FAQs—Workers' Compensation Claims

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The impact of a work injury affects individuals in their daily lives. The nature of the injury and its impact on an individual's ability to function at work and home is always significant. The Workers' Compensation Act defines injury as:

...an injury to an employee, regardless of his past physical condition, arising in the course of his employment and related thereto... "It includes a new injury, aggravation of a prior condition, death, and certain occupational diseases. It also includes physical and psychological injuries. There need not be a specific trauma as in repetitive-type injuries."

Occupational diseases occur when workers are exposed to dust, fumes, asbestos, loud noises, chemicals, and smoke in a workplace which fails to provide sufficient ventilation or safeguards. These substances may cause or aggravate a disease, condition, or ailment. If exposure to any substance affects any part of the body, a worker may be entitled to workers' compensation benefits.

When a worker's injury results in disability, it is important that the worker receive proper medical care and treatment from knowledgeable doctors, hospitals, and other healthcare professionals. Additionally, it is crucial that the injured worker be made aware of his/her rights under the Pennsylvania Workers' Compensation Act and consult with an experienced attorney. The lawyers of Weinstein, Schleifer & Kupersmith, P.C., have a combined 75 years of experience in the field of workers’ compensation. The following is a list of frequently asked questions and relevant information to assist you in handling a claim for workers’ compensation benefits.

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Q1: How do I protect myself if I am hurt at work?

A1: You must give notice to your employer. It is the worker's burden to notify the employer of a work injury. The worker has one hundred twenty (120) days from the date of injury in which to serve the employer with notice of the injury. Notice may be given verbally or in writing, but it must be provided to a supervisor or manager. A worker should obtain a copy of an Incident Report and confirm that the employer notified its insurance carrier of the claim. Failure to meet the notice requirement may prohibit a worker from pursuing any claim for workers' compensation benefits. In some instances, time may elapse before a worker becomes aware of any injury sustained as a result of a work related activity. In these cases, the worker has one hundred twenty (120) days from when the worker discovered the injury in which to provide notice to the employer.

Q2: What happens after I tell my employer I am hurt?

A2: When employers are placed on notice of an injury, they must report the claim to their workers' compensation insurance carriers. Thereafter, the insurance carrier has twenty one (21) days to respond. An insurer may respond in the following manner:

1) The Insurance Company Accepts Liability
When the insurer accepts liability for a work-related injury, the employer must provide a worker with a Notice of Compensation Payable (NCP). It is important that the worker verify that all injuries and wage information is properly identified in the NCP. If the employer does not properly list your injury, you may need the assistance of an attorney to file a petition to have the correct injury identified.
2) The Insurance Company Denies Liability
When an insurer claims it is not liable for an injury, it must provide a worker with a Notice of Compensation Denial within twenty one (21) days of receipt of notice of the work injury. A Claim Petition must then be filed by an attorney on behalf of the worker to fight the denial.
3) The Insurance Company Temporarily Accepts while Investigating the Injury
In some instances, the insurer may not be certain whether it is responsible for a worker's injury. In these cases, the insurer may make payments by issuing a Temporary Notice of Compensation Payable (TNCP) without admitting liability for the claim. If the insurer does not file a Notice stopping the Temporary Notice of Compensation Payable within ninety (90) days, the TNCP automatically converts to an NCP and benefits continue. If a Notice stopping the Notice of Temporary Compensation Payable is issued, then the claim is denied and a Claim Petition must be filed by an attorney on behalf of the worker to fight the denial.

Q3: Are employers required to notify their insurance carriers after all work injuries?

A3: The Workers' Compensation Act requires that the employer provide immediate notice to its workers' compensation carrier of all work-related accidents and injuries. The workers' compensation carrier's obligation to pay benefits does not begin until the employer provides it with notice of a work incident. However, once such notice is given, the carrier is under an obligation to issue documentation to the worker and to the Bureau of Workers’ compensation either accepting or denying responsibility for the injury. Should the carrier deny that the injury took place, the worker should seek legal representation with an experienced Workers’ Compensation attorney.

Q4: Is a worker required to give a statement to the employer's workers' compensation carrier?

A4: When a worker first reports an injury, he/she may be asked to give a statement to the employer's workers' compensation carrier. The worker should comply with this request if the questions seem reasonable. The statement may occur in person or over the telephone. The person from the insurance company may try to attribute the worker's injury to non-related causes. Therefore, it is important that the worker carefully read the statement and make all necessary corrections to the statement, before signing it. The worker should also request a copy of the signed statement. The insurance adjuster may contact a worker only if he/she is not represented by a lawyer. If represented, all of the adjuster's communications must be directed through the worker's attorney.

Q5: If I cannot work, does my employer pay me lost wages?

A5: Yes. You are entitled to receive lost wages (disability benefits) if you cannot work. An entitlement to Disability benefits arise when a worker is unable to earn as much after the injury as he/she earned prior to the injury. There are two types of disabilities.

A Temporary Total Disability occurs when a worker is totally unable to work following an injury. The worker's inability to work may be temporary or permanent. In either instance, the loss of earnings suffered while a worker remains unable to work is known as Temporary Total Disability.

A Partial Disability occurs when a worker is able to return to work with restricted hours and/or restricted duties which may result in a loss of earnings. The change in a worker's employment status must be acknowledged by the insurance company.

Q6: How does the insurance company calculate my lost wages?

A6: The amount of Disability Benefits which are paid to an injured worker is calculated based upon the Amount of wages or salary which the worker earned prior to injury. Pre-injury earnings are known as Average Weekly Wage (AWW). A worker's AWW is determined by the worker's weekly average earnings during the year prior to injury. If a worker failed to work a full year prior to injury, the worker's AWW is based upon the weekly average of all earnings. Further, if a worker also worked another job on the date of accident, the wages of the other job (or jobs) are also included in the AWW calculation.

Q7: How long can I get Disability Benefits?

A7: In some instances, Temporary Total Disability Benefits may be paid during the entire life of a worker, whereas Partial Disability benefits may be received for up to five hundred (500) weeks. The disability benefit entitlement of a totally disabled worker may however, be limited in duration, under what is known as an impairment rating procedure. Under this procedure a worker who has received total disability benefits for at least two years may be asked by the insurer to submit to an impairment rating evaluation. An evaluator will use the American Medical Association's guidelines for rating permanent impairment and assess the extent to which the worker's overall physical functioning is impaired as a result of the work injury. If the impairment is rated at less than fifty percent (50%), the worker's entitlement to total disability benefits will thereafter be limited to 500 weeks.

Q8: Who pays for my medical treatment?

A8: The insurance company has an absolute duty to pay for all reasonable and necessary medical expenses of a work-related injury. If there is a work-related injury, but no disability (i.e. no loss of earnings), the insurer must still pay a worker's medical expenses. A work injury may include any physical, mental, emotional, or cognitive impairment. The medical treatment provided for the injury may include hospitalization, nursing care, physical therapy, acupuncture, psychiatric treatment...in other words, anything your doctor(s) prescribe for you which relates to the work injury and is “reasonable and necessary."

Q9: If an employer's workers' compensation carrier pays a worker's medical bills, does that mean that the carrier has legally accepted the worker's claim for workers' compensation benefits?

A9: No. It is a very important to recognize that the mere payment of medical bills by the employer's workers' compensation carrier does not mean that the carrier has accepted a worker's claim. Many workers are falsely led to believe that their claim has been, or is about to be accepted. Consequently, it is important to contact an attorney who can determine whether a worker's claim has been accepted by the employer's workers' compensation carrier.

Q10: What medical treatment is the workers' compensation carrier responsible to pay for?

A10: The employer's workers' compensation carrier is only obligated to pay medical bills for treatment of conditions which are work-related. Therefore, it is very important that the employer's carrier identify all injuries related to the work incident. If the carrier fails to acknowledge all injuries, a worker, with the help of an experienced lawyer, must file a Petition to force it to acknowledge all of his/her medical conditions which resulted from the work accident. Medical documentation supporting the relationship of the medical condition to the work injury is crucial. All medical conditions which a worker feels are related to a work injury must be identified as soon as possible (i.e. in the emergency room, initial physician consultation, or when the symptoms first appear).

Q11: Can a worker treat with his or her own doctor?

A11: The law requires that, during the first ninety (90) days, the worker treat with the company or panel doctors. This only applies when the employer posts a list of panel physicians and the worker has signed an acknowledgment that the employer has a list of panel physicians. A worker may choose any doctor from the list. The employer has no right to direct the worker where to treat. If a specialist is needed, and not on the list, the worker is not restricted to the list of panel physicians. If a worker treats with a doctor that is not a panel physician during the first ninety (90) days of treatment, the worker may be held personally responsible for the payment of all medical bills for treatment rendered during that period. Ninety (90) days after the date of the injury, the worker may treat with any physician or rehabilitation specialist of his/her choice.

Q12: Can the workers' compensation carrier force a worker to switch treatment from one medical professional to another?

A12: No. The employer's workers' compensation carrier may never direct a worker's medical treatment and care; the carrier is also not permitted to force an individual to switch healthcare providers.

Q13: What is an Independent Medical Examination (IME) and must the worker attend the examination?

A13: An independent medical examination (IME) permits the employer's workers' compensation carrier, through a doctor of its own choosing, to assess the worker's medical condition. The law permits these examinations every six months unless a new condition is alleged. In these instances, the carrier will be entitled to conduct another examination. Failure to attend an examination may result in litigation and ultimately, the suspension of a worker's benefits.

Q14: What information should a worker provide to his/her treating physicians and the IME physician?

A14: It is important that a worker provide all doctors including the company doctor with detailed information about the worker's accident, injuries, job title, and duties. This information will assist a doctor in determining whether a worker's condition is caused by work and whether the worker can perform his/her job.

Q15: What recourse does a worker have if an employer refuses to honor a doctor's restrictions?

A15: The worker should speak with an appropriate supervisor or human resource representative. All communications with the employer should be documented. If the employer continues to overlook the restrictions, the worker should consult with an experienced Workers’ Compensation attorney.

Q16: If the employer's carrier refuses to pay a worker's medical prescription bills, how can the worker get the bills paid?

A16: The worker should submit the medical bills to his/her private insurance carrier and that carrier must pay the bills. This does not relieve the employer's workers' compensation carrier of its obligation for payment of the bills. An experienced Workers’ Compensation attorney may be needed to file a petition to force the carrier to pay the worker's medical bills and/or reimburse the worker's private insurance carrier.

Q17: How does my lawyer get paid?

A17: The law limits the fee that an attorney can charge to represent an injured worker. The attorney must enter into a written agreement and can only charge up to twenty (20%) percent of the compensation a worker receives. This agreement must be approved by a Judge. The court may order an employer to pay an attorney's fee if it is determined that a contest is unreasonable.

Q18: What happens if I have an amputation or a permanent scar?

A18: Specific Loss Benefits are paid weekly in cases of catastrophic injuries. An amputation of a body part or a loss of use of a body part entitles a worker to receive a certain number of weeks of total disability benefits, payable in a lump sum. The number of weeks of benefits varies according to the body part involved. The statute provides for example, that loss of an index finger is compensated for fifty (50) weeks of total disability benefits. Disfiguring scars of the head, neck, or face also constitute "specific losses." This benefit is payable without regard to the amount of time actually lost from work. An additional number of weeks of disability compensation is payable relative to the healing period for each specific loss, provided the worker remains out of work for the duration of the healing period. In an injury producing a specific loss that has some disabling aspect separate and distinct from the actual loss, then total or partial disability benefits are allowable in addition to the specific loss benefit. These benefits are required to be paid before payment of specif­ic loss benefits. In the event of death, specific loss benefits are payable to the estate or family of the worker.

Q19: What are my rights if a member of my family dies?

A19: In the unfortunate case of a death resulting from a work injury, the deceased worker's widow/widower and dependents are entitled to receive total disability benefits. For the widow/widower, death benefits continue indefinitely but, will be cut off by remarriage or entry into a relationship which resembles marriage. The dependents (usually children under the age of 18) may collect death benefits for as long as the dependency continues. Further, the death must occur within three hundred (300) weeks following the injury from which it resulted. Burial expenses up to $3,000 are also recoverable.

Q20: I have received a petition from my employer which says I am recovered from my work injury. What should I do?

A20: Employer/Insurer's Petitions are generally filed following an independent medical exam (IME) of the worker which is conducted on behalf of the insurer. If the IME physician concludes that the worker has fully recovered from his/her injury, a Termination Petition may be filed. If the IME physician concludes that the worker has made less than a full recovery, but is capable of meeting the physical demands of another type of job (sedentary, light- or medium-duty work), then a Suspension or Modification Petition may be filed. If you receive one of these petitions, you should immediately seek legal representation with an experienced Workers’ Compensation attorney.

Q21: Do I need an attorney to help settle my case?

A21: Although you do not need an attorney to settle your case, you should seek the advice of an experienced Workers’ Compensation attorney to make sure you are getting the full value of your injury. All Workers' Compensation settlements are set forth in a Compromise and Release Agreement and must be approved by a Workers' Compensation Judge. An attorney can help you understand the rights you are giving up by entering in to such a settlement. In order to settle a case, a worker must attend a hearing for the worker to testify to his/her understanding of the parties' agreement. If the Workers' Compensation Judge is satisfied that the settlement is fully understood, the Workers' Compensation Judge will approve the Compromise and Release Agreement and direct that its payment terms be compiled with.