What You Need To Know About Pennsylvania Worker’s Compensation Benefits

  • If you are unable to work because of a job injury or a work-related illness, Pennsylvania workers’ compensation takes care of your medical expenses and pays wage-loss compensation benefits until you are able to go back to work. Death benefits for work-related deaths are paid to your dependent survivors.

    Benefits are paid by private insurance companies or the State Workmen’s Insurance Fund (SWIF), a state-fun insurance company or by employers What Are The Benefits? themselves if they are an approved self-insured.

  • Nearly every Pennsylvania worker is covered by the Pennsylvania Workmen’s Compensation Act. Employers must provide workers’ compensation coverage for all of their employees, including seasonal and part-time workers. Non-profit corporations, unincorporated businesses, or even employers with only one employee, must comply with the Act’s requirements, and coverage is mandatory.

  • If your work duties or environment causes or contributes to any injury, illness or disease, you may be entitled to workers’ compensation benefits. Even a pre-existing injury or illness that is aggravated by your work may be covered under the law.

  • Coverage begins on the date of hire and continues so long as you are employed.

  • Occupational diseases are covered if caused by or aggravated by the duties of 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, or asbestos hazard for at least two years during the ten years prior to your disability.

    Diseases which are common and particular to an industry ar business are also covered.

  • 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 have an injury or illness and that it is work related. Once you have lost a day or shift of work, your employer is required to report your injury to the Bureau of Workers’ Compensation through the filing of an Employer’s Report of Occupational Injury or Disease.

  • The law provides several types of workers’ compensation benefits:

    Payment For Lost Wages

    Wage-loss benefits are paid for total disability and partial disability. Total disability benefits will be paid so long as it is determined that you are totally disabled. Partial disability benefits are paid if you return to work at a lower paying job due to work-related injury restrictions or if your disability is converted to partial status. If the injury results in death, surviving dependents may be entitled to benefits for various periods of time depending on the dependent’s age and marital status.

    Specific Loss Benefits

    If you have lost the use of all or part of your thumb, finger, arm, leg, foot, toes, sight, hearing, or have a permanent scar of your face or neck, you may be entitled to a specific loss award of money benefits which is payable even if you do not lose any time from work.

    Medical Care

    In the event of a work-related illness or injury, you are entitled to the payment of reasonable and related surgical and medical services rendered by a physician or a duly licensed practitioner of the healing arts.

    Medicine, supplies, hospital treatment and services, orthopedic appliances, and prostheses and travel expenses (under some circumstances), are also covered for as long as they are reasonable and necessary, even if you have not lost time from work. There is no deductible and all costs are normally paid directly by your employer’s worker’s compensation carrier to the medical provider.

  • If your employer has posted a list of six or more physicians or other duly licensed practitioners of the healing arts in your work place, then you are required to choose one of them for initial treatment. You may treat with that practitioner or another on the list for a period of 90 days following the first visit. If, during the 90 day period, you visit other medical practitioners not on the list, your employer or your employer’s insurance carrier can refuse to pay for such treatment. After 90 days, as well as in situations where your employer had not properly posted the list, you may seek treatment with any physician. You should notify your employer of the practitioner you have selected. During treatment, the employer or the employer’s insurance carrier has the right to have you examined by a physician of their choice.

  • Disability wage-loss benefits are equal to approximately two-thirds of your average weekly wage, up to a maximum set by the State. 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 employee is entitled to the most favorable calculation.

    Worker’s Compensation Payments are Currently Tax Free. In addition, there are no deductions taken from your benefits for social security, union, retirement fund or pension plan benefits.

  • If you report the injury promptly and you miss more than seven days of work, you should receive your first compensation check within 21 days of your absence from work. After that, you will receive a check as regularly as you received your wages prior to the injury, until you are able to go back to work. There is a seven day waiting period for wage benefits, although medical benefits are payable from the first day. If you are off work due to your injury for more than 13 days, payments will be made for the first seven days.

  • Wage-loss benefits can only be stopped under these defined circumstances:

    1. By a Worker’s Compensation Judge after a hearing;

    2. If you sign an “Agreement to Stop Workers’ Compensation” (commonly referred to as a Final Receipt) which terminates benefits, or you sign a “Supplemental Agreement” for which may, under some circumstances, suspend or terminate workers’ compensation benefits.

    3. When you return to work at your prior wages and the employer files a petition to terminate or modify your benefits or files a notice of stopping of benefits.

    4. After the 500 week period of partial disability expires.

  • If you request for workers’ compensation benefits if 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 exposure and a petition must be filed no later than 3 years from the date of disability.

    Failure to file a petition on a timely basis may result in forfeiture of your right to benefits.

    If past workers’ compensation benefits were terminated, you have three years from the last payment of lost wage benefits to reopen the claim. If your benefits were suspended, you may have 500 weeks to file for a reopening, depending on the circumstances.

    Payments of medical benefits by your employer does not mean that your claim has been accepted or reopened but may extend the time limits for a filing claim.

  • I. There are new provisions that apply to Workers’ Compensation Benefits for employees injured after June 24, 1996.

    1. Workers’ compensation wage-loss payments can be offset by 50% of any “old age” Social Security benefit the worker receives, unless he/she was receiving that old age Social Security benefit prior to the injury.

    2. Workers’ compensation wage-loss payments are offset by severance payments and retirement pension plan benefits paid by the employer to the extent funded by the employer.

    3. Unemployment compensation received during the period of disability is credited against wage-loss benefits.

    4. Wages received through employment and self-employment while on disability also reduced the amount of work loss benefits. Employees are required to report any of the above “income” to their insurance carrier if it is received after the date of injury, and also to authorize a verification of Social Security benefits received. False repporting can lead to penalties and criminal sanctions.

    5. For an injury occurring on or after June 24th, 1996, a worker can be required by the employer to submit to a medical examination within 60 days after the first 104 week period.. In this examination, the worker’s degree of impairment due to the compensable injury is determined pursuant to the most recent edition of the American Medical Association’s “Guide to the Evaluation of Permanent Impairment.” If a worker is not determined to have a 50% impairment, insurers can shift employees to partial disability status which has a 500 week maximum duration. If it is determined that the employee meets the 50% impairment level, the employee can continue to receive full benefits. The doctor chosen for the examination is one designated by the Bureau of Workers’ Compensation.

    6. When calculating the amount of wage-loss benefit for injuries occurring on or after June 24th, 1996, employees are entitled to 66 ⅔ of their pre-injury average weekly wage (within the maximum statewide average weekly wage allowance and minimum restrictions) which can be reduced by the “earning power of the employee.” This earning power is the amount the employee is earning after the injury or what the person could be earning, at jobs available within the medical restrictions imposed as a result of the injury. An “Expert” in vocational rehabilitation approved by the department must present evidence of available employment to establish earning power. For those living outside Pennsylvania, the usual employment area is that where the injury occurred.

    7. Employers must offer available work for which the injured worker is qualified and capable of performing, before the worker’s benefits can be reduced.

    8. The method of calculating average weekly wages used to determine the employee’s weekly wage-loss benefit level was changed. Wages include employer provided room and board, and bonus/incentive pay and vacation pay earned on an annual basis. Gratuities (tips) reported for federal tax purposes are calculated as earnings.

    II. Agricultural Exemptions

    Employers of agricultural labor must provide workers’ compensation coverage to their employees if, during the calendar year, they pay more than $1,200 to one person or employ one person for 30 days or more. A spouse or child is exempt unless they work under a written contract. A copy of the contract must be filed with the Bureau of Workers’ Compensation.

    III. Imprisonment After Conviction & Change Of Status

    Employers/insurers are not required to make compensation payments to claimants during imprisonment.

    Total disability benefits are not payable to those employed or receiving wages. (They may instead qualify for partial disability status benefits which have a 500 week limit).

    IV. Employers Who Have A List Of Six Designated Medical Providers On Or After August 23, 1996.

    No more than four of the medical providers may be supplied through a coordinated care organization (CCO).

    Employees must treat with one or more of the listed providers for 90 days following their first visit after injury.

    If invasive surgery is prescribed by a listed medical provider after August 23, 1996, employees may obtain a second opinion from a medical provider of choice the employer’s expense. Employees who decide to follow the course of treatment prescribed by the second opinion must do so for an additional 90 days through a medical provider on the employer’s list.

    V. Disputes About Medical Bills

    There can be disagreements between insurers and medical providers about the medical bill. These are submitted to the fee review procedure.

    VI. Utilization Review

    Utilization reviews have one step. Further disputed issues of the reasonableness or necessity of medical treatment must be petitioned and decided by a Workers’ Compensation Judge. The petition must be filed within 30 days of receiving the initial utilization review organization report. During the dispute the employer is not required to pay the medical bills.

    VII. Certification Of Coordinated Care Organizations (CCO’s)

    Responsibility for providing certification of CCO’s was transferred from the Department of Health to the Department of Labor and Industry effective August 23, 1996.

    VIII. Employment And Receipt Of Wage-Loss Benefits

    Employees receiving worker’s compensation wageloss benefits or filing a petition for these benefits on or after August 23, 1996 are required to notify their insurer in writing, if they are employed or self-employed. Every six months, insurers can require a verification that an employee’s status to receive compensation has not changed.

    IX. Physical Examinations Or Expert Interviews

    Physical examinations or expert interviews can be requested by insurers for anyone seeking worker’s compensation on or after August 23, 1996. Insurers must pay for these services. Employees can take a health care provider of their choice to the examination, but they have to pay for the attendance of their provider. The insurer must pay for the employee’s reasonable travel expenses and loss of wages in the examination is ordered by a Worker’s Compensation Judge.

    X. Informal Conferences

    On or after August 23, 1996, informal conferences may be requested by joint agreement to the Bureau of Worker’s Compensation, if a petition has been filed. A Worker’s Compensation Judge or hearing officer will hold the informal conference in a confidential manner.

    If the employee is not represented by an attorney at the informal conference, the employer/insurer cannot have an attorney represent them. If an agreement is not reached, the petition is heard in the normal fashion.

    XI. Temporary Compensation

    On or after August 23, 1996, the insurer or self-insured employer can temporarily make benefit payments for up to 90 days without admitting liability. Payments will continue unless a Stopping Notice and Denial form is issued within the 90 day period from the injury.

    XII. Cessation Of Benefits/Return To Work

    If an employee has returned to work at or above his or her prior earnings level, worker’s compensation payments can be suspended, if the Bureau of Worker’s Compensation and employee are notified within seven days of the insurer/employer’s stoppage of payments. Employees have 20 days from their receipt of this notice to challenge the suspension of benefits. (Effective August 23, 1996.)

    XIII. Modification Of Benefits/Return To Work

    If the employee has returned to work, the employer can modify (reduce) the worker’s compensation payments by an appropriate amount if they mail notification to the employee and the Bureau of Workers’ Compensation within seven days of modifying compensation with an affidavit attesting to this fact. The employee can challenge this matter by so indicating on the notification form and filing such with the Bureau within 20 days of receiving the modification notice. (Effective August 23, 1996.)

    XIV. Supersedeas Hearing

    The insurer/employer can send to the Bureau of Worker’s Compensation a Physician’s Affidavit that the employee has fully recovered, based on an examination (conducted) within 21 days of filing the petition to terminate payments. The Worker’s Compensation Judge must them hold a special hearing and decide if worker’s compensation payments will be stopped. (Effective August 23, 1996.)

    XV. Worker’s Compensation Judges Decision

    Workers’ Compensation Judges have to explain their reasons for rejecting competant and uncontroverted evidence when writing their decision. Judges must also meet new qualification standards to be hired, must complete 20 hours of added training per year, and must meet extensive ethical requirements.

    XVI. Delays in Litigation

    Excessive or unreasonable delays by employers/insurers can lead to penalties of up to 50%. The penalty is paid to the person receiving compensation.

    XVII. Compromise and Release Agreement

    The Parties can enter into a Compromise and Release Agreement (settlement). Both parties must agree to the terms of the agreement and a Workers’ Compensation Judge must approve it.

  • If you and your employer or its insurance company cannot agree on the payment of benefits to you for any claim, then the matter should go into litigation in front of a Worker’s Compensation Judge. After a trial the Worker’s Compensation Judge will issue a decision either granting or denying you workers’ compensation benefits. Worker’s Compensation Judge decisions can be appealed to the Workmen’s Compensation Appeal Board and them to the Commonwealth Court.

  • 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 notice to the employer of your work related disability to decide to accept or deny your claim.

    If the problem still hasn’t been resolved, it may be necessary to see a lawyer and file a petition with the Bureau of Workers’ Compensation. Forms can be obtained through the Hotline at 1-800-482-2383, the website www.dli.state.pa.us or (TDD) 1-800-362-4228 for people with a hearing loss. The Bureau is responsible for assigning petitions to a local Worker’s Compensation Judge.

  • Worker’s compensation litigation is complex and your employer or your employer’s insurance carrier will be represented by an experiened attorney. In order to have the best chance of winning your case, YOU SHOULD HIRE a worker’s compensation lawyer. Any fee that you agree to pay the lawyer must be approved by a Workers’ Compensation Judge. Usually the fee is contingent on the lawyer getting you benefits.

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