In Pennsylvania, workers compensation insurance is compulsory. You must have workers compensation insurance, if you have one employee, with very few exceptions (coverage for one domestic servant is voluntary and there are some narrow agricultural exceptions). Waivers are not permitted. Workers compensation insurance can be purchased from a private insurance carrier, the employer may self insure, and workers compensation coverage can be obtained through the state fund.
Claim Reporting:
The employee must report the injury to the employer within 120 days of the accident, illness or disease. If the employee reports the injury within 21 days of the accident, the indemnity benefits are payable from the date of the accident, if they apply. If the injury is report 22 days to 120 days after it occurred, the indemnity benefits are payable from the date the injury is reported. The employer must report the accident to the Bureau of Workers’ Compensation within 21 days to avoid sanctions.
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Medical expenses including doctor visits, surgical expenses, hospital expenses, prescriptions, mileage expenses, orthopedic devices and durable medical equipment are all covered by Pennsylvania workers compensation coverage. There are no time limits and no monetary limits. A medical fee schedule based on 113% of the 1994 Medicare rates (and adjusted each year since 1994 by the State) is utilized to control the cost of medical care.
The initial choice of a medical provider is controlled by the employer. The employer provides a panel of at least six designated health care providers of which no more than four can be in a coordinated care organization and no fewer than three must be physicians. To utilize the panel, the employer has to have the employee sign a Rights and Duty form at the time of hire acknowledging the employee must chose from the designated panel if an injury occurs. After 90 days the employee is free to choose his own medical provider, but must notify the employer within 5 days of the first visit to the new physician. If the employer does not have the Rights and Duty form or does not have a panel of designated health care providers, the employee can choose his own medical provider immediately.
The workers compensation insurance company is limited to requesting two independent medical examinations (IME) of an injured employee each year. If the injured employee does not attend the IME, the insurance company can petition for a suspension of benefits.
Temporary Total Disability (TTD) Benefits:
The employee’s total income over the 52 weeks prior to the injury is used to calculate the average weekly wage. Total income includes overtime pay, vacation pay, bonuses and commissions in addition to the weekly wage. TTD is to two-thirds of the average weekly wage if the average weekly wage is over $633.76 (in 2010, adjusted annually by the State). The TTD benefit can not exceed $845.00 in 2010 (the maximum is adjusted annually by the State). If the average weekly wage in 2010 is between $469.44 and $633.75, the employee will receive a weekly TTD benefit of $422.50. If the average weekly wage in 2010 is below $469.43, the employee receives 90% of the average weekly wage. (While the State government may have humanitarian intentions in paying the lower income workers 90% of their gross pay, it provides a huge disincentive to return to work when the employee is receiving as much, or more, from work comp then they received before the accident in their net take home pay.) The state minimum weekly benefit is $50.00.
The first 7 days of disability (the waiting period) is not paid to the injured employee unless the employee is disabled for more than 14 days. TTD benefits can be paid for the employees lifetime, or to the employees return to work, or to the resolution of the claim through a Compromise & Release Agreement, or to the termination of the benefits by Bureau of Workers’ Compensation Judge, or to the modification of benefits to temporary partial.
Return to Work:
To the credit of the Pennsylvania Department of Labor & Industry, which oversees workers compensation, they have a model Return to Work program that they actively promote. Their recommended return to work program can be viewed at: http://www.portal.state.pa.us/portal/server.pt?open=514&objID=602303&mode=2
The Return to Work program recommended by the Pennsylvania Department of Labor & Industry promotes the buy-in of the employee, the employer, the medical providers, the unions and the workers’ compensation insurer by explaining how the Return to Work program benefits all parties.
Our website also has a tremendous amount of information that will benefit the Pennsylvania employer with the creation or management of a Return to Work program. For more information on Pennsylvania Return to Work, please go to: http://reduceyourworkerscomp.com
Temporary Partial Disability (TPD) Benefits:
TPD is limited to two situations – 1) when the employee is returned to work at a lower rate of pay due to the injury, or 2) when the employee is working reduced hours due to the injury. The employee receives two-thirds of the difference between what he was earning before the injury and what he earns after the injury. TPD is limited to 500 weeks.
Permanent Partial Disability (PPD) Benefits:
PPD benefits are paid when the employee sustains a permanent loss of function, or scarring and disfigurement of the face and/or neck as the result of a work related injury. Specific loss benefits for body parts are payable based on a stated number of weeks listed in Section 306 of the workers’ compensation statute.
Permanent Total Disability Benefits:
While TTD can go on for a life time in Pennsylvania, and TPD can go on for 500 weeks, there are no statutory permanent total disability benefits in Pennsylvania.
Death Benefits:
The simple part – there is a $3,000 burial benefit. The complex part – the weekly benefit is a percentage of the average weekly wage (AWW), not to exceed the statewide average weekly wage (as published annually by the State). Dependent children are eligible for weekly benefits until age 18 or age 23 if they are a full time student. If there are no dependent children, the surviving spouse receives 51% of the AWW. If there is one child, the surviving spouse receives 60% of the AWW. If there are two or more dependent children, the surviving spouse receives 66 & 2/3% of the AWW. If there is no surviving spouse, but dependent children, there is a graduated scale with 32% of the AWW for one child, and up to 66 & 2/3% for six or more children, with the benefits being paid to the guardian(s). If the surviving spouse remarries, the surviving spouse is no longer entitled to the death benefits, but the dependent children are. There are also guidelines for paying death benefits to parents and dependent siblings when there is no surviving spouse or dependent children.
Vocational Rehabilitation:
All that is required for a modification or suspension of benefits is the performance of a labor market survey by a vocational expert to prove the employee’s earning capacity.
Settlements:
Lump sum settlements are allowed. Compromise and Release Agreements are used to resolve future medical exposure, future indemnity exposure or both. If the parties agree, a structured settlement may be used to pay the claim. All settlements are subject to the requirements of Medicare.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.
Contact: [email protected] or 860-553-6604. www.LowerWC.com
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MODIFIED DUTY CALCULATOR: http://www.LowerWC.com/transitional-duty-cost-calculator.php
WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
SUBSCRIBE: Workers Comp Resource Center Newsletter
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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