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Does your Pennsylvania Business Need Workers' Compensation Insurance? Continued.


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WHAT TO DO WHEN A WORK INJURY OCCURS


Employees must report any work-related injuries and illnesses to their supervisor within 21 days to be eligible to receive benefits, which will then be retroactive to the date of injury. If the employee reports the injury to the employer between 21 and 120 days after the date of injury, the employee will be eligible for benefits only from the date that notice was given to the employer. If the employee does not report the injury within 120 days of the date of the injury, payment of benefits usually is not required.

When informed of an employee's work-related injury, employers should document the date of the employee's notice in writing and must then immediately inform their insurance carrier about the injury. If the injury was sustained over a period of time, beyond one day or a regular shift, the employer must also report the injury to the Bureau by filing a "First Report of Injury" within seven days, or if a death resulted from the injury, within 48 hours. An insurance carrier will appoint its own counsel to handle the matter. Then it usually responds within 21 days to approve the claim by filing a "Notice of Compensation Payable" (NCP) or deny the claim by filing a Notice of Workers' Compensation Denial. If the claim is approved, the employer must file with the Bureau a "Statement of Wages" form to calculate the employee's wages and should send a copy to the injured employee-then the employee will begin receiving benefit payments. If the claim is denied, then the employee will have the right to file a Claim Petition with the Bureau for a hearing.

Instead of immediately approving or denying the claim, the insurance carrier also has the option of issuing a "Notice of Temporary Compensation Payable" (TNCP) to extend the 21-day response period to 90 days without admitting liability, but it must temporarily pay benefits during that time. The employer must still file with the Bureau a "Statement of Wages" form to calculate the employee's wages and should still send a copy to the injured employee. The insurance carrier then has 90 days to revoke the temporary acceptance of liability by filing a "Notice Stopping Temporary Compensation Payable" and either approve or deny the claim. If the insurance company fails to do so or continues making payments after the 90-day period, the notice automatically converts into a Notice of Compensation Payable requiring the payment of benefits to the employee. The insurer or employer must supply the injured employee with copies of the "First Report of Injury," the NCP, and/or the TNCP.

HEARING


If the employer and insurance company deny the claim, the employee has three years from the date of injury to file a Claim Petition for a hearing. Claims are assigned to workers' compensation judges in the region where the employee resides; then all parties are notified in writing as to the date, time, and place of the hearing.

At the hearing, or through multiple hearings, the judge hears evidence presented by both parties. Unless the judge determines that mediation would be futile, the judge assigns the claim to mediation. The judge must approve any settlement before it can be finalized so that a record exists to show that the employee understood the terms of the settlement. If no settlement is reached, the judge will issue a written decision after all evidence has been submitted.

Either party then has 20 days from the date of decision to file an appeal with the Workers' Compensation Appeal Board (Board). After the Board reviews the case and renders a final decision, either party has 30 days from the date of decision to appeal to the Commonwealth Court. After the Commonwealth Court renders a final decision, either party has 30 days from the date of decision to appeal to the Supreme Court of Pennsylvania.

SEMI-ANNUAL RE-CERTIFICATION


Employers have the right to require injured employees to be evaluated by a doctor of the employer's choice once every six months for an Independent Medical Examination (IME). These IMEs are used to assess the extent of the employer's liability for the work injury and the employee's ability to return to work. The chosen doctor should look for inconsistencies in the employee's history, symptoms, restrictions, and limitations, and also whether the employee is exaggerating complaints of pain or other symptoms.

RETURN TO WORK


When an injured employee returns to their previous employment, the insurer may file a "Notice of Suspension or Modification" form within seven days of the employee's return to work.The insurer must then file a Final Statement of Account of Compensation Paid form with the Bureau after the final payment of compensation. A "Final Receipt" - officially called The Agreement to Stop Workers' Compensation Payments - form is filed when a worker's benefits terminate, with a copy sent to the employee. An employee has three years from the date of the last benefits payment to file a Claim petition to contest the termination or denial of benefits. If the employee is unable to return to the previous position, the employer is not obligated to retrain the employee or place the employee in a different position, subject to the applicability of other laws.

OTHER LAWS


Despite the existence of appropriate Workers' compensation coverage, workers' injuries or their compensation payments may be impacted by other laws such as social security, unemployment compensation, pension and benefit laws, tort laws, or discrimination laws. For example, the Americans with Disabilities Act ("ADA") makes it illegal to discriminate against an individual in employment on the basis of the individual's disability. Likewise, the Family and Medical Leave Act (FMLA) requires employers, with 50 or more employees within a 75 mile radius, to provide up to twelve weeks of unpaid leave to eligible workers for certain family and medical reasons. Lastly, while the existence of appropriate Workers' Compensation coverage will most likely preclude it, employees can still assert a legal claim of negligence against the employer related to the employer's actions (or lack thereof) or to perceived wrongdoing by a coworker or third party. Feel free to contact us for more information or referals to agents that we or our other clients have had good experiences with in having workers compensation policies procured.

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These guides provide general information only and are not intended as legal advice, nor do they create an attorney-client relationship. The facts in your particular situation may render a different result. Therefore, for more information on this general topic, please contact the us via the navigation menu at the top.