If you been injured on the job in Pennsylvania or you are suffering from an illness that is directly connected to the work that you do, you are eligible for workers’ compensation. In Pennsylvania, even companies that have only one employee must participate in the workers’ compensation insurance program.
There are many important things to know about workers’ compensation, and you can find many detailed articles on our website. Here are a few things we consider the most important:
- Your employer’s workers’ compensation insurance company will cover all medical expenses that you incur as a result of the injury or the illness that you have suffered at work. You will also receive compensation for lost wages for as long as your injury or illness prevents you from working.
- Workers’ compensation in Pennsylvania is a “no-fault” insurance program. This means that it does not matter who is at fault — if you are injured on the job, you are eligible to receive workers’ compensation benefits. So even if your accident is a result of carelessness on your part, you are eligible for benefits. On the other hand, if you decide to participate in the workers’ compensation program, you give up the right to sue your employer.
- Although you should report your injury immediately to your manager, supervisor or company nurse if you are injured on the job, you have up to 120 days to report the injury. Some workplace illnesses resulting from exposure to radiation or asbestos, for instance, have longer time frames for reporting.
- You are eligible for up to two-thirds of your average weekly wage, to a maximum that is set yearly by the Pennsylvania Workers’ Compensation Commission.
- These benefits are tax-free and continue for as long as you are unable to return to work.
Table of Contents
What Role Does My Employer’s Insurance Company Play in Workers’ Compensation?
Either your employer or the insurance company that they have hired to manage their workers’ compensation claims are required to provide you with workers’ compensation benefits if it can be proven that your injury is work-related and is preventing you from returning either full-time to your job or at a reduced level. This is the trade-off that they have made in return for not being sued by their workers for a work-related accident.
You should know, however, that your employer’s insurance company is not there to make sure you receive benefits to which you are entitled. Although in some cases the insurance company cannot avoid paying benefits, they will do everything in their power to pay you as few benefits as they can or none at all if they can get away with it.
The insurance company will try every trick in the book. For instance, when they contact you, they will often ask if you will give them a recorded statement about your injury. Always say no. The reason they ask for this recorded statement is that if they find any discrepancies between the injury report that you have given to your employer when you are first hurt and the statement that you have just given to them, they will use it to argue that you are not injured and do not deserve benefits.
Another trick the insurance companies like to play is to claim that you are a consultant and not a full-time employee. Under Pennsylvania law, consultants are not eligible for workers’ compensation. If this has happened to you, and you know you are not a consultant, make sure you contact an experienced workers’ compensation attorney immediately.
Another way that the insurance companies will try to find a way to deny you benefits is through the assigning of a Nurse Case Manager (NCM) to your case. When you hear the word nurse, you may think that this is a person whose goal is to help your health improve after your work-related injury. Sadly, in most cases, it is not. This is a person assigned to your case by the insurance company whose number one goal is to find a way to either deny or reduce your benefits.
Can I Refuse an Insurance Company Nurse?
Often the insurance company will have a nurse call you and/or go to your doctors’ appointments with you after a workers’ compensation injury. These nurses may seem to care about you and your injury, but many of these nurses do not have your best interests at heart.
They work for and are paid by the insurance company. Their job is to get you back to work and off workers’ compensation as soon as possible, even if you do not feel well enough to return to work. Therefore, remember the following important points:
- You are not required to meet with the company nurse.
- You do not have to allow the nurse to come to your doctors’ appointments.
- You do not have to provide any information, medical or otherwise, to the company nurse.
If a nurse continues to appear, uninvited, at your doctors’ appointments, you should call your workers’ compensation lawyer immediately.
No matter how friendly the NCM might be, it is always important to keep in mind who is paying them. NCMs are infamous for their efforts to convince doctors that injured workers are either faking it or malingering and should be returned to work as soon as possible. They may try to convince the doctor to eliminate any restrictions or limitations placed on an injured worker who is returning part-time to the job, even if the physician does not agree with them.
At other times, they try to supersede the doctor’s opinion with the insurance company, telling them that they disagree with the doctor and that an injured worker is either ready to return to the job or was never injured in the first place.
Not all NCMs are like this. Some genuinely care and want injured workers health to improve. Unfortunately, they are in the minority, so you should treat any interaction with an NCM with caution.
What Is the Best Way to Deal With the Nurse Case Manager?
NCMs often rely on an injured worker’s lack of knowledge about what their rights are in this situation. Most people believe that nurses want to help them, and let their guards down. This is a mistake with an NCM. The most important thing you can do with an NCM — or for anyone that you are involved with during your entire workers’ compensation case — is to know your rights.
1. Insist Your Doctor Give You a Private Examination Without the NCM Present
You are not obligated in any way to allow the NCM to attend any examination with your physician. You want to be able to discuss your medical situation or ask any questions that you have of your physician in private.
If the NCM is already in the examination room when you arrive or enters the room as the examination is underway, you are entirely within your rights to ask for privacy. The NCM has no legal or statutory right to be in that room without your approval, regardless of what they might say or the way they may act.
If the nurse case manager attempts to speak to your doctor privately after your examination is over, you are completely within your rights to ask if you can attend that meeting. People typically try to be polite and say yes whenever they can. However, if the NCM tells you that he only wants to speak to your doctor for a moment, so do you mind waiting outside, politely reply no, you want to be present for the meeting. You also have the right to request any written information that the NCM prepares for the insurance company.
2. Do Not Let the NCM Change Your Physician Without Your Knowledge of Consent
Insurance companies like to engage in “doctor shopping.” Many of the doctors who perform examinations for insurance companies are retired doctors who are looking to make some extra income. They realize that the insurance company will not continue to retain them if they are continually upholding injured workers in a workers’ compensation cases.
NCMs help facilitate this by trying to delay or change your physician when that physician’s opinion does not support the insurance company’s position. This is often the case when the physician has recommended restrictions or limitations on what you can and cannot do when you return to work.
NCMs will try to tell you that your doctor is not available and that you can see another physician this week. This is a blatant attempt by the NCM to get you into the care of these compliant physicians who will support the insurance company over an injured worker.
One reason that the NCM tried to delay your appointment is so that the insurance company can arrange video surveillance. Insurance companies often hire private investigators to spy on injured workers. If you agree to the NCM to request to change your appointment, this allows the investigator to know the exact place and time of your visit so they can set up their surveillance in advance.
This is not a fanciful story. Remember, workers’ compensation insurance companies will do anything to reduce or deny your workers’ compensation benefits.
If this happens to you, tell the NCM that you are not interested in seeing another doctor. Make an appointment with your doctor’s office for the next month and let the receptionist know that if your regular doctor has any cancellations, you will be happy to come in at any time.
3. You Do Not Have to Discuss Your Treatment Plan With the NCM
You do not have to discuss any treatment recommended for you by your regular physician with the nurse case manager if you do not want to. This is a discussion only for you and your physician.
4. If You Agreed to Discuss Your File With the NCM, Do It in a Neutral Setting
If you have decided to discuss your case with the NCM – although we would advise you to be very careful if you decide to do this – make sure you do it in a neutral setting that you suggest. Do not hold any discussions with an NCM in a hospital office or at the insurance company office. Insurance companies are notorious for secretly videotaping or audio taping injured workers. Allowing an NCM to select a meeting place could make it easier for the insurance company to do this.
Ground Rules for NCMs
It is crucial that you and your attorney set ground rules for the nurse case manager from the very beginning. You can allow the NCM to work on your file if they follow the following rules:
- They are never present when you are undergoing an examination in your doctor’s office or if your doctor is providing you with treatment.
- They agree not to speak to the doctor without you being present.
- They agreed to provide you with copies of all written material and reports they give to the insurance company, to your employer or to your employer’s attorney.
If you establish these ground rules from the beginning, there is a good chance the NCM will abide by them. If they do not, you have the right to revoke the authority for them to work on your file even if they have already attended several appointments.
Beware of Telephonic NCMs
We already know that insurance companies will do anything they can to save money by reducing or denying your benefits. They also try to save money by assigning telephonic NCMs. These telephonic NCMs replace the nurses who attend your scheduled appointments. When the insurance companies try to use these telephonic NCMs, they often hesitate to provide written reports. That would violate rule number three above, so it is in your best interests never to allow these telephonic NCMs to work on your file.
Inform Your Attorney About the Actions of the NCM
Your lawyer needs to know about all your discussions and interactions with the nurse case manager. This is especially so if you feel the NCM is trying to undermine you with your physician and is acting against your best interests.
If you are concerned about the intentions of your NCM, your lawyer can help you write a letter explaining the guidelines under which you are willing to proceed with them working on your file or revoking the NCM’s authority to be your case manager.
Let KBG Injury Law Help You Deal With Insurance Companies and Nurse Case Managers
If a nurse case manager keeps appearing at your appointments, contact an attorney at KBG Injury Law immediately. Our experienced workers’ compensation attorneys can advise you on how to deal with the situation and help you understand your legal rights and how they apply to nurse case managers.
If you are interested in talking to one of our attorneys, you can call us at 1-800-509-1011, or you can visit our contact us page and leave us your contact information and some details about your workers’ compensation situation.