks to a new level of up to 400 weeks, extending the benefit to the entire body, and not just to the head, face and neck, and allowing these benefits to be paid simultaneously with indemnity benefits. The bill was passed by the House on April 7, 2025, and has now been referred to the Senate Labor & Industry Committee. It is now under Senate Bill 1094 and has yet to be reported from the committee.
Other Proposed Legislation of Interest in the 2025-2026 session
The following selected amendments to the PA Workers’ Compensation Act have been proposed, but as of this date are in early stages, and no formal vote has been held, and these are referred to their respective L&I Committees:
In the Senate: (these are still in committee)
Senate Bill 801 – Seeks to clarify that the Act provides the exclusive remedy for any injury or disease that may arise out of hazardous occupational exposure, whether the disease is compensable or not.
Senate Bill 894 – Seeks to clarify the “Independent Contractor Classification.”
Senate Bill 1151 – Removal of Clinical Practice Requirement for Physicians Performing Impairment Rating Evaluations (IREs).
Approved by the Senate on March 24, 2026 – Sent to the House and referred to Committee.
Senate Bill 1053 – Seeks to clarify workers’ compensation coverage for EMS Volunteers.
In the House Only: (these are still in committee)
House Bill 1766 – Workers’ Compensation Coverage of Prescribed Medical Cannabis (Formerly HB 1079).
House Bill 2087 – Ensuring that volunteer firefighters and EMTs are covered under workers’ compensation when injured during fundraising activities.
NEW JERSEY WORKERS’ COMPENSATION
CASE SUMMARIES
3/1/2026 – 3/31/2026
WAIVING SECTION 40 LIEN RIGHTS
Tomaselli v. Petco
Superior Court of New Jersey, Appellate Division
A-2252-24; 2026 WL 585448
Decided: 3/3/2026
Background:
Joseph Tomaselli was employed by Petco and was injured on December 23, 2017. He filed a claim petition for workers’ compensation benefits. Petco answered the claim petition and asserted its rights pursuant to section 40 for a potential third-party lien. Tomaselli subsequently pursued and obtained two third-party settlements from the incident. A letter was sent to Tomaselli’s counsel requesting 1/3 of the third-party settlement that Tomaselli had received. Tomaselli’s counsel forwarded a check for 1/3 of the settlement with a letter stating that it was full and final payment of any outstanding workers’ compensation lien. The check was cashed.
A workers’ compensation Judge later issued a decision on Tomaselli’s case and included that the payment of the lien was full satisfaction of the section 40 lien and any future lien had been waived by agreement of the parties. Petco appealed.
Holding:
The issue was whether Petco waived its section 40 lien by agreeing to accept 1/3 of the third-party recovery. The court found that the waiver resulted from cashing the check after receiving the letter. This conveyed intent to accept the payment as full and final payment of any outstanding workers’ compensation lien. An explicit reference to section 40 lien was not necessary, as the lien rights are encompassed within the plain meaning of any outstanding workers’ compensation lien. If there is a need for a release from the third-party defendant’s carrier, the release should state that a lien still exists as to future compensation benefits, including but not limited to, permanent disability benefits.
Affirmed.
NAMING THE PROPER DEFENDANT
Amtrust North America v. Liberty Mutual Ins. Co.
Superior Court of New Jersey, Appellate Division
A-2587-24; 2026 WL 848822
Decided: 3/27/2026
Background:
An employee was injured while riding as a passenger in a work vehicle. A workers’ compensation lien of $75,339.52 had accrued. The third-party driver had a minimum policy limit of $15,000.00, which was paid to Plaintiff. A balance of $60,339.52 was left on the lien. Plaintiff contends there was also uninsured coverage issued by Liberty Mutual. Plaintiff filed a UIM claim with defendants, which was denied. Plaintiff then filed a declaratory judgment regarding its rights under the policy. It was dismissed for failure to state a claim. Plaintiff filed a complaint pursuant to the Declaratory Judgment Act. Defendant’s motion to dismiss with prejudice was granted. Plaintiff appealed.
Holding:
The court held that the trial court did not err as they did not name the proper defendant. The proper defendant is Ohio Security Insurance Company which issued the policy. The mistake could have been fixed by amending the complaint. Therefore, the court should not have dismissed the complaint with prejudice. The court further imposed a sanction of $1,000.00 on the plaintiff’s attorney for using AI which cited a non-existent case in their brief.
Affirmed in part and remanded for an order dismissing the complaint without prejudice.
NEW JERSEY LEGISLATIVE UPDATE
Assembly Bill 4617
Concerns certain workers’ compensation supplemental benefits and funding method.
Last Action: March 10, 2026 – Introduced, Referred to Assembly Labor Committee
Senate Bill 3984/A1023
Requires workers’ compensation, PIP, and health insurance coverage for the medical use of cannabis under certain circumstances.
Last Action: March 19, 2026 – Introduced in the Senate, Referred to Senate Commerce Committee
Senate Bill 3342
Increases statutory mandatory retirement age for Supreme Court Justices, Superior Court Judges, Tax Court Judges, Administrative Law Judges, and Workers’ Compensation Judges from 70 to 75.
Last Action: February 5, 2026 – Introduced in the Senate, Referred to Senate Judiciary Committee
Senate Bill 3571
Provides certain volunteer and other workers with maximum compensation benefit for workers’ compensation claim regardless of outside employment.
Last Action: March 2, 2026 – Referred to Senate Budget and Appropriations Committee
