The Pennsylvania Workers’ Compensation Act provides that if you are injured at work or sustain a work-related illness, you are entitled to have your medical expenses paid and to collect lost wages until you’re able to go back to work. Also, workers’ comp death benefits for work-related deaths are paid to your dependent survivors. workers’ compensation benefits are paid by the insurance company who insures your employer, or by the employer if it is self-insured.
Every Pennsylvania employer must comply with the Act’s requirement and provide workers’ compensation coverage for all of their employees, including seasonal and part-time workers. This includes non-profit corporations, unincorporated businesses, and even employers with only one employee. Even if you are a volunteer (such as a volunteer firefighter or EMT) you can be covered under the Pennsylvania Workers’ Compensation Act. Some Pennsylvania employees are covered by other compensation laws, including federal civilian employees, railroad workers, longshoremen, and shipyard and harbor workers. Other employees who may not be covered by the Pennsylvania Workers’ Compensation Act are agricultural laborers, casual employees, domestic workers and employees who have been granted a personal religious exemption from the Act.
Most work-related physical injuries, occupational illnesses and diseases, psychological and stress-related conditions, and deaths are covered by the workers’ compensation laws. An exclusion to this coverage is an injury or death that is intentionally self-inflicted or is caused by the worker’s violation of the law, such as the illegal use of drugs. Other exclusions may apply.
When you are injured at work, you must report the injury (or work-related illness) to your employer immediately, specifically setting forth the date and place of the injury in the workplace. If you fail to properly notify your employer, your claim may be denied or your benefits may be delayed. Once you have missed a day or shift of work, your employer must file a First Report of Injury with the Pennsylvania Bureau of Workers’ Compensation (“Bureau”). The employer will either accept or deny your claim. If your claim is denied, you must file a Claim Petition with the Bureau for a hearing before a Worker’s Compensation Judge. Even if your claim is accepted as compensable by the workers’ compensation insurance company, there may be issues with the description of injury or the amount of your wage loss benefits.
Under the Pennsylvania Workers’ Compensation Act, you may be entitled to several types of workers’ compensation benefits. Medical benefits are the payment of reasonable, necessary and related medical expenses including surgical and medical services rendered by a physician or other health care provider, as well as the cost of medicine, hospital stays, physical therapy, orthopedic appliances, and prostheses. Wage-loss benefits are paid if you are totally disabled and unable to work or partially disabled and receiving wages less than your pre-injury earnings. You may be entitled to specific loss benefits if you have permanently lost the use of all or part of your thumb, finger, hand, arm, leg, foot, toe, sight, or hearing, or if you have a permanent disfigurement of your head, face or neck. If your workplace injury or illness results in death, your surviving dependents may be entitled to death benefits. This applies whether your death is the result of a workplace accident, a complication from an injury, such as infection or organ failure, or an occupational disease.
If your employer accepts your workers’ compensation claim and has posted a list of six or more physicians in your place of employment, then you must choose one of those physicians for your initial treatment provided you have signed an acknowledgment of these obligations before and after the work accident. You are required to continue treatment with that physician or another on the list for a period of 90 days after the accident. You may choose any physician on your employer’s list. If the physician prescribes invasive surgery, you can seek a second opinion paid for by your employer or the insurance carrier. Your employer or its insurer may refuse to pay for treatment if you visit a physician not on the list during the 90-day period. After the 90 days, or if your employer has not posted a list or has posted an improper list, or if you have not acknowledged in writing your obligation to treat with a panel provider, you may seek treatment with any physician you choose.
Once you begin receiving workers’ compensation benefits, your employer or its insurance carrier is permitted to require you to see a doctor of its choice for an examination. This is referred to as an independent medical evaluation (IME). An IME may be intended to determine if there has been a change in your disability and therefore justification for modification or termination of your benefits. If you refuse to appear for this examination, the employer may seek an order from the Workers’ Compensation Judge requiring you to attend the examination. Continued refusal to attend the examination may result in a suspension of your workplace compensation benefits.
The Pennsylvania Workers’ Compensation Act covers many work-related injuries and illnesses. If you are disabled as a result of an occupational disease, you may be entitled to workers’ compensation benefits if your illness was caused by or aggravated by your employment. There are, however, strict guidelines that must be met in order to receive these work injury benefits. Your disability must occur within 300 weeks of your last employment in an occupation where you were exposed to the hazard. Also, for certain lung diseases, you must have worked in the Commonwealth of Pennsylvania in an occupation that exposed you to silica, coal or asbestos for at least two years during the ten years prior to your disability.
“Total Disability” benefits status applies to injured workers for a period during which they are considered completely unable to work. If you are considered totally disabled and out of work for more than 104 weeks, your employer or its insurance company can require that you attend a medical examination to determine if the condition of your injury has left you at least 50% impaired according to the American Medical Association guidelines. This examination is referred to as an impairment rating evaluation (IRE). If your condition does not meet the 50% threshold, your status can change to “partial disability”.
“Partial Disability” benefit status applies if you return to work earning less than your time of injury wage, or you have been determined less than 50% impaired during an IRE. Partial disability benefits are paid for a maximum of 500 weeks. While on partial disability status, if you obtain a determination of impairment equal to or greater than 50% from a qualified impairment rating physician, you may file a Petition for Reinstatement of total disability status.
Generally, workers’ compensation wage-loss benefits are equal to approximately two-thirds of your average weekly wage, up to a weekly maximum. Lost wages can be offset for your employer-paid portion of your retirement pension, severance pay, unemployment compensation, 50% of Social Security “old age” benefits, or other earnings you may receive. There is no consideration for cost-of-living increases. Under the Act, your average weekly wage can be calculated several different ways. The minimum compensation rate is the lower of 90% of the workers’ average weekly wage or 50% of the statewide average weekly wage.
You must be out of work because of your work-related injury for more than 7 calendar days before workers’ compensation payments are due to you. After 14 days of missed work, you will receive retroactive benefits for the first 7 days. Typically, if you immediately report the injury to your employer, are out of work for more than 7 days of work and your employer’s insurance company accepts your claim, you will receive your first wages-lost payment within 21 days of your first day of missed work. After that, you will receive a check weekly or bi-weekly.
If your employer has not decided whether to accept or deny your workmans comp claim within 21 days of notice of the accident, it may send you a Notice of Temporary Compensation Payable which provides that your employer will pay you benefits until it decides whether your claim is going to be formally accepted or denied. These temporary benefits may continue up to 90 days. In order to terminate the temporary benefits, your employer either send you a Notice of Stopping Temporary Compensation Benefits within 5 days of your receiving your last check and send you a Notice of Denial during the 90-day period. If your employer fails to do so, benefits will likely continue after the ninety-day period.
After you begin to receive workmen compensation benefits, your employer or the insurance carrier may seek to reduce or stop your wage-loss benefits by proving that employment is available to you, within your medical restrictions and in your local area. It is important to consider the physical requirements of the job. Whether your own physician approves the job can be critical. Failure to respond in good faith to a job offer may result in the insurance company filing a Petition to Suspend or Modify your workers’ compensation benefits.
Wage-loss benefits will terminate if:
Your employer or its insurance carrier denies your claim and they notify you that they are terminating any temporary compensation they have been paying you during the 90 days following your injury;
A Termination Petition is filed, and after the presentation of evidence, a Workers’ Compensation Judge orders that your benefits be terminated;
You execute 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 benefit status expires or your benefits are suspended; or,
You retired from employment and the insurance company alleges you withdrew from the workforce.
Notice of Work Injury:
An employer is not obligated to provide workers’ compensation benefits to an injured employer until it has notice of the injury. You must give notice to your employer of your work-related injury no later than 120 days after the accident. When an employee claims lost wages as a result of those injuries, the employer has 21 days from the date of notice of the accident and injury to accept or deny the claim. The employer may choose within the 21-day period to begin temporary payments of workers’ compensation benefits, but reserve the right to deny the claim within an additional 90 days.
Job Injury Claim Petition:
If your employer or your employer’s insurance company denies your request for workers’ compensation benefits, you must file a Claim Petition within 3 years from the date of injury. In the case of an occupational disease, your disability must occur within 300 weeks from the date of your last employment in an occupation in which you had exposure to a hazard and a Claim Petition must be filed no later than 3 years from the date of disability. Failure to file a timely Claim Petition may result in forfeiture of your right to benefits.
Petition to Reinstate Injured Worker Benefits:
If your work injury benefits were terminated, you may file a Petition to Reinstate wage-loss benefits within 3 years after the date of your most recent wage-loss payment. If your benefits were suspended or modified, you may file a petition to have benefits reinstated within 500 weeks from the date of suspension or modification.