Frequently Asked Questions About Pennsylvania Workers’ Compensation Claims

Yes. Section 311 of the Workers’ Compensation requires that notice of an injury be given within twenty-one (21) days after it occurs, or at the latest, within 120 days of the injury. In general, you should tell your supervisor or boss as soon as you are hurt, even if you think it is a minor injury or will go away without requiring medical care.

A “work injury” is any injury, medical condition or disease that is caused by a person’s job, according to Section 301(c)(1) of the Pennsylvania Workers’ Compensation Act, 77 P.S. §411(1). The Act does not list specific types of injuries, other than the requirement that the condition must be related to the worker’s employment. In addition, a work injury also includes occupational diseases and pre-existing conditions that are aggravated by a person’s job. This means that everything from broken bones to strains and sprains to latex allergies to hepatitis may be considered a work injury.

Under the Workers’ Compensation Act, an employer and its insurance company have 21 days after they receive notice of the injury to either agree that an injury is work-related (and issue a Notice of Compensation Payable or Notice of Temporary Compensation Payable) or to deny the claim (and issue a Notice of Compensation Denial). Before you can receive wage losses, there must be medical proof from a doctor confirming your injuries and whether you can return to work or there are any restrictions on the type of work you can do. Most insurance companies mail checks every other week to injured workers, although a few pay wage loss benefits weekly.

Workers’ compensation wage loss benefits are calculated based upon what is called the injured worker’s “average weekly wage.” The average weekly wage is generally 2/3rds of the amount a worker had earned before getting hurt on the job. There are exceptions to this rule. For example, there is maximum benefit rate, so highly-paid workers often receive less than 2/3rds of their average weekly wage. In addition, some workers will receive either a fixed rate or 90 percent of their prior average earnings, depending upon various factors. Also, it is crucial for you to report any income from jobs that you performed other than the job where you were injured (this is called “concurrent employment”). You may be entitled to a higher workers’ compensation rate based on the income from this concurrent employment.

Under Section 306(f.1)(1)(i) of the Pennsylvania Workman’s Comp Act, an injured worker only has to treat with a “company doctor” for 90 days from the first visit only if the employer creates a list of at least six designated health care providers, provides written notification of the employee’s rights and duties to the employee, and obtains the employee’s written acknowledgment that he or she has been informed of these rights and duties. If an employer fails to do this, an injured worker can receive treatment from any doctor or provider.

Doctors, hospitals and other licensed medical providers are paid for their services based upon a fee schedule that changes annually. What you need to know is that injured workers are never required to pay a co-pay or any other fee for medical care related to the work injury. Instead, your doctors and other providers must submit their bills to the insurance company for payment.

There is no set time limit to receive benefits. It is possible that an injured worker will receive workers’ compensation benefits until he or she is ready to go back to work or settles his or her case. However, most employers will try to limit how long a worker can receive workers’ compensation benefits in myriad ways described in more detail below.

Employers file utilization reviews (UR) in order to challenge the reasonableness or necessity of some or all of the care a worker receives. If you receive a UR, you should give a copy to your lawyer immediately. Injured workers also have the right to supply a personal statement to the reviewer explaining why the challenged treatment is necessary or helpful.

The answer to this question is almost always, “No.” In exchange for receiving workers’ compensation benefits, an injured worker gives up the right to sue his or her employer for pain and suffering. There are very few exceptions to this rule. This does not mean that you cannot sure other parties that may have been responsible for your injuries. In fact, you can often sue other parties. For example, if you are involved in a work-related motor vehicle accident and sustained injuries as a result of the negligence of a third party, you may be able to file a personal injury action against the third party seeking pain and suffering for your injuries.

Yes. In many cases, you can file a lawsuit for your pain and suffering against persons or companies whose negligent conduct caused your injuries. Often, injured workers file products liability, motor vehicle or slip and fall claims, so it is important to speak with an attorney about these claims as soon as possible. That way, your lawyer can investigate your case, get witness statements, have experts review the case, etc. If you think you may have a case against another party, you should contact an attorney as soon as possible.

Yes. You may be able to receive Social Security, unemployment or other benefits as a result of your injury (and possibly because of other conditions you may have). In some cases, if you receive these benefits, either your workers’ compensation or the other benefits will be reduced. Regardless, injured workers should speak with an attorney to determine whether they can receive Social Security, unemployment or disability benefits and how these benefits may integrate with your receipt of workers’ compensation benefits.

Yes, the law requires injured workers to report any income earned while out of work on workers’ comp. Before doing so, you should consult a lawyer to make sure you are reporting the information correctly. If you had more than one job before and/or after you got hurt, this may affect the benefits you can receive. You may even be entitled to more wage losses than you thought. Be safe, and consult an attorney.

Section 314 of the Pennsylvania Workers’ Compensation Act provides that the employer/insurance company is entitled to have you examined by a doctor whom it chooses at a reasonable time and place. These doctors are not your treating doctors and are being paid by your employer to perform this evaluation. Most Judges have interpreted this provision to allow for such an examination twice a year. Although you are generally required to attend these exams (which are sometimes called IMEs), there are certainly exceptions. Therefore, before attending an IME you should speak with your attorney.

Yes. The insurance company will have a lawyer and you will be at a severe disadvantage if you do not retain a lawyer as well. The law is very complicated and it is extremely difficult to win a case without an attorney. Attorneys who concentrate their practices in workers’ compensation know the law and procedures. Thus, having a good attorney can make the difference between winning and losing a case or between getting a large lump sum settlement or a small one.

If you receive a Petition to Terminate, a Petition to Modify or a Petition to Suspend your benefits, you should contact an attorney immediately. These petitions mean that your employer or its insurance company is trying to try stop or reduce your wage loss and/or medical benefits. It is very important for you to meet with an attorney so that you can defend yourself.

In some circumstances, an employer may be entitled have you examined by a vocational expert. That is why if you receive a Notice of a Vocational Examination, you should contact an attorney immediately. It is possible that you might not have to attend. If you do have to go to the examination, your attorney will prepare you for the meeting and may attend or send a representative to the vocational examination.

Under the Workers’ Compensation Act, an employer may request that an injured worker attend an Impairment Rating Examination (IRE). An IRE can have an effect on a claimant’s right to receive wage losses. Therefore, if you receive a Notice of an Impairment Rating Examination, you should contact an attorney immediately. It is possible that you might not have to attend. If you do have to go to the IRE, your attorney will prepare you for the meeting and may attend or send a representative with you.

Not necessarily. Unfortunately, unless you are a union member or have an employment contract your receipt of workers’ compensation benefits does not necessarily protect your job or other employee benefits such as health insurance. We reside in an employment-at-will state so an employer is not obligated to leave your job open forever. As a result, if you are out of work and receiving workers’ compensation benefits, your employer may be able to fire you or lay you off if they cannot reasonable accommodate your physical restrictions. However, an employer cannot fire you or lay you off solely because you made a workers’ compensation claim. In addition, an employer does not have to maintain your health insurance or other benefits while you are receiving workers’ compensation benefits. You may, for example, receive what is called a COBRA Notice, allowing you to pay for medical insurance at your own expense. If you do, you should discuss this with your attorney.