Pennsylvania’s job market has changed a lot the past 25 years, and not necessarily for the better. You could say the same about the state’s workers compensation system.
More than 300,000 manufacturing jobs have moved to foreign countries since 1994. Pennsylvania’s workers compensation system has downsized and streamlined along the way.
The results are mixed.
“We have one of the more generous workers compensation systems,” said Catherine Surbeck, a workers compensation attorney for the Freedman and Lorry law firm in Philadelphia.
The average weekly check is $572, the 13th-highest among states. The maximum allowed is $1,130, which beats the heck out of Mississippi’s max of $398.
Like all states, however, insurance carriers do their best to minimize those payments in Pennsylvania. Politicians in Harrisburg have passed laws designed to whisk workers through the system, sometimes to the workers detriment.
That’s been especially hard on workers who are seriously injured.
“Our state does a reasonable job compensating minimally and moderately impaired,” said Joseph Baumann, a partner in the Abes Baumann law firm in Pittsburgh. “The severely impaired, no.”
Have you ever heard of a Utilization Review? How about an Independent Medical Exam or an Impairment Rating Examination? They go by the acronyms like UR, IME and IRE.
Insurance companies use them to contest workers compensation claims. It’s not easy for the average worker to keep track of the acronyms, much less contest them in court.
Not that Pennsylvania wants cases to go to court. Legislators first introduced the concept of “voluntary mediation” in 1996. It encouraged warring parties to settle cases before going to court.
The law was strengthened in 2006, and now four out five cases are settled before going to a judge.
“Both laws were pushed by insurance carriers, who figured out they’d pay less over time,” Baumann said.
With the loss of manufacturing jobs, workers compensation claims have plummeted from about 150,000 a year in 1991 to 80,000 in 2021. Now there’s a system designed to whisk workers through, but sometimes you need to hit the brakes.
That’s what workers compensation attorneys are for. But if you want to pursue a case on your own, here’s a quick primer on the system you’ll enter.
How to File a Workers Compensation Claim in Pennsylvania
You have 120 days from the date you were injured to tell your employer. Do not wait that long.
“The first thing I tell clients is give notice immediately,” Bauman said. “If somebody gets hurt on Friday and reports it on Monday, that claim might be denied because the insurance company will say you got hurt over the weekend.”
You can receive workers comp benefits from the date you were injured, but only if you report the incident within 21 days of its occurrence. If you wait more than three weeks to report it, you’ll receive benefits from the date you reported the injury.
Once you have lost a day, shift or turn of work, your employer has three days to file a First Report of Injury with the Pennsylvania Bureau of Workers Compensation. Your employer has to report your injury to its insurance company within 21 days of being notified of the incident.
Insurance Company’s Role
If your employer’s insurance company accepts your claim, you’ll be issued a Notice of Compensation Payable and start receiving benefits. In some cases, the company will issue a Notice of Temporary Compensation Payable.
That means it hasn’t made a decision on your claim, but will pay benefits until it does. If the insurance company rules in your favor, it can still reverse its ruling within 90 days and stop paying benefits.
If your claim is denied, you’ll be issued a Notice of Workers Compensation Denial. Then you have the right to file a claim petition with the Bureau for a hearing before a workers compensation judge. You have three years to file such an appeal.
How to Appeal a Workers Compensation Claim in Pennsylvania
You have three years from the date of your injury to file a Claim Petition (LIBC-362) if your benefits are denied. It’s a good idea to hire an attorney during this part of the process. They will come in handy collecting information and presenting your case.
After you file the petition, the case gets assigned to a workers comp judge, who will hear evidence from both sides during a hearing.
The judge will then schedule the case for mediation, in which both parties will try to negotiate a settlement.
If they aren’t able to reach an agreement, they may ask for an informal conference or settlement conference with the judge, who will issue a ruling.
If the ruling goes against you and you choose to pursue your case, you can file an appeal with the Workers Compensation Appeal Board within 20 days of the judge’s decision.
Odds are the Appeal Board will not reverse the judge’s decision, since it gives judges a lot of discretion in deciding cases.
If the Appeal Board rules in favor of your employer, that decision can be appealed to the Commonwealth Court of Pennsylvania. Unlike the Appeal Board, the Commonwealth Court is not required to hear all cases. It takes cases with compelling legal issues, which amounts to about 10% of all appeals.
Eligibility for Workers Compensation in Pennsylvania
Workers compensation coverage is mandatory for most employers in the state. Federal workers, longshoremen and railroad workers are not handled by the state system.
So unless you are one those exceptions, you are eligible for benefits. Your injury or illness must require treatment beyond simple first aid.
And if you have doubts about whether your employer has workers comp insurance, you can use this tool provided by the Bureau of Workers’ Compensation to verify coverage.
Benefits: What Does Workers Compensation Cover in Pennsylvania?
Medical expenses, travel expenses and death benefits are all part of the program. All have requirements you must meet, of course, and employers routinely challenge whether workers qualify. That’s done through the aforementioned URs, IMEs, IREs.
Medical Benefits Workers’ comp covers services rendered by a doctor and other healthcare providers, including chiropractors. That includes what the state describes as “reasonable surgical and medical services needed.”
If you need to be hospitalized, treatment, services and supplies are covered. You get a semi-private room, or a private one if there are no semi-private ones available.
Prescription medicines and supplies are also covered. As far as doctors go, your employer has the right to designate six health care providers whom you must choose from. For the services to be covered, you must be treated by a member of this “panel list” for the first 90 days from your first visit.
This is where a little skepticism and a lawyer might come in handy.
Since doctors are chosen by your employer’s insurance company, there is an inherent conflict of interest. Some might lean toward less-expensive treatment options.
“There are exceptions,” Baumann said. “But if a competent doctor calls it the way he sees it too many times, that doctor is removed from the panel.”
Replacement of Lost Wages
Injured workers generally receive two-thirds of their pre-tax salary, though there are exceptions based on the severity of the injury and how long a worker will be off the job.
That amount of money is based on a worker average weekly wage. There is a cap, so if you were making $12,000 a week before getting hurt you won’t be collecting $8,000 afterward.
Again, the maximum in 2021 is $1,130 per week, which was a bump of about 5% over the past two years. As for how long those payments last, it depends on how the injury is diagnosed and classified.
Partial Disability Benefits
These begin when an IRE indicates you are partially disabled or a doctor determines you can perform light-duty work, but you are not completely recovered and may recover some of your lost wages.
If the new position offered pays less than the job you were doing when you were injured, you are entitled to receive two-thirds of your pre-injury wage. Partial Disability Benefits are paid up to 500 weeks, though the payments do not have to be consecutive.
Specific Loss Benefits
These are paid if a work-related injury results in loss of vision or hearing, or the loss of a specific body part. The injury does not have to be disabling, but the worker must prove he or she suffered at least 50% loss of use.
Workers may be entitled to a specific-loss benefit even if they don’t suffer lost wages. It would be based on their weekly salary and severity of the injury.
“Healing time” benefits might also be computed into the total benefit. Disfigurement Benefits
These are similar to Specific Loss Benefits, but instead of payment for loss of a body part, they are compensation for permanent scarring of the head, face or neck “of such character as to produce an unsightly appearance.” Even if a worker can perform all of his or her duties and doesn’t miss a day of work, they are entitled to disfigurement benefits if the injury leaves them living a life of potential embarrassment. The benefits awarded range from 1 week to a maximum of 275 weeks.
Total Disability Benefits
These are paid if you are completely disabled as a result of your injury or work-related illness and can no longer work in the capacity for which you were trained. An IME doctor will determine whether you are partially or totally disabled, though that decision can be appealed.
If the doctor determines the injury has left you 35% or more impaired, you would qualify for total disability benefits.
There is no time limit for those payments.
If you die from a work injury, your heirs will be eligible for death benefits. The amount would be based on your average weekly wage.
A deceased worker’s spouse would receive 51% of the worker’s weekly salary. That increases if there are dependent children. Benefits are paid to spouses until he or she remarries. Even then, they are entitled to two more years of benefits.
Children are eligible for benefits until they turn 18. If the child is enrolled full time in an accredited college, university, or trade school, he or she may also continue to receive benefits until they turn 23.
If the deceased worker had no children or spouse, family members who were dependent upon the deceased may also be eligible for benefits. Partially dependent parents can receive 32% of the worker’s wages at the time of death, while two totally dependent parents can receive 52%. Dependent brothers or sisters can receive 22% to 32%.
Death Benefits also include $3,000 in funeral expenses.
Returning to Work in Pennsylvania
Your employers can’t force you back to work, but it can require you to get an IME. That’s when a doctor selected by your employer’s insurance company examines you and determines your fitness.
They’ll often say you can return without restrictions or you can resume light-duty work. If you disagree, you can get a second medical opinion of your choosing.
If that doctor doesn’t think you’re ready to return, you don’t have to. Your employer will probably appeal, but your benefits will continue until a judge reviews your case.
If you have to return to work, any reasonable medical expenses related to your injury will continue. And your compensation might resume if you are laid off, fired without cause or your doctor.
The good news is the payments are tax free. The bad news is employers’ insurance companies will try to keep those payments as small as possible, and Pennsylvania’s system largely lets them control the process.
That’s where attorneys come in.
My job is to get them out of system on their own terms rather than the insurance company’s terms,” Baumann said. “It’s just not fun.”
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