The Pennsylvania Workers’ Compensation Act (Pa WC Act) is very specific that a workers’ compensation insurance carrier is responsible for the payment of all reasonable and necessary medical expenses, which are related to a work injury.  The Commonwealth Court of Pennsylvania recently addressed the issue of a Workers’ Compensation Judge’s ability to award penalties for nonpayment of medical bills following a Fee Review Determination in the case of Day-Timers, Inc. v. Rhonda Horton (Workers’ Compensation Appeal Board).

Under the PA WC Act, a workers’ compensation insurer has 30 days to either pay a medical bill related to a work injury, or file for Utilization Review (UR) Request, which challenges the reasonableness and necessity of such treatment.  If a healthcare provider is not satisfied with the timing or amount of the payment for medical treatment, the provider has the ability to file for Fee Review.

In the Day-Timers case, Alliance Medication Service filled several prescriptions related to the work injury and submitted bills to the insurance carrier. The insurer paid a portion of each bill. As a result, Alliance Medication Service filed for Fee Review on each bill.  All of the Fee Reviews were found in favor of Alliance Medication Service and the Bureau awarded a total payment of $1,490.25.  The insurance carrier did not dispute any of the Fee Reviews, but simply failed to make the payment.

The injured worker filed a Review Petition since the insurance carrier did not make the payment pursuant to the Fee Review Determinations.  The insurance carrier presented no evidence during the litigation, but argued that the WCJ lacked jurisdiction to address this issue since it pertained solely to the amount of the payment made on medical bills. The WCJ granted the Review Petition and ordered the insurance carrier to pay a 50% penalty on all unpaid and untimely paid medical bills.  Additionally, the WCJ ordered the payment of counsel fees for unreasonable contest. The insurer appealed to the Workers’ Compensation Appeal Board (WCAB) and argued that a WCJ lacked jurisdiction to address matters that would fall under Fee Review.  The WCAB rejected this argument, similar to the WCJ.  The WCAB reasoned that the entire purpose of penalties is to assure compliance.  The WCAB noted that the provider filed for Fee Review and obtained successful Determinations in that process.  The insurer did not contest any of the Fee Review Determinations and failed to issue payment. According to the WCAB, this made the assessment of penalties and attorney fees completely appropriate by the WCJ.

The insurer then appealed to the Commonwealth Court of Pennsylvania, arguing that the WCJ lacked jurisdiction to address the matter.  The Insurer was, once again, unsuccessful.

The Court, in affirming the WCAB, noted that the Fee Review process applies to healthcare providers.  There is no prohibition from an injured worker filing a Petition for Penalties when medical bills related to the work injury are not properly paid per the terms of the PA WC Act.  As to the merits, there was no dispute that the insurer failed to pay for medical treatment related to the work injury.  The Court determination this was a violation of the PA WC Act, for which a WCJ is perfectly within his/her purview to assess penalties and attorney fees.

The Court further observed that the issue before the WCJ was not the amount of the payment made which would fall under Fee Review, but instead, whether the insurer violated the PA WC Act by failing to pay the amounts owed under the Fee Review Determinations.

For attorneys representing workers’ compensation insurance carriers, it is necessary to review the Fee Review Determinations to determine if a Request for Hearing should be filed to challenge the Bureau’s award of payment of medical bills to a medical provider. If an insurer does not properly pay medical bills related to a work injury awarded from a Fee Review Determination, this could lead to a Penalty Petition for violation of the PA WC Act and an award of penalties and unreasonable contest attorney’s fees by a WCJ.

Zachary M. Rubinich is a partner in our Philadelphia office. He focuses his practice on the defense of insurance carriers, self-insured entities and third-party administrators against workers’ compensation claims in Pennsylvania. Based on his extensive experience, the Pennsylvania Bar Association Workers’ Compensation Law Section has certified him as Specialist in the practice of workers’ compensation law Zach has handled all aspects of litigation before workers’ compensation judges, the Workers’ Compensation Appeal Board, the Commonwealth Court and the Pennsylvania Supreme Court. Zach has been appointed to the following American Bar Association Tort Trial and Insurance Practice (TIPS) leadership positions: Past Chair of the Litigation and Trial Practice Committee; Vice-Chair of the Appellate Advocacy Committee; member of the Ethics and Professionalism Standing Committee; and member of the CLE Board Committee. He is the Past Chair of the ABA’s Tort Trial and Insurance Practice (TIPS) Workers’ Compensation and Employers’ Liability Law Committee from 2018-2019. He has served as a Vice-Chair of this committee from 2015 to present. In addition, Zach served as Vice-Chair of the 2017-2018 American Bar Association Standing Committee for Diversity and Inclusion. He is also a Committee Member of the ABA’s Legal Opportunity Scholarship Fund. Zach has been rated AV Preeminent by Martindale-Hubbell for the thirteenth consecutive year for 2025. He has been selected as a 2019, 2020 and 2021 Pennsylvania Super Lawyer by Super Lawyers. He was selected as a Pennsylvania Rising Star by Super Lawyers from 2010 to 2014. He was selected as an International Advisory Experts (IAE) Award recipient in 2019 for his accomplishments as a workers’ compensation attorney in Pennsylvania. Zach has been selected as a Fellow of the College of Workers’ Compensation Lawyers Class of 2020. Mr. Rubinich has been recognized as a Main Line Today 2023 and 2024 Top Lawyer.

Zach can be reached directly at: (215) 575-4340 (office) or (215) 478-5053 (cell) • zrubinich@rawle.com

Workers’ Compensation Section

CHAIR: Claudio J. DiPaolo
PARTNERS: Zachary M. Rubinich, J. Brendan O’Brien, Christian M. Stein, Jennifer Schwartz, Anisha S. Abraham
OF COUNSEL: James Curry, Edward J. Chiodo, Daniel Spafford, William Copetas, Anthony Lategano
ASSOCIATES: Mary Bergmann, Andrew Patrick, John K. Taylor

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