Find the Answers to Your Pennsylvania Workers’ Compensation and Disability Benefits Questions
Most people navigating the workers’ compensation and disability benefits application processes come to us with questions and confusion. Here, we share some of the questions that we answer most about the disability and workers’ compensation application and appeals processes. If you have a question for us, check out this page to see if we have answered this question for others!
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My doctor has released me to light duty, but my employer does not have light duty. What should I do?
You do not have any obligation to do anything. If your employer offers you light duty, you may have an obligation to make a good faith effort to follow through on the offer of employment. But be wary. Click here for a discussion of some of the things that might go wrong.
I’ve suffered a Pennsylvania work injury, and it’s my understanding that I have to treat with a company doctor. My employer won’t tell me where to treat or return my calls. What should I do?
Very few people really have an obligation to treat with a company doctor. Unless your employer complies with the law and regulations governing treatment by a company doctor, you are free to treat with a physician or medical provider of your choice. You can go to any physician or medical provider if your employer fails to return your calls. You can also get in touch with the insurance company directly to report your claim and request information. To find out the name, address and phone number of your employer's workers' comp insurance company, click here.
How do I calculate my Pennsylvania workers' compensation benefits?
Workers' compensation wage loss ("indemnity") benefits are calculated by analyzing the wages you received during the 52 calendar weeks before your work injury. If you were employed by more than one employer on the date of injury, you are entitled to receive benefits based on wages that you were receiving from all employers. If you have any questions concerning the method by which your employer calculated your compensation benefits, call The Boles Firm and we will provide you with a free calculation of your benefit rate.
When you begin receiving benefits, you are supposed to receive a Statement of Wages that describes how your Average Weekly Wage (AWW) was calculated. As you can see by clicking on the link for the Statement of Wages form, if your gross (before tax) wages are fixed by the week, this wage plus gross weekly board/lodging, federally reported gratuities, annual bonus, incentive or vacation pay is your Average Weekly Wage under the Pennsylvania Worker’s Comp Act. Because board/lodging, vacation pay, bonus and incentive pay are the most frequent source of errors in Statements of Wages, be careful to double-check these calculations!
If your wages vary from week to week, you must gather your paystubs for the 52 weeks before your work injury occurred to calculate your benefits. If you do not have your paystubs, ask for a printout from the personnel office of your employer.
To determine your weekly benefit, you must divide the 52 calendar weeks that preceded your work injury into four 13 week periods and add up the gross wages you earned during each 13 week period. Make sure you use the pay period covered by your paycheck (which should be stated on your paystub) and not the day your employer issued the check.
If you are paid every two weeks, this presents a slight problem: when calculating the total gross wages you earned for a particular 13 week period, the last pay stub in each period will overlap with the next period. You handle this by dividing by two the gross wages earned during the two weeks that run from one period into the first week of the next period and. Assign one half of your gross wages for this two week period to period one, and half to period two.
Let's give an example. Assume your injury occurred on March 31, 2016 and you work Monday to Friday. The four 13 week periods preceding the date of injury are as follows:
First period 3/29/2015 – 6/27/2015
Section period 6/28/2015 – 9/26/2015
Third period 9/27/2015 – 12/26/2015
Fourth period 12/27/2016 – 3/26/2016
Let's assume you are paid biweekly gross wages ranging from $1,520.00 to $1,650.00. Let's further assume for the pay period ended October 2, 2015, you earned $1,620.00. The two week pay period ended October 2, 2015 does not match any of the four periods that set forth above. Handle this by dividing the amount you received for that 2 week period, $1,620.00, in two, yielding $810.00. Assuming you earned $1,580.00 for every 2 week period ended through September 18, 2015, your total pay for the second period would be $10,290.00. When you divide $10,290.00 by 13 you get your average weekly wage for period two, $791.54. This procedure must be followed for each of the four periods.
First period 3/29/2015 – 6/27/2015 $10,290 ÷ 13= $791.54
Second period 6/28/2015 – 9/26/2015 $11,300 ÷ 13= $869.23
Third period 9/27/2015 – 12/26/2015 $12,100 ÷ 13= $930.77
Fourth period 12/27/2016 – 3/26/2016 $ 9,700 ÷ 13= $746.15
Annual Bonus and Vacation $ 1,400 ÷ 52 = $ 26.92
To calculate your AWW and compensation rate, you must take the sum of the highest three period weekly averages, and divide by three. Divide by 52 the total amount of any annual bonus, incentive or vacation pay you received during the year before the injury and add that to the weekly wage. In our example, This yields an AWW of $890.77 ($791.54 + $869.23 + $ 930.77 = $2,591.54/3 = $863.85 + $26.92 = $890.77) for the year. If you worked more than one job, you must do the same calculation for each and add them together.
If you haven't worked for the employer for at least three consecutive periods of 13 calendar weeks in the 52 weeks preceding the injury, the same calculations are done but only for completed 13 week periods. You then average any completed 13 week periods to get your AWW.
If you've worked less than a complete period of 13 weeks and you don't have a fixed hourly wage, your AWW consists of your hourly wage times the number of hours you were expected to work per week under the terms of your employment. You must add to that your annual bonus, incentive or vacation pay divided by 52.
These calculations will cover most situations. There are some other more unusual situations in which you should almost certainly consult an attorney, including when you are working a seasonal occupation or worked less than 13 weeks for the employer.
Once you calculate your AWW, you must determine your weekly benefit (compensation rate). For most people, this will be tax free benefits equal to two-thirds of your AWW. In our example, the weekly benefit that will be paid is $593.85. For individuals who have low wages, the compensation rate may well be different, and there is a maximum rate you can receive no matter how high your wages were.
If you click here, it will take you to the Pennsylvania Bureau of Worker's Compensation's compensation rate schedule page. Click on the year your injury occurred, and the rate schedule will appear. In our example, the injury occurred during calendar year 2016. For people earning $733.51 or more, the compensation rate is their AWW multiplied by .667, though their benefit rate may not exceed $978, the maximum for 2016. For individuals earning between $489.00 and $733.50 in gross weekly wages, the compensation rate is $543.33. For individuals earning $543.32 or less per week, the compensation rate is .9 times the AWW. The AWW and Compenpensation Rate will appear on the Notice of Temporary Compensation Payable (NTCP) or the Notice of Compensation Payable (NCP).
What's included in calculating my Average Weekly Wage (AWW)?• Wages received from all concurrent employment are used to determine the AWW. If you work for more than one employer, your AWW should be calculated for each job and then added together. Any additional job must be one you have at the time of injury.• Earnings must come from an employment relationship and wages received as an independent contractor are not included.• Overtime pay may not be eliminated in determining your pre-injury AWW.• If you were expected to work overtime but suffer a work injury before a 13 week period has ended, the overtime pay you would have earned had you not suffered the injury is to be included in the calculation of the AWW.• Gross wages include gratuities and board and lodging received from the employer. Gratuities can be included in wages only if reported by the employee for federal income tax purposes. Money advanced to reimburse an employee for board and lodging is to be included in computing the AWW even if they are not included in the employee's federal income tax return.• Bonuses, incentive and vacation pay are to be pro-rated over the year and added to the AWW after the annual amount is divided by 52.• Supplemental unemployment benefits paid pursuant to a collective bargaining agreement are included in the AWW.• Profit-sharing payments may be wages for purposes of calculating the AWW.• Exercised stock options may constitute wages for purpose of calculating the AWW.• Fringe benefits are not included in wages.• Unemployment compensation benefits are not included.• Commissions earned by an employee for the part-time sale of real estate are not added to earnings from the employer liable for payment compensation if the sales person qualifies as an independent contractor for state or federal tax purposes.• Veterans and Social Security benefits are not wages.• Flex dollars provided by the employer for an employee to use to pay the cost of medical and dental benefits are health and welfare benefits and are not included in the calculation of the AWW.• Volunteer emergency workers, including members of volunteer fire departments, are employees and have an irrebuttable presumption that their wages are at least equal to the statewide average weekly wage.• If an employee missed time from work and received workers' compensation benefits for a prior work-related injury during the 52 weeks prior to the most recent disabling injury, the AWW of the employee for the first injury is to be included as earnings when calculating the AWW for the second injury.
There are many ways a workers' compensation insurance company can cheat you if you do not pay attention, but there are remedies available if you are not being paid properly. If you'd like an insider's view of the Pennsylvania workers' compensation system, download a free copy of The Wounded Worker: Inside the Pennsylvania Workers' Comp Maze.
Should I let a rehabilitation nurse accompany me to visits to my physician?
The Pennsylvania Workers' Compensation Act does not give the insurer the right to have a rehabilitation nurse accompany you for visits to medical providers. Furthermore, you have the legal right to explicitly prohibit your physicians, even company doctors, from talking with the rehabilitation nurse. Though they are legally entitled to file with the insurance company medical report forms and records so that they may be paid for treatment rendered, otherwise physicians and other medical providers must respect the confidentiality of your relationship. Why, therefore, would you ever decide to cooperate with a rehabilitation nurse?
You may be receiving benefits pursuant to a Notice of Temporary Compensation Payable in which the insurance company has not yet accepted full legal responsibility for your injury. In that situation, you may want to cooperate as much as you can with the insurance company, taking the risk that a rehabilitation nurse may not be helping you. Why? As a practical matter, insurance companies deny claims all the time, even when the claims are valid. They do so because they know that they can "starve you out" and often force you to return to work, often long before it is appropriate for you to do so. Thus, until the insurance company has accepted full legal responsibility for your work injury either by issuing a Notice of Compensation Payable, or paying wage loss benefits to you for a period of more than 90 days under a Notice of Temporary Compensation Payable, you may wish to cooperate.
Furthermore, although the quality of rehabilitation nurses varies widely, there are many rehabilitation nurses, even those hired by the insurance company, who will support you, make sure that the medications you take are appropriate, and coordinate care with other medical providers. Other rehabilitation nurses, however, are little better than spies for the insurance company. It is often impossible to tell if a rehabilitation nurse falls into that category until it is too late.
Thus, if the insurance company is using a rehabilitation nurse, you should be represented by an attorney. Most good firms, including our firm, will monitor your claim at no charge under these circumstances and will charge fees only in the event of a dispute.
If you have a good relationship with a rehabilitation nurse and wish to maintain that relationship, we usually place conditions on the continued interaction of the rehabilitation nurse with you or your physician. First, we insist that all conversations between the rehabilitation nurse and any medical provided be done in your presence. Second, we require all communications with the insurance company by the rehabilitation nurse to be in writing with copies to our firm.
It is our belief that you should not permit a rehabilitation nurse to speak privately with your physician. You not only want to be present when a rehabilitation nurse, even one you trust, speaks with your physician, you also want to write down afterwards everything you hear. If you are suffering from a serious work injury, it is best to be safe than sorry.
How does the Pennsylvania Workers' Compensation Office of Adjudication assign petitions?
The office assigns petitions to Workers' Compensation Judges who have hearing locations near the residence of the injured worker. If you live out of state, the bureau will probably assign the petition to the location of your employer, though the Workers' Compensation Judge will consider requests to have the case assigned to a hearing location that is more convenient to the injured worker.
What are the most common types of petitions that are filed with the Pennsylvania Workers' Compensation Office of Adjudication?
• Claim: A claim petition is filed by an injured worker to prove that he is entitled to benefits for a work injury.
• Termination: The insurance company or employer files this petition if it claims that the injured worker is fully recovered from a work-related injury and is no longer entitled to receive any benefits.
• Suspension: This petition is filed where an injured worker is not fully recovered, but has returned to work or is capable of returning to available work without a loss of earnings.
• Modification: The insurance company or the employer files this petition when an injured worker is not fully recovered, but has returned to work or is capable of returning to available work with a loss of pay.
• Review: This petition is filed by any party to correct mistakes in workers' compensation documents.
• Review Medical Treatment: This petition is filed to determine whether specific healthcare is related to an on-the-job injury.
• Utilization Review: This is a petition filed to figure out whether medical treatment an injured worker is receiving for a work injury is reasonable and necessary.
• Seek approval of a Compromise and Release: This petition is filed by a party to seek approval of a settlement by a Workers' Compensation Judge.
• Employee challenge: If you return to work, you may receive a Notice of Suspension of your wage loss benefits that claims you returned to work at no loss of wage or at reduced wages. If you believe that notice of suspension is incorrect, you can file an appeal and it will be assigned to a Workers' Compensation Judge.
After the Pennsylvania Workers' Compensation Office of Adjudication assigns a petition, what occurs?
After the Office of Adjudication assigns it to a Workers' Compensation Judge, the parties will be notified of the assignment and the non-filing party will have to file an answer to the petition. The Workers' Compensation Judge will schedule a prompt hearing.
How does my case end up before a Workers' Compensation Judge?
In Pennsylvania, the injured worker, employer, or an insurance company may file a petition with the Workers' Compensation Office of Adjudication online via mail or online system called WCAIS. When a party files a petition, the party must send a copy of the petition to all other parties. The Workers' Compensation Office of Adjudication sends copies of a Notice of Assignment informing the parties that the petition has been assigned to a particular Workers' Compensation Judge, who will schedule a prompt hearing.
Must I sign an authorization to release medical records to the insurance company if I've suffered a work injury in Pennsylvania?
Under Pennsylvania law, injured workers have an obligation to help the insurance company investigate their claims, which means that you must provide the insurance company with medical records proving you are disabled due to a work injury. Although the Health Insurance Portability and Accountability Act (HIPAA) ordinarily protects the privacy of medical records, it does not apply to medical records sent to an insurance company regarding a work injury.
Because it is in your interest to ensure that the insurance company has medical proof that you suffered a disabling work-related injury, you need to do everything you can to get medical records supporting your claim to the insurance company as quickly as possible. This may mean that you are better off signing a medical records authorization.
You should, however, take a careful look at the authorization. The authorization may give the insurer or the insurer's representative the right to speak directly with your medical providers. This is not a wise idea. The authorization may grant the insurance company the right to send a vocational nurse to your medical evaluations. You should avoid signing a document that allows them to do so.
The most common problem that we see in medical records authorizations issued by workers' compensation insurance companies in Pennsylvania is their wide scope. For example, many authorizations permit the insurance company to obtain copies of HIV/AIDS, drug and alcohol abuse, and psychological treatment records.
We always tell people not to authorize the insurance company to obtain such records. If necessary, you should cross out the portions of the authorization that permit the recovery of such records, initialing the sections that you crossed off. When your psychological condition is not at issue, requests to obtain copies of your psychological records are particularly reprehensible. Any information contained in the records the insurance company obtains will be used against you. The last thing you want to do is permit the insurance company to obtain records that document a sexual affair, alcoholism, drug use, history of psychological problems, or personal difficulties in your life.
On the other hand, you do not want to make the authorization too narrow. If you do not care about the production of medical records, it makes little sense to get into a dispute with the insurance company over these records. Furthermore, the insurance company is entitled to, at least some extent, determine whether you are disabled for reasons unrelated to the work injury. Finally, the insurance company is legally entitled to know about your past medical history as it pertains to the work injury that you suffered.
When signing a medical records authorization, use your common sense.
What happens at a Pennsylvania workers' compensation hearing?
You may need to testify in opposition to a petition filed by the insurance company or your employer, or you may need to testify in support of a petition that you have filed. The topics you will probably testify to are described in this article. Other evidence, including medical depositions, may be submitted. For more information on this topic, order a free copy of The Wounded Worker: Inside the Pennsylvania Workers' Comp Maze by calling 877-959-1811 or download a free copy of by clicking here. Two short chapters (7 and 10) provide the information you need to reduce your anxiety about the Workers' Comp process.
For more detailed answers to your questions, consult the Frequently Asked Questions bar to the left or download a copy of The Consumer’s Guide to Pennsylvania Workers’ Compensation. For the definitive guide to making your way through the Pennsylvania workers’ compensation system, order a free paper copy of The Wounded Worker: Inside the Pennsylvania Workers’ Comp Maze by calling 877-959-1811 or download a free e-copy by clicking here.