Is there any Way to Punish a Pennsylvania Workers' Compensation Insurance Company for Cheating Me?

Greg Boles
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Partner at The Boles Firm | Experience Matters

I was injured on the job in Pennsylvania, and I am being cheated by the insurance company. I have bills to pay. What can I do?

Although injured claimants may not recover "insurance bad faith" damages against an insurer for failing to comply with the Pennsylvania Workers' Comp Act, a workers' compensation judge has the discretion to award up to 50 percent of compensation and interest payable to an injured worker in cases of unreasonable or excessive delays.  To recover penalties, a claimant must file a Petition for Penalties with the Pennsylvania Bureau of Workers' Compensation.  The decision to award penalties and the amount of any penalty awarded is up to the workers' compensation judge hearing the case. For a discussion of some of the types of conduct that may result in penalties, read my article, "The Top Ten Ways Pennsylvania Workers' Comp Insurance Companies Cheat Injured Workers."  

Getting the insurance company to pay wage loss benefits on time

The most frequent situation in which penalties are assessed against an insurance company is for the failure to pay wage loss benefits within 30 days of an award by a workers' compensation judge.  Furthermore, under Pennsylvania law, an insurance company is supposed to issue its first payment of compensation within 21 days of the date that an individual becomes disabled under the Act.  The failure to issue payment within that 21 day period has been a common basis for awards of penalties by workers' compensation judges.  Though the practice has been less frequent in recent years, insurance companies sometimes take “self help” and stop paying wage loss benefits, which is generally not permitted without a court order, an agreement signed by the injured worker, or upon the filing of a Notice of Suspension filed when the employee returns to work. It is not unusual, however, for there to be delays in the payment of compensation or for an insurance company to inadvertently drop an injured claimant from “automatic pay” of compensation benefits. 

Workers' compensation judges generally do not like to issue decisions on small delays of payment unless there is a pattern.  To make sure that the insurance company complies with its obligation to pay wage loss benefits promptly, keep copies of all workers’ comp paystubs and the envelopes in which the checks were received.  By checking the postmarks on the envelopes, a pattern of slow or non payment can be proved.

Penalties can also be assessed against an insurance company when it fails to file forms required by law, including a Notice of Compensation Payable, a Notice of Temporary Compensation Payable, a Notice of Workers' Compensation Denial, and a Notice of Benefits Offset.

My medical bills are going to collection agencies. What do I do?

Another area in which it is common for judges to award penalties is the failure to pay medical expenses in a timely manner.  Providers have the right to file an Application for Fee Review if the insurance company fails to pay a medical bill on time, but injured claimants typically file petitions to get payments made because Applications for Fee Review must be filed within a relatively short period following non payment or the provider loses the right to file an Application.  An injured claimant, on the other hand, can file a penalty petition, sometimes years after the medical bill has been unpaid. Penalties are paid to the injured worker, not the medical provider.

Ordinarily an insurance company must pay all medical expenses associated with a work injury unless they have denied your claim, in which case you may send your bills to your health insurer until your claim is resolved. If the workers' comp insurer accepts your claim but does not pay work-related medical bills, your medical providers have no right to bill you. If you are receiving "dunning notices" for non-payment of medical bills for your work injury, contact the workers' comp company immediately. Call the medical provider and make sure all providers have the claim number for your injury and the name, address, and telephone number of the insurance company. Remind the medical providers that they may bill the insurance company only. If the carrier continues to refuse to pay your bills or if you keep getting billed by your providers, contact us.

Any disputes regarding the reasonableness and necessity of medical treatment are to be resolved through “utilization review” procedures.  An insurance company has the right to file a Petition to Review Medical Treatment and/or Billing, but where the employer stops paying medical expenses because it claims that the medical expenses are not related to the work injury, the employer or insurance company assumes the risk that penalties will be assessed against them if the judge finds the medical costs to be causally related to the work injury.

As a practical matter, for medical bills to be payable, they must be billed in accordance with the requirements of the Act.  This means that, at a minimum, it must be billed on the appropriate form with an appropriate diagnostic code along with the medical reports documenting the treatment rendered.  Although medical bills submitted to a workers' compensation insurance company should be filed with an LIBC 9 medical report form, penalties can still be awarded if it is clear that the treatment rendered was related to the work injury.