COMPENSABILITY
Claim Decision: 21 days to accept or deny following notice of injury. Acceptance or denial must be confirmed with filing of appropriate state forms. Temporary compensation benefits, without formal acceptance of the claim as compensable, can be paid for 90 days.
Defenses: Not in course and scope of employment; no employer/employee relationship; intentional self-inflicted injury; suicide; violation of work order; no work-related causation disability; available work post-injury; untimely notice; 3 year statute of limitations; intoxication/drug use (difficult proof).
BENEFITS
Temporary Total Disability: Payable for work-related injury resulting in disability; payable at statewide maximum rate, 2/3 if less than SMCR, and at 90% if less than statewide minimum rate; 7 day waiting period; concurrent employment wages compensable; TTD terminates with death, proof of full recovery, or settlement with employer release.
Temporary Partial Disability: Payable at 2/3 of difference between pre-injury AWW and RTW wages; payable for 500 weeks, and need not be consecutive; also payable at post-injury wage rates with IRE assessment of less than 50% impairment.
Specific Loss Benefits: Statutory schedule for amputation, or complete loss of use for all “practical intents and purposes”; also for facial scarring and disfigurement.
Fatal Claim Benefits: Payable to dependents for work-related fatalities within 300 weeks of injury; statutory dependency schedule for surviving spouse and dependents.
Medical Benefits: Payable for reasonable, necessary and causally related medical care for work injury; IMEs allowed every 6 months, IREs allowed, post-payment of 104 weeks of TTD, mileage can be reimbursable for both treatment and IME attendance.
Compromise and Release: Settlements can be for all claims or benefits.
Penalties: 2 kinds; proven violation of the Act; also payable, as reimbursement of quantum meruit attorney fee, if claim contested without a reasonable basis.
Offsets: Social Security old age offset at 50%; unemployment compensation, pension offset, if employer-funded; offsets for employer-funded disability benefits; third-party personal injury recovery for work injury requires repayment of subrogation lien; forfeiture of TTD for refusal of reasonable and medical procedure.
MEDICAL COMPENSATION BENEFITS
Direction/Control: Virtually non-existing; employer panel lists are very rule-specific; require claimant to treat with panel physicians for 90 days post-injury; outside of 90 days, claimants are free to treat, subject to reasonableness and necessities.
Standard: All care, from palliative to surgical, must be reasonable necessary causally related to work injury to be compensable.
Duration: Until full recovery from disabling injuries; can be lifetime, absent proof of change in condition.
Consultations: IMEs are permissible every 6 months; IREs allowed post-payment of 104 weeks of TTD; multiple IMEs and IREs are allowed; second opinion is also allowed for surgical/treatment consults.
Fee Schedule: Fee schedule regulated by statute, dependent on Medicare reimbursement rates and diagnostic codes.
Medical Review: Utilization reviews allowed to challenge reasonableness and necessity of medical care.
IRE: Impairment rating of less than 50% of whole man under AMA Guides results in conversion of TTD to TPD; allowed after 104 weeks of TTD.
PENALTIES/FINES
Attorney’s fees statutorily regulated at 20% of indemnity benefits; litigation costs reimbursable by statute; interest payable by statute; penalties allowed for proven violation of the Act; quantum meruit attorneys’ fees allowable for unreasonable contest.
MEDIATION
Two kinds; mandatory and voluntary. Mandatory mediation required in all litigated claims post-2007. Mandatory mediation requires employer/carrier settlement authority. Voluntary mediations encouraged by the Bureau since last substantive reforms in 1996.
SETTLEMENT/CASE RESOLUTION
All settlements must be approved by workers’ compensation judges. Judge required to determine that settling claimant understands “legal significance” of settlement, requiring formal hearing with claimant testimony. Settlements include all compensation benefits. Settlements typically include employment resignation.
VOCATIONAL REHABILITATION
Allowed in Pennsylvania, and typically utilized to convert exposure for TTD to exposure for TPD. Technical requirements controlled by statute and decisional authorities. Hypertechnical application by judges. Any RTW requires issuance of Notice of Ability to Return to Work with attached medical indicating release for work. Pennsylvania workers’ compensation is disability-based, heightening the importance of RTW and vocational.
CONNORS LAW NEWSLETTER/SEMINAR
Please contact us directly to subscribe to Workers’ Compensation Newsletters, or to request a training seminar or in-house “lunch and learn”.
Kevin L. Connors, Esquire
Phone: 610-524-200 Ext. 112
Kate A. O’Dell, Esquire
Phone: 610-524-2100 Ext. 119
