Table of Contents
We have entitled this resource the “Survival Guide” because injured workers who are placed on workers’ compensation without the benefit of experienced lawyers on their side are left to rely upon human resource managers, workers’ compensation insurance adjusters and others for advice and information regarding their worker’s compensation rights. Often, injured workers mistakenly believe that workers compensation insurance is their own insurance. Nothing could be further from the truth. Rather, workers’ compensation insurance is for the employer, and an injured worker is considered a “claim.” Reading this workers compensation guide will help you avoid mistakes and survive the system. Dealing with workers’ compensation insurance adjusters can be difficult, but we make it our goal to give you the workers’ compensation resources you need!
Advice From Pennslyvania Workers Compensation Attorneys on Surviving the System
While workers’ compensation may seem straightforward, as this workers’ compensation guide shows, it can be anything but. Employers do not always secure coverage, and some deserving workers have difficulty getting their checks on time or receiving benefits at all. At every stage of the claims process, issues can arise. Working with Frommer D’Amico can help.
Our attorneys are all certified workers’ compensation experts offering personal attention to clients. We work to answer your questions, take your calls and deal with unpaid medical bills or late checks and provide the best workers compensation advice for Pennslyvania citizens. If your case involves major litigation, our attorneys have the experience to handle that as well. We resolve claims that are in court or have been denied, so if you are having any issues, contact us.
Workers Compensation Tips for Injured Workers
1. Knowledge Is Power
The employer and insurance company are well informed regarding workers’ compensation law. The insurance company has experts such as rehab nurses, company doctors and lawyers on their side. In contrast, the injured worker placed on workers’ compensation has no support system and is left to trust the insurance company to protect his or her rights. We believe that trust is misplaced. This Survival Guide is a start. However, it is not a substitute for consulting a lawyer. Even though this guide provides educational information for injured workers, you still need a certified expert to help you manage your case.
2. Make Informed Decisions
There are many crossroads during the life of a workers’ compensation claim. Starting from the time that the injured worker is placed on workers’ compensation and continuing until the time that the injured worker successfully returns to work, the choices made at each crossroad can and do change the outcome, for better or worse. Don’t make the wrong workers’ compensation decisions. Let us be your workers’ compensation guide. Get more than the average workers’ compensation settlement in PS, and stop dealing with workers’ comp insurance adjusters. Let us handle your claim for free today! We are available to answer questions and will provide workers’ compensation tips and consultations at any time for no charge. We hope you find the Survival Guide helpful and encourage you to call us sooner, rather than later.
3. Be Sure Your Injury Description is Correct
When a worker is injured on the job, Pennsylvania workers’ compensation law requires the workers’ compensation insurance company to issue a document called a Notice of Compensation Payable. This important document is to be filed with the Pennsylvania Department of Labor and Industry and represents the employer’s legal recognition of a work injury. A notice of compensation payable contains a description of the injury and sets forth the employee’s average weekly wage. This form lists other details of your claim, including the claim number. Once this form is issued, your employer or your employer’s insurance company accepts your claim.
The Notice of Compensation Payable is prepared by the workers’ compensation insurance company, and often the description of the employee’s injury is not accurate. It is very common for the insurance company to describe the injury as less severe than it really is. For example, an employee might injure his/her wrist on the job and go to the hospital emergency room or the company doctor for treatment. X-ray reveals that the wrist is fractured, but when the injured worker receives the Notice of Compensation Payable, the injury is described as a wrist sprain.
Many employees do not look at the injury description when they receive the document. However, an inaccurate injury description almost always favors the insurance company and not the injured worker. It is critical to check the injury description to ensure you get the compensation you deserve and need. If the injury description is incorrect, you are entitled to file a petition to review and to rectify the injury description on the Notice of Compensation Payable.
The Notice of Compensation Payable should have an accurate injury description. If the nature of the injury has changed, for instance, a low back sprain is later determined to be a herniated lumbar disc, the Notice of Compensation Payable should be changed to reflect the diagnosis of the more serious condition. If you have not received a Notice of Compensation Payable or if your injury description is not accurate, you should contact us. We will correct your injury description at no charge.
When looking at your Notice of Compensation Payable, consider whether the form is “medical only.” In some cases, employers and insurers will only take legal responsibility for medical costs, denying that you have suffered wage loss. This may occur if you return to light duty with no loss in wages.
If your wages have decreased, however, or if you did lose time at work for your injury, it is important to dispute a “medical only” Notice of Compensation Payable. If you missed time at work or returned to duty at a lower wage but the employer or insurer only wants to pay for medical expenses and not wage loss benefits, contact Frommer D’Amico.
4. Confirm You’re Not Underpaid
If the insurance company miscalculated your wages when you were hurt, you will be underpaid every week. The Notice of Compensation Payable includes the injured workers’ average weekly wage. The workers’ compensation insurance company calculates the average weekly wage by using one of several formulas selected depending on the injured workers’ individual circumstances. The average weekly wage should include salary and/or hourly wages, overtime, and bonuses. It may be adjusted for seasonal employment and should include income from other employment.
Mistakes in calculating the average weekly wage are often made. The injured worker should receive a document, filed with the Department of Labor and Industry by the workers’ compensation insurance company, called a Statement of Wages.
This document shows how the workers’ compensation insurance company calculated the average weekly wage. The average weekly wage is very important because it is the basis from which the injured workers’ weekly non-taxable workers’ compensation benefit is calculated. In most instances, an injured worker should receive 2/3 of their average gross weekly wage. Therefore, the Statement of Wages form and the calculations made by the workers’ compensation insurance company should be double-checked! Failure to review the calculations may result in an underpayment to an injured worker that goes undiscovered. We will review these calculations to ensure that you receive your maximum benefit at no charge.
5. Document the Receipt of Late Checks.
Late weekly workers’ compensation checks are a common complaint. There are ways to correct late checks. We provide services to correct this problem as part of our traditional case management.
Pennsylvania workers’ compensation law requires workers’ compensation insurance companies issue wage loss benefit checks in the same pay cycle that an injured worker would receive his or her regular paycheck. If you were paid weekly before the injury, you should receive your workers’ compensation check weekly. Stopping late checks often requires taking the workers’ compensation insurance company to court.
If you are experiencing a problem with late checks, you should contact us and take the following steps:
- Make a copy of the check when it is received;
- Attach the copy of the check and any check stub that accompanied the check to the envelope in which the check came;
- Write the date that you received the check on the envelope.
If you are getting late checks, one of the best things you can do to is to keep a record. This lets you document whether late checks are a pattern. Consider whether checks may be late due to holidays. If you have moved, make sure the insurance company has your correct address. Checks that are late by 14 days or more should be immediately addressed with the team at My Comp Lawyers.
Late checks are a serious problem and should not be ignored. Workers’ compensation checks are supposed to arrive on time, and their tardiness could prevent you from meeting your financial obligations.
Insurers may push the limits when it comes to mailing checks on time and may have many excuses for late payments. They may blame slow postal service, confusion over addresses and other issues. Keeping note of when checks arrive and keeping the envelopes helps you establish a pattern of late payments. Working with Frommer D’Amico makes certain insurers are not allowed to jeopardize your financial life.
Our office can use this evidence to prove that the workers’ compensation insurance company is not sending the checks on time. Regardless of whether your checks are late, we recommend that all injured workers keep these records. We will take the insurance company to court to correct late checks at no charge to you.
6. Beware of Offsets to Your Benefits.
Pennsylvania workers’ compensation laws provide for the reduction of an injured worker’s weekly wage loss benefits if the injured worker receives severance payments, pension payments, or Social Security retirement benefits. You will not be notified about these offsets. This includes offsets from a 401K.
However, the injured worker is required to report the receipt of any of these benefits to the insurance company. There are ways to avoid these offsets, and the law in this area is still changing. There are also some strategies that can be employed on behalf of injured workers to reduce the impact of these offsets.
If you are receiving workers’ compensation benefits and expect in the future to receive severance, pension or Social Security retirement, you should consult with our office. In fact, you will want to consult with us if you will be receiving income or earnings from any source, as this can affect your workers’ compensation benefits.
7. Prepare for an Independent Medical Exam.
An Independent Medical Examination (IME) is not independent. It should be called an Insurance Company Medical Examination. The doctor is chosen and paid by the insurance company, will review an injured worker’s medical records and examine the injured worker. The IME doctor will then issue a written a report to the workers’ compensation insurance company. A copy of that written report is often not provided to the injured worker. The law requires an injured worker to attend an IME requested by the insurance company, but the injured worker does have rights!
There are several things you can do to ensure an IME does not unfairly affect your workers’ compensation benefits:
- Get adequate rest before the IME.
- Arrange an appointment with your treating physician after your IME. You will want the doctor to evaluate your condition. If you were injured during the IME or your symptoms were made worse, your doctor can document this.
- Always double-check that the IME doctor you are seeing is the IME doctor you were told you were going to see. No one representing the employer or insurance company should be present — only the IME physician.
- Ask for the IME to be close to your home and ask for payment for travel to and from the IME.
- Take note of when you arrive, when you see the physician, how long the consultation is and when the IME doctor leaves. Have the person you bring to the exam note this information as well.
- If you become uncomfortable during the IME or if the IME causes you pain, speak up. If your symptoms are worse after or during the IME, take photos of them so you have evidence that the examination exacerbated the symptoms.
- Ask the IME doctor to forward any reports from the IME to yourself and the physician responsible for your treatment. Also, ask the claim adjuster of the insurance company — or your employer if your employer is self-insured — to send you a copy of the IME report they have. If it does not, contact Frommer D’Amico. Compare the IME you receive from the doctor and the one from the insurer to make sure they are the same.
An IME costs the worker’s compensation insurance company money. Therefore, it is usually requested when the insurance company has doubts about the injured worker’s doctor or treatment. The other reason that an insurance company will request an IME is to challenge the restrictions on the injured worker. In those instances, the insurance company requests an IME to force an injured worker to do more work than is recommended by his/her treating physician. In either event, AN IME SPELLS TROUBLE! If you have been asked to attend an IME, you should call our office right away.
8. Choosing Your Own Doctor and Insurance Company Nurses
If your employer accepts your workers’ compensation claim and has posted a list of at least six health care providers or physicians in your place of work, you may need to visit one of the professionals on this list for initial treatment. You will need to continue to seek treatment from that provider or another one on this list for the 90 days after your first visit.
Your employer cannot tell you which of the health care professionals on the list you can or should see. If your employer does not post an eligible list or does not accept your claim, you can select your own physician or health care provider.
If you must see a listed health care provider, be aware of your rights. If a listed provider recommends invasive surgery for your condition, you can seek a second opinion. This second opinion is paid for by the insurer or employer. If the second opinion results in a treatment option you accept, you must choose a listed provider for this treatment for 90 days.
You can choose to visit a provider not on the list during the 90-day period, but the employer or their insurance company may choose not to pay for the treatment. If you do select a provider who is not on the list, either during or after the 90-day period, you must inform your employer about the physician or health care provider you have chosen. Monthly reports will be sent from your provider to the employer or their insurance company.
Injured workers have the right to choose their own doctors after they have been treated for their work injury for 90 days. The injured worker’s right to select his/her own doctors includes the right to select specialists outside of the area when appropriate. If an injured worker is treated outside of the area, the workers’ compensation insurance company may be required to reimburse the injured worker for travel expenses. Workers’ compensation law provides the injured worker with the right to control his or her own medical treatment, and if you are having trouble in this area, we can help.
The insurance company will sometimes assign a nurse to your case. The nurse will call an injured worker before and after doctors’ appointments and sometimes attend the doctors’ appointments. The nurse will report to the insurance company on the treating doctor’s recommendations and will often guide an injured worker to other doctors or specialists. The injured worker should be aware of the fact that while everyone, including the insurance company, has an interest in seeing that the injured worker gets better, there is an advantage to the insurance company if it is able to control medical treatment. You do not have to talk to the rehab nurse. You do not have to allow the rehab nurse into the examination room with you. You can tell your doctor not to talk to the rehab nurse out of your presence.
Once you get workers’ compensation benefits, your employer may ask you to see a specific health care provider for an examination. They can even seek an order from a workers’ compensation judge to compel you to attend such an examination. If you find yourself in this situation or if there is some confusion about which medical practitioner you can get treatment from, contact Frommer D’Amico for prompt help.
If you need workers’ compensation resources or assistance getting the benefits you are entitled to, our certified workers’ compensation specialists will answer your questions and even work to resolve challenging issues through litigation, if necessary.
9. Surviving The Vocational Interview
Pennsylvania workers’ compensation law no longer requires the insurance company to find light duty work for an injured worker who is unable to return to his/her pre-injury job. The law now permits the insurance company to conduct a Labor Market Survey. The Labor Market Survey allows the insurance company to identify light duty jobs that are advertised through newspapers, temporary employment agencies, or Commonwealth job placement services without providing notice of these jobs to the injured worker. Once jobs are identified, a vocational expert hired by the insurance company compiles them into a Labor Market Report. The insurance company’s lawyers will introduce that report at a hearing before a workers’ compensation judge and request that an injured worker’s weekly wage loss benefits be reduced or stopped altogether. There are many ways to fight this procedure, and it is important to do so.
One way is to conduct your own Labor Market Survey that considers your transferable skills, your work history, your educational experience, certifications and limitations to determine what jobs you could take. The judge does not look at whether you will get the job.
As job hunters know, there is considerable difference between applying for a job and securing a position. Even if you are told you could perform within a specific career task, it does not mean employers will agree or that you will secure that task.
In addition, you may find the job you are “qualified” for earns less than your current job or requires a significant career change. Also, some advertised jobs used in a Labor Market Survey may not actually be available or may not exist if they are recruiter-created advertisements designed for market research. You could find your benefits affected but still find yourself unable to get a job you have been told you qualify for.
Like the IME, the Labor Market Survey can indicate your employer or the insurance company is going to attempt to stop or reduce your benefits. In many cases, the Labor Market Survey is not a formalized process and can take place over the phone without an in-depth look at how likely you are to get a specific job or how realistic a career change is for you.
The Labor Market Survey typically begins when an injured worker is contacted by a representative of the insurance company for an initial interview. This contact will often come by phone or letter. You should not wait for this initial contact to occur. If you have been injured at work and it appears that you may be unable to return to your pre-injury job, you should contact us. We will prepare a strategy to help you in advance of a Labor Market Survey. If you are contacted for the vocational interview, we recommend you call us. We will attend the interview with you and make sure the results are fair.
10. Understanding a Utilization Review of Your Doctor
If you are already receiving workers’ compensation benefits, you should be aware of the fact that your medical treatment can be subject to utilization review. This is a process in which the insurance company challenges whether your medical treatment is reasonable and necessary, not whether the treatment is related to the injury. Once the insurance company receives the medical provider’s bill and notes, it can file for utilization review, which allows the insurance company to avoid paying for the treatment. When the insurance company does this, a doctor with the same specialty as your doctor reviews the treatment.
This doctor or medical team is known as a utilization review organization (URO), and their job is to review the treatment you are getting. The utilization review depends heavily on treating physicians submitting documentation on time.
Issues have arisen in Pennsylvania workers’ compensation cases where doctors have failed to submit paperwork on time or have submitted encrypted information digitally. Therefore, the URO was unable to access documents.
Even if you do everything right, a busy medical practitioner’s office can make mistakes that affect your benefits.
There are specific time limits for utilization reviews, and even if the treatment is found not to be reasonable and necessary, you still have rights. You cannot be held responsible for paying the medical bill and you can take an appeal of that decision. In fact, utilization review is not only available to the insurance company. You, too, can file for utilization review if necessary to compel coverage.
Often an insurance company will not pay for a medical bill because it believes the treatment is not related to the work injury. You should not let these bills sit around even though you know they are related to the work injury. Your bill may be submitted to your private health insurance, or it may go unpaid. If you are having trouble with the payment of bills or receive a Utilization Review Request, we can help.
11. Plan Before You Settle
Lump sum settlements may be used to close your claim. There is typically a very big difference between what the insurance company wants to pay in a lump sum settlement and what an injured worker should accept. It is important to remember that the insurance company cannot make an injured worker accept a settlement. It is also crucial to remember that lump sum payments should take your total expected costs into account so you are not left paying for expenses out-of-pocket.
Many times, a settlement, even when it provides for a large payment, is not in the injured worker’s best interest. A settlement will not include any complications or additional expenses that may occur over time from a work-related injury. If your condition turns out to be more serious than you and your medical team realized or if your medical condition worsens due to your injury, you may end up requiring more medical treatment.
We have developed detailed standards for workers’ compensation settlements and provide our clients with the insight necessary to know when it is in their best interest to walk away from the settlement table. Likewise, in cases where a settlement is achieved, we negotiate based on years of experience and targeted legal strategy. The insurance company always wants to close your claim, but we ensure that any settlement is in your best interest.
Settlements are not easy. They involve complex issues of law including integration with Social Security Disability Benefits and Medicare. In addition, workers’ compensation insurance companies will often want to settle your claim for medical benefits, and there are serious legal questions involved in this aspect of settlements.
Generally speaking, you should consult our office if any of the following is true:
1. You have been on workers’ compensation for more than six (6) months;
2. You suffered a serious work injury; or
3. You think there may be a chance that you cannot return to your pre-injury job.
As always, we will review your case at no charge.
12. Keep More Records Than You Think You Need
One of the best tips for injured workers is to keep records of as much as possible. Note the time and severity of your injury as soon as it happens and keep a list of all medical treatments, appointments, discussions with insurers, forms received and other details. It can be useful to keep this information in a notebook and keep a folder of any letters you receive. When you take a call about your workers’ compensation case, always note who you spoke with, what the call was about and the time and date of the call. On envelopes you receive that are related your workers’ compensation claim — including checks — get into the habit of writing down the date the letter arrived. If any symptoms get worse, take photos of them and get to a doctor to document the symptoms.
You may never use all of the information, but if there is ever a problem with your claim, having more injured worker information can be important. If your workers’ compensation checks have been late three times, for example, being able to reveal exactly when they were late and how late they were can help you establish a pattern on the part of the insurance company or employer.
Common Workers Compensation Mistakes to Avoid
When you get hurt at work, there’s no playbook to guide you through the process. You may not realize that some mistakes can hurt your workers’ compensation case.
We’ve made a list of common workers’ comp claim mistakes to help you navigate this time and avoid doing anything that might hurt your case.
1. Posting Your Activities on Social Media
Your employer or their insurance company will often conduct surveillance on injured workers to see how active they are in their daily lives. Often, they will contact your coworkers, who may be “friends” with you, or hire a company that will conduct a search of your social media accounts looking for pictures that you posted of your activities, statements that you posted, or even search your friends to see what they posted about you and your activities. Anything you post or anything posted about you can and will be used against you!
2. Allowing Your Doctor to Talk to an Insurance Nurse
The insurance company often sends a “Rehab Nurse” to your medical appointments or wants you to allow them to call your doctor. Even without your permission, many such “nurses” will call your doctor to do their best to encourage the doctor to release you from care, release you to work full duty, or question whether a diagnostic film or medical procedure is needed. You are well within your rights to ask your doctor whether the insurance nurse is contacting him or her and what is being said. If the nurse comes to your appointments, some doctors will agree to talk to the nurse privately after your visit. You should insist on being present when your medical condition is being discussed. After all, who has the most vested interest in your health care? YOU!
3. Paying Your Own Litigation Costs in Court
You can hire many law firms under the “no recovery- no fee” arrangement. But what about litigation costs? These are the costs that must be paid if your case is in court and include costs of medical records, hearing transcripts, and witness fees. These costs often add up to thousands of dollars. When you hire a lawyer, you must ask if you are responsible for those costs or not. Will you be asked to advance $3,000 for your doctor’s deposition fee? Even if your lawyer will advance those costs, are you responsible for reimbursing your lawyer? At MyCompLawyers Frommer D’Amico, we advance all costs and never seek reimbursement from our clients.
4. Assuming Your Job or Health Care Insurance is Protected
The Pennsylvania worker’s comp act does NOT require your employer to hold your job open for you or continue to pay for your health insurance after a work injury. This is a common misconception. Some employers will voluntarily hold your job or pay for insurance for a while if they believe you may be back to work shortly, but they are not required by the PA workers’ comp act. Many employers will NOT hold your job and may send you a bill if you want to personally pay for your health insurance after a work injury.
5. Not Reporting Your Injury to Employer
Trying to work through your injury is one of the mistakes that can hurt a workers’ compensation case. You compromise your ability to file a claim if you don’t inform your employer about what happened. With no official record of the injury, your employer or its insurance company may accuse you of lying about your condition. You have 120 days from the day of your injury to report it to your employer, but the sooner, the better.
6. Missing Deadlines Related to Your Case
When you miss deadlines, you give your employer’s insurance company a reason to reject your claims on a technicality. You can avoid one of the most common workers’ claim mistakes by meeting all paperwork deadlines and going to all medical appointments scheduled by the insurance company.
Deadlines also include appeals. If you plan to appeal a decision in your case, you only have a limited window to file. Ask an attorney to keep you on track to meet all your deadlines.
7. Submitting the Wrong Paperwork or Filing it Out Incorrectly
Workers’ comp claims are often rejected on technicalities, such as filling out the wrong paperwork or forgetting to sign a claim. Look over your paperwork to catch any mistakes and sign along all the dotted lines. Consulting with a workers’ compensation attorney can ensure you get the right forms and turn them in to the right place.
8. Not Doing What the Doctor Tells You
Take your physician’s advice seriously. If you fail to follow it — such as returning to work without crutches if your doctor has required them — your claim could be denied. Your doctor should write down what you are supposed to do.
If you have questions about your workers’ compensation case or think you may have made some mistakes throughout the process contact Frommer D’Amico. Our team of Workers’ Compensation Specialists will work with you to help you save thousands and get the compensation you deserve.
Getting Help Navigating the Workers’ Compensation Guidelines and Process
We hope you’ve found this guide for injured workers useful. Keep in mind, however, that if you’re having problems with your claim, the best help for injured workers may be personalized advice from a workers’ compensation expert. If it appears the insurer is trying to reduce benefits or if you have any concerns at all, contact Frommer D’Amico for assistance and workers compensation advice. Our workers’ compensation tips are designed to help, but in many cases the best advice for injured workers is to know when to seek guidance from legal professionals.
Generally speaking, you should consult our office if any of the following is true:
- You have been on workers’ compensation for more than six (6) months;
- You suffered a serious work injury; or
- You think there may be a chance that you cannot return to your pre-injury job.
As always, we will review your case at no charge. All of our attorneys are certified workers’ compensation experts and provide excellent workers compensation tips for surviving the system. We work to answer your questions and resolve your claims, even if your claim is in court or has been denied. We make sure you can reach us easily when you need us, even on weekends. Our team also has the trial experience to handle major litigation, if that is what your case requires.
If you need certified workers’ compensation experts, contact Frommer D’Amico today for a consultation.