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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Can my employer challenge the reasonableness or necessity of my medical treatment?
Yes. An employer has the right to challenge the reasonableness and the necessity of medical treatment by filing a Utilization Review Petition with the Bureau of Workers' Compensation. Bills submitted within 30 days of filing the petition may be reviewed. The Petition will be assigned to a Utilization Review Organization that will request your medical provider to send a copy of your medical records and will request a statement from you regarding your perspective on the treatment you received.
The Utilization Review Organization will assign your case to a doctor who practices in the same medical specialty as your treating doctor, and that doctor will issue a report that states whether your treatment was reasonable or necessary.
If your physician or medical provider fails to provide copies of your medical records to the Utilization Review Organization, the treatment will ordinarily be found to be unreasonable or unnecessary. It is therefore essential that your provider forward copies of your medical records to the Utilization Review Organization if your treatment is being reviewed.
If the Utilization Review Organization finds that your treatment was wholly or partly unnecessary or unreasonable, you as well as your doctor have the right to appeal this decision to a workers' compensation judge. You are not required to pay for any treatment that the Utilization Review Organization deemed unnecessary or unreasonable. The Utilization Review process is also discussed extensively in my free booklet, The Doctor's Guide to Pennsylvania Workers' Compensation Billing.
Should I continue to be treated by the employer-designated doctor after the required period?
After you have been treated by an employer-designated physician for 90 days, you have the right to be treated by the physician or medical provider of your choice. In general, you should exercise this right. While there are many employer-designated physicians who are competent, you should be treated by physicians and medical providers who exercise independent medical judgment.
How can I get the workers' comp carrier to pay my medical bills fast?
The workers' compensation insurance company has an obligation to pay only medical bills for treatment related to the work injury. The bills are supposed to be submitted to the insurance company on appropriate billing forms with an attached medical report form. This form should clearly identify the nature of the treatment and confirm that the treatment was rendered in connection with a work-related injury. In this article, we provide all the information and forms your doctors need to get paid quickly.
If you receive notice from your medical provider that bills have not been paid by the workers' compensation insurance company, make sure the bills have been submitted properly. If the bills are being denied, ask the reason why the bills are being denied. If necessary, request a written denial so that the bills can be submitted to your insurance carrier. For more information, review this article.
Should I continue to be treated by the employer's physician after my claim has been denied?
There is no reason for you to continue to be treated by employer-designated physicians after your claim has been denied. Pennsylvania Insurance Department regulations require health insurance companies to pay bills where the workers' compensation company has denied liability, and thus you may be treated by the physician or medical provider of your choice.
Can my employer require me to be examined by a physician of their choice?
Your employer or its workers' compensation insurance company is entitled to have you examined periodically by physicians of their choosing. You have a right to have your own physician present at such an examination, but you must pay the cost of having your physician present. When being evaluated by an insurance company physician, it is essential that you be accurate and honest with respect to your condition.
If you are requested to undergo such an evaluation, feel free to contact the law firm of The Boles Firm and we will send you our Guide to Attending Independent Medical Evaluations. Moreover, even if you have not sought the services of an attorney prior to being asked to participate in an examination by some physician chosen by the insurance company, this would be an important time to reconsider your decision. Often, this examination is conducted specifically to accumulate evidence to be used in connection with a petition to reduce your benefits. Any experienced workers’ compensation attorney will make certain that prior to attending an examination requested by the insurance company you have mustered the evidence necessary to counter the allegations that will be brought against you in the future.
Do I have any obligation to be treated by a company doctor?
The Pennsylvania Workers’ Compensation Act permits employers to require injured employees to be treated by a physician or medical provider from a list that is to be posted prominently in the workplace for the first 90 days following their injury. Thereafter, injured employees may be treated by a physician or medical provider of their choosing. If the physician or medical provider is not on the employer's list, employers may refuse to pay bills incurred during the 90-day period. If the employer has not provided the employee with a panel list, the employee is free to choose his own provider from the outset, and need not wait until 90 days have passed. Because employers fail to comply fully with the requirements of the Pennsylvania Workers' Comp Act, employees are free to treat with the providers of their choice, as explained in this article, which explains the issue more deeply.
Under some circumstances, it is advisable for employees to treat with their own physicians, even if they have to pay for it out-of-pocket. If the company doctors do not listen to you when you describe your injury, the symptoms you are suffering, and the findings of a physical examination independently documented. If you do not do so, you may find yourself in a situation in which it is hard to reconstruct the first 90 days after your injury since your injury will have been documented only by a doctor or doctors with a considerable relationship to your employer or its insurance company.
What medical benefits may I receive?
Employers and their insurance companies are obligated to pay for all reasonable and necessary medical expenses associated with any work-related injury or disease – whether or not the injury or disease causes the employee to lose time from work. These benefits are paid directly to the medical provider in accordance with a strictly regulated fee schedule. Under Pennsylvania law, a medical provider is not entitled to bill you the difference between the provider's charge and the amount allowed under the Workers’ Compensation Act. You may not have the benefit of this protection which is known as “no balance billing” if you treat outside the Commonwealth of Pennsylvania, as medical providers in other states are not governed by Pennsylvania law. Payment of medical expenses does not necessarily mean that your claim has been accepted.
Are workers’ compensation benefits available to the family of a person who dies from a work injury?
If an employee dies within 300 weeks of suffering from a work-related illness or injury, the employee’s widow or widower is entitled to receive benefits that vary depending on the number of dependent children in the family. Widows or widowers who remarry are entitled to receive a lump sum “dowry” equal to two years of compensation payments, after which all compensation ceases. Children who are full-time students at an accredited school are entitled to receive benefits until they reach the age of 23 years.
Reasonable expenses of burial, not to exceed $3,000, are also available.
May my employer take legal action to reduce or terminate my workers' compensation benefits?
If you and your employer disagree about the nature and extent of your disability, your employer may file a petition to reduce or terminate your benefits.
If your employer has received medical evidence that you are recovered in full from the effects of your work injury, the employer may file a petition to terminate your workers' compensation benefits.
If your employer has evidence that you were offered employment that is consistent with medical restrictions that have been placed upon you by your examining physician, the company may file a petition to suspend or modify your workers' compensation benefits if you refuse such employment.
If such a petition is filed, the Bureau will assign the petition to a workers' compensation judge in the county in which you live. The judge will schedule a hearing and a representative of the insurance company will present written evidence to the judge and argue that the employer is entitled to an immediate suspension or modification of your benefits. You should hire an attorney to represent you at such a hearing.
May I receive benefits if I suffer a disfigurement?
You may receive up to 275 weeks of benefits for a permanent disfigurement of the face, neck, or head. The award is supposed to be proportionate to the extent of the disfigurement.