Pennsylvania Workers' Comp FAQ
What is workers' compensation?If you sustain a job injury or a work-related illness, the Pennsylvania Workers' Compensation Act (Act) provides for your medical expenses and, in the event you are unable to work, wage-loss compensation benefits until you're able to go back to work. Additionally, death benefits for work-related deaths are paid to your dependent survivors. Benefits are paid by private insurance companies (also includes third party administrators) or the State Workers' Insurance Fund (a state-run workers' compensation insurance carrier) or by employers themselves if they are self-insured. Am I covered? Nearly every Pennsylvania (PA) worker is covered by the PA Workers' Compensation Act. Employers must provide workers' compensation (WC) coverage for all of their employees, including seasonal and part-time workers. Non-profit corporations, unincorporated businesses, and even employers with only one employee, must comply with the Act's requirements. Some PA employees are covered by other compensation laws, including: Federal civilian employees, railroad workers, longshoremen, shipyard and harbor workers. Some others who may not be covered are volunteer workers, agricultural laborers, casual employees, domestics and employees who have been granted a personal religious exemption from the Act. Certain types of executive officers of for-profit and not-for-profit corporations may elect exemption from the Act. A worker should seek further information if there is any doubt as to coverage. What is covered? If your work causes an injury, illness or disease, you may be entitled to WC. No compensation shall be paid when an injury or death is intentionally self-inflicted, or is caused by an employee's violation of the law including, but not limited to, the illegal use of drugs. An injury or death caused by intoxication also may not be covered.
Coverage begins on the date of hire. Medical benefits are payable from the first day of injury; payment of lost wages are addressed in the question, When are wage-loss payments made? How do I get the benefits? Prompt reporting is the key. Report any injury or work-related illness to your employer or supervisor immediately. You must tell your employer that you were injured in the course of employment and inform your employer of the date and place of injury. Failure to notify the employer can result in the delay or denial of benefits. Once you have lost a day, shift or turn of work, your employer is required to report your injury to the Bureau of Workers' Compensation (bureau) by filing a First Report of Injury.
The law provides several types of workers' compensation benefits: Payments For Lost Wages Death Benefits Specific Loss Benefits Medical Care In the event of a work-related illness or injury, you are entitled, if covered under the Act, to the payment of related reasonable surgical and medical services rendered by a physician or other health care provider.
You are free to choose your own doctor unless the employer accepts your claim and has posted a list of six or more physicians or health care providers in your workplace, then you are required to visit one of them for initial treatment. You are to continue treatment with that provider or another on the list for a period of 90 days following the first visit. You may see any provider on the list; your employer may not require or direct you to any specific provider on the list. If a listed provider prescribes invasive surgery, you are entitled to a second opinion which will be paid for by your employer/insurer. Treatment recommended as a result of the second opinion must be provided by a listed provider for 90 days. If during the 90-day period you visit a provider(s) not on the list, your employer or your employer's insurance carrier may refuse to pay for such treatment. After the 90 days, as well as in situations where your employer has no posted list or an improper list, you may seek treatment with any physician or other health care provider you select. You must notify your employer of the provider you have selected. During treatment, the employer or the employer's insurance carrier is entitled to receive monthly reports from your physician or provider. Injured workers should be advised that your health care providers may need information concerning your claim. Some of this information may be contained in correspondence you receive from your insurance carrier, and you may want to provide copies of letters or forms to your health care provider. Once you begin receiving WC benefits, the employer/insurer has the right to ask you to see a doctor of their choice for examination. If you refuse, the employer is entitled to request an order from the WC judge requiring you to attend an examination. Failure to then attend may result in a suspension of your benefits.
Occupational diseases under the Act are covered if caused by or aggravated by employment. Your disability must occur within 300 weeks of your last employment in an occupation where you were exposed to the hazard.
Wage-loss benefits are equal to approximately two-thirds of your average weekly wage, up to a weekly maximum. WC wage-loss benefits can be offset for 50% of Social Security "old age" benefits, the employer-paid portion of a retirement pension, severance pay, unemployment compensation or earnings the employee receives. The law does not allow for a cost-of-living increase.
Do I have to reporting wages & other benefits received?
The above-mentioned reports and other WC forms must be honestly completed to avoid violating PA fraud provisions. When are wage-loss payments made? You must be disabled more than seven calendar days (including weekends) before WC payments for disability are payable. Benefits for time lost from work are payable on the eighth day after injury. Once you have been off work 14 days, you receive retroactive payment for the first seven days. If you report the injury promptly, miss more than seven days of work and your claim is accepted by the insurance carrier, you should receive your first compensation check within 21 days of your absence from work. After that, you will receive a check on a regular basis. Payments of temporary compensation may be made by your employer or the insurance carrier for up to 90 days, even if your claim is not accepted by your employer or its insurance carrier. If your employer or their insurance carrier advises you that it will not continue your temporary compensation checks past 90 days, you have the right to file a Claim Petition with the bureau for a hearing if you believe you are entitled to benefits. Can I accept an offer of employment? If, after you begin to receive benefits, your employer has evidence to prove that employment is available to you, within your medical restrictions and in your local area, you may receive an offer of employment. You have the right to either accept or decline the job offer. If you decline, the employer may then petition a WC judge to either reduce or stop your wage-loss benefits based upon that job. The insurer/employer must continue to pay benefits during the hearing process unless the judge orders otherwise. In open hearings, the judge will evaluate medical evidence, both from you and your insurer/employer, on the availability of the work and your ability to do it, before rendering a decision. Can wage-loss payments stop? Wage-loss benefits can be stopped by an employer/insurer who has evidence that you have returned to work at wages equal to or more than your earnings level prior to the injury and after providing a timely notice of that fact. In addition, if you are receiving temporary compensation benefits during the 90 days following the report of injury, the insurance carrier/employer may notify you they are stopping benefits because they are not accepting the claim of a work-related injury.
What if there is a problem?
Cooperative communication with your insurance carrier is recommended. If the problem is not resolved, it may be necessary for you to file a petition with the bureau. Forms can either be obtained through the Claims Information Helpline (800-482-2383) or filed online (www.dli.state.pa.us, Keyword: workers comp). The bureau is responsible for resolving disputes by assigning petitions to WC judges who decide each case after holding hearings on the issues. Are there time limits to file a workers' compensation claim? Unless an employer has knowledge of the injury or the employee gives notice to the employer within 21 days of the injury, no compensation is due until notice is given. Notice must be given no later than 120 days after the injury for compensation to be allowed. If your request for WC benefits is denied by your employer or your employer's insurance carrier, you have three years from the date of injury to file a Claim Petition. In occupational disease cases, injury/disability must occur within 300 weeks from the date of last employment in an occupation in which you had exposure to a hazard, and a petition must be filed no later than three years from the date of injury/disability. Failure to file a petition on a timely basis may result in forfeiture of your right to benefits. If your benefits were terminated, you may file a Petition to Reinstate WC benefits within three years after the date of your most recent WC check. If your benefits were suspended, you may file a petition to have benefits reinstated. This petition must be filed within 500 weeks from the date of suspension. Payment of medical benefits by your employer does not mean that your claim has been accepted or reopened. What is alternative dispute resolution? If either you or your employer files a petition with the bureau, the WC judge will schedule mediation unless it would be futile. If the case does not settle at this mediation, the parties may resume mediation or a settlement conference later in the proceedings. The parties may also request mediation or a settlement conference later in the proceedings if the judge had previously found mediation futile. You may also request an informal conference to try to resolve your issues. If you are not represented by an attorney at an informal conference, your employer is not entitled to be represented either. Informal conference forms are available from the Bureau of Workers' Compensation Claims Information Helpline at (800) 482-2383.
WC judge decisions can be appealed to the Workers' Compensation Appeal Board and then to the Commonwealth Court. You will be informed of appeal rights upon receiving the WC judge's decision.
CONTACT MANSMANN & MOORE FOR A FREE CONSULTATION |
