Adequacy of Cash Benefits: Don’t Be Limited

Insurance carriers and employers seek any and every way to limit, modify, suspend, or terminate benefits payable to injured workers under Pennsylvania law.  This is occurs in many forms:

  • CALCULATION OF AVERAGE WEEKLY WAGE (AWW): In order to determine how much it will need to pay out on any given claim, the first step for the insurance carrier or employer is the calculation of an AWW.  An injured worker’s AWW is the average of his or her earnings of the 52 weeks prior to the date of injury.  While the insurance company does not pay the injured workers’ AWW, the AWW determines how much they will have to pay in weekly compensation.  The AWW is also used to determine whether an insurance carrier or employer can stop paying benefits when an injured worker returns to work.  As a result, there is a great incentive for the insurance company to limit the calculation of your AWW.  The correct calculation of your AWW could literally mean more money in your pocket.
  • IMPAIRMENT RATING EVALUATIONS (IRE): This is an area of law that is under appellate review; however, it continues to be an important weapon used by insurance companies to limit how long you can receive benefits.  An IRE is an examination requested by the carrier wherein an injured worker is sent to a physician to determine “whole person impairment” according to medical guidelines.  The physician is not chosen by the carrier; however, if the impairment rating is less than 50 percent, the insurance company wins a cap on the payment of benefits totaling 500 weeks.  Once 500 weeks ceases, the insurance company is relieved of the obligation to pay benefits—whether you are restricted from work or not.  Your payments simply cease as a matter of law.
  • MODIFICATIONS/SUSPENSIONS/TERMINATIONS: When an injured worker is out of work, an insurance carrier or employer can seek to modify how much it pays in benefits by offering a return to work or creating a labor market survey establishing an earnings capacity.  A labor market survey is a report created by a “vocational expert” outlining jobs available within an injured workers’ geographic area.  These jobs provide earnings and are said to establish an earnings capacity for the injured worker.  As a result, even though an injured worker never actually works the job, if a judge believes he or she is capable of working the positions identified, the carrier may modify or suspend benefits.

Terminations are often the most severe weapon an insurance carrier can use to attack benefits.  When an injured worker is deemed “fully recovered” from an injury, the carrier can seek to “terminate” its obligation to pay benefits in court.  If the carrier wins, the injured workers’ benefits cease.

The danger is real.  The methods outlined above can severely limit the adequacy of benefits for injured workers—who often do not see these dangers before it is too late.  Do not let an insurance company or employer use the advantages each has in the system against you.  Visit our FAQ page and contact us for your free consultation.

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