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WORK INJURY?
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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.
ARE YOU 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.
WHEN AM I COVERED?
Coverage begins on the date of hire. Medical benefits are payable from the first
day of injury.
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 an Employer’s Report of Occupational Injury or
Disease.
The employer may choose to either accept or deny the claim. If your claim is
denied, you have the right to file a Claim Petition with the bureau for a
hearing before a WC judge.
WHAT ARE THE BENEFITS?
The law provides several types of workers’ compensation benefits:
Payments For Lost Wages
Wage-loss benefits are available if it is determined that you are totally
disabled and unable to work or partially disabled and receiving wages less than
your pre-injury earnings. Please see the “Total and Partial Disability
Benefits Status” section for further information as to disability status.
Death Benefits
If the injury results in death, surviving dependents may be entitled to
benefits.
Specific Loss Benefits
If you have lost the permanent use of all or part of your thumb, finger, hand,
arm, leg, foot, toe, sight, hearing, or have a serious and permanent
disfigurement on your head, face or neck, you may be entitled to a specific loss
award.
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.
Medicine, supplies, hospital treatment and services, orthopedic appliances
and prostheses are also covered for as long as they are needed. (To assure
payment of medical services, see the “Choice of Doctor” section.) Even if you
have lost no time from work, health care costs for a work-related injury or
illness are payable at the fee schedule rate. However, an employee may not be
charged the difference between the health care provider’s charge and the amount
paid by the employer or its insurance carrier. In other words, there can be no
“balance billing” to you.
Please be warned that, if you seek medical treatment outside the Commonwealth of
Pennsylvania, you may be subject to the risk of balance billing by the medical
provider. You should discuss this with your medical provider prior to initiating
treatment.
CHOICE OF A DOCTOR?
If your employer 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.
Employers are responsible for advising workers of their rights and duties under
Section 306(f.1)(I)(i) of the Act (medical benefits). The written notice of
these rights and duties is to be provided to the employee at the time of injury
or as soon after the injury as is practicable.
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 health care provider 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.
Once you begin receiving WC benefits, the employer/insurer has the right to ask
you to see their doctor 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
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.
For certain lung diseases, you must have worked in an occupation with a silica,
coal, asbestos hazard for at least two years in the Commonwealth of Pennsylvania
during the ten years prior to your disability.
TOTAL AND PARTIAL DISABILITY BENEFITS STATUS
Total Disability Benefits Status
Applies to injured workers for a period during which they are considered totally
disabled and unable to work. After 104 weeks of such status, the employer/
insurer can require a medical examination to determine if the employee is at
least 50% impaired based upon his/her work injury according to American Medical
Association standards. If the 50% threshold is not met, the employee’s status
can change to partial disability.
Partial Disability Benefits Status
This benefit status is for a maximum of 500 weeks. If, while on partial
disability status, you obtain a qualified physician's impairment rating which is equal to or greater than 50%, you may file
a Petition for Reinstatement of total disability status.
Partial disability of up to 500 weeks of benefits are paid if you can return to
work at a lower paying job within work related restrictions or you are found not
totally disabled.
HOW MUCH ARE THE PAYMENTS FOR LOST WAGES?
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.
There are several different ways of calculating the average weekly wage under
the Act. The minimum compensation rate is the lower of 90% of the workers’
average weekly wage or 50% of the Statewide average weekly wage.
REPORTING WAGES AND OTHER BENEFITS RECEIVED
Under the Act, any worker who has filed a petition for total or partial
disability benefits or who is receiving such benefits is required to report, in
writing to the insurer, any information which is relevant in determining
entitlement to, or amount of, compensation including, but not limited to,
information regarding the receipt of wages from another employer or from
self-employment. The worker is obligated to cooperate with the carrier in an
investigation of employment, self-employment, wages and physical condition.
INSURANCE FRAUD IS A CRIME
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.
There is a seven-day waiting period of wage benefits, although medical benefits
are payable from the first day.
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 modify or
terminate your 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.
WHEN 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.
Other reasons that benefits may be stopped include: a WC judge stopped benefits
after a hearing; the employee signs either a Supplemental Agreement or an
Agreement to Stop Workers’ Compensation (commonly referred to as a Final
Receipt); the 500 week period of partial disability status expires.
WHAT IF THERE IS A PROBLEM?
If you think you haven’t received benefits due you, contact your employer or
your employer’s insurance carrier. The insurance carrier is allowed 21 days from
your notice to the employer of your disability to decide to accept or deny your
claim or to make payments of temporary compensation for up to 90 days.
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. The bureau is responsible for resolving disputes by assigning petitions
to WC judges who decide each case after holding hearings on the issues.
TIME LIMITS
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.
IF I RECEIVE COMPENSATION, CAN I STILL SUE MY EMPLOYER?
No. Because the law makes the employer responsible for a worker’s injuries
regardless of the employee’s carelessness, the law also provides that employees
do not have the right to recover from the employer in any legal action other
than workers’ compensation. However, it the employer fails to carry the
appropriate workers’ compensation insurance coverage, and is not self-insured
for workers’ compensation, the employee can sue for damages. If your work injury
is caused by a third party, that party is subject to a civil suit.
WHAT NOT TO DO?
• Do not sign any incomplete papers.
• Do not sign any papers or statement unless you completely understand them.
• Do not sign any written statements about your injury or exposure to disease
unless you have a witness, union representative, or your attorney present and
you fully agree with the written statements. Always get a copy of any statements
you sign.
• Do not sign any Supplemental Agreements unless they correctly represent the
current status of your disability. It may also help to have the Supplemental
Agreement reviewed by a lawyer.
• Do not sign a Final Receipt of compensation unless you are fully recovered
from your injury.
This information was provided in LIBC-100 by: The Department Of Labor & Industry
Bureau of Workers’ Compensation 1171 S. Cameron St., Room 324, Harrisburg, PA
17104-2501
The Law Firm of DOUGLAS BARE helps protect your legal rights. For a FREE
consultation call 717-854-1900 or toll free
at 1-877-799-1900.
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