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WHAT IS WORKER'S 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.
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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 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.
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