What Benefits Can I Receive Following a Work Injury?
If you suffered a work-related injury, you might be entitled to medical benefits and wage-loss benefits. Under the Pennsylvania Workers’ Compensation Act, employer-provided insurance covers almost all employees in the state if they suffer a work-related injury. An injury does not always have to be an apparent physical injury. Work-related injuries may sometimes be psychological. For example, if an employee undergoes an experience at work resulting in post-traumatic stress disorder, they may be eligible for workers’ compensation. Likewise, a job may aggravate or cause an occupational disease, such as lung disease, which may also be a work-related injury.
To receive benefits and prevent delays or issues with your claim, it is critical you report your injury immediately. Once you notify your employer of your injury, they should report it to their insurer or the person in charge of the workers’ compensation program. Your employer will then either accept liability, extend the investigation period or deny liability. We will look at the different benefits you may receive if your employer accepts liability. We will also answer common questions about workers’ compensation benefits, including what you should do if your claim gets denied.
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What Are the Types of Workers’ Compensation Benefits?
The Pennsylvania Workers’ Compensation Act ensures workers recover fair compensation for work-related injuries. This includes payment for lost wages and medical expenses. If your employer accepts liability for your injury, you can expect one or more of the following benefits, depending on your injury:
1. Lost Wage Payments
First, you may be entitled to wage-loss benefits. If you are unable to work at all, or if your employer cannot accommodate whatever restrictions you may have, you are entitled to what is called total disability benefits, which are generally two-thirds of your gross weekly pay, but that figure can vary. Approximately once every six months, your employer can require a medical examination to make sure you are still unable to perform the job due to the work-related injury.
If you have returned to work with restrictions, but you are not making as much as you were before the injury, you may qualify for partial disability benefits. For instance, if you can only work part-time due to restrictions from your doctor, or if your modified job pays a lower hourly rate, you are entitled to two-thirds of your lost wages.
If you have multiple jobs at the time of your injury, your time of injury employer must consider your full weekly earnings from all of your employers when calculating your workers’ compensation benefits. You will need to contact your other employers to let them know of the injury.
2. Medical Care
In addition to wage-loss benefits, the law requires your employer’s insurance company to pay for all your reasonable and necessary medical expenses related to the work injury or disease, even if you do not miss any time from work. These may include payment for doctor bills, hospital bills, co-pays, medication or a prosthesis.
3. Specific Loss Benefits
In cases of severe injuries involving the loss, or loss of use of a limb or body part, or hearing or vision loss, you may also be entitled to specific loss benefits, which vary greatly depending on the body part involved. You can be entitled to specific loss benefits, in addition to disability benefits. The compensation for a specific loss, such as the loss of a body part, is based on your weekly compensation rate multiplied by a set number of weeks. You are entitled to this benefit without any regard to loss of earning power, and even if you don’t miss any time from work.
Also, if your injury results in some type of disfigurement to your head, face or neck, such as from a burn or a surgical scar, you are entitled to a separate disfigurement award, which is based upon the severity of the disfigurement. You may receive disfigurement benefits anywhere from one week of your weekly compensation rate to a maximum of 275 weeks. You and your employer or their insurance company will need to agree on the amount. You may file for a hearing in front of a judge if you and your employer cannot reach an agreement.
4. Death Benefits
Please note, this has only been a very brief summary of the benefits available to you. Each case is different and it is important to contact a knowledgeable attorney to evaluate the specific issues related to your case to determine what benefits you may or may not be entitled to.
When Will I Receive My Benefits?
After you notify your employer of your injury, the insurance company must either pay you within 21 days of the date you give notice, or send you a Notice of Denial. Also, you must be off work more than seven days to receive weekly benefits. However, medical benefits are payable from the first day of injury.
The insurance company has the option to pay you temporary compensation for up to 90 days while they investigate your claim. If the insurance company tells you they are stopping your temporary compensation checks, you should immediately consult with a workers’ compensation attorney to see if you could be entitled to additional benefits or a settlement.
What Is a Notice of Denial?
Your employer may either accept or deny liability for your injury. If your employer and their insurance company decide to deny liability, they must issue a Notice of Workers’ Compensation Denial within 21 days after the employer has notice or knowledge of your injury. Once an employer denies your claim and files their Denial with the Bureau of Workers’ Compensation, the claim is closed. An employer might issue a Notice of Denial for any of the following reasons:
- You did not suffer a work-related injury.
- Your injury did not occur within the scope of your job.
- You were not employed by the employer when the injury occurred.
- You did not report your injury within 120 days of when it occurred.
- Your employer finds other good cause to deny liability.
The employer must inform you of the reason for denial in the notice.
If your employer sends you a Notice of Denial and you believe it is unfair, you have a right to contest their decision. To do so, you will need to:
- File a petition in the Workers’ Compensation Automation and Integration System electronically or by mail.
- File a petition within three years of the injury, or 300 weeks for occupational disease or death claims.
Once the petition is filed, you will be assigned a judge for a hearing and notified of a hearing date. Workers’ compensation cases are complicated, so it is best to contact an attorney if you wish to dispute a Notice of Denial. You may also want to contact a lawyer if your employer failed to send a Notice of Denial within 21 days.
How Does the Insurance Company Decide to Pay Me Temporary Compensation?
Your employer and their insurance company may decide to pay you temporary compensation if they need more time to investigate your claim. Doing so allows them to continue the investigation for 90 days. During this time, your employer can decide whether or not to accept or deny liability for your injury.
For example, if an employer suspects something else caused an injury for which they are not liable, they may send a Notice of Temporary Compensation Payable. Perhaps an employer believes an employee had been drinking on the job and fell off of a ladder as a result. In such a case, they may speak to other employees to obtain an eyewitness account of the injury. For instance, if they find out the worker had been intoxicated when the injury occurred, they can cease temporary payment and send a Notice of Denial. Employees are not covered under the act if they are impaired on the job or intentionally cause a self-inflicted injury.
Regardless, you should not go without wages while your employer explores the possibilities. Temporary compensation payments cover lost wages during the investigation period, even if your employer decides to deny liability. If your employer chooses to deny liability, they may stop temporary compensation at any time during the 90 days. In such a case, you have a right to file a petition for a hearing.
If your employer stops paying you temporary compensation, they must send you a Notice Stopping Temporary Compensation, followed by either a Notice of Compensation Payable, Agreement for Compensation or a Notice of Denial, within the 90-day timeframe. If your employer stops sending payments without notifying you, you may need to contact an attorney. Failure to notify you means they admit liability, and your employer’s insurance company should automatically send you compensation.
Your employer must file a Notice of Temporary Compensation Payable with the Bureau of Workers’ Compensation and send you a copy of the notice with the first payment.
What If the Insurance Company Does Not Pay Me If I Was off for More Than 7 Days?
If you missed work for more than seven days due to a work-related injury, and if you reported the injury to your employer, that obliges your employer to take action. Your employer has 21 days to either deny your claim or send you a compensation check. If they fail to pay you within 21 days of your injury, they must have at least sent you a Notice of Compensation Denial or a Notice of Temporary Compensation Payable accepting the claim on a medical only basis.
Contact your employer or their insurance company and try to resolve the issue if they have not sent compensation or a Notice of Denial after 21 days. If the issue remains unresolved, contact an attorney. You may need to file a petition.
What Are the Insurance Benefits If I Was out of Work for Less Than 7 Days?
If you miss less than seven days of work due to a work-related injury, it does not require your employer to pay compensation for lost wages. However, they will be required to pay your medical expenses related to the injury even if you did not miss any work. This includes coverage for medicine, hospital services and any medical service necessary to treat the work-related injury.
To receive disability payments, you must be out of work for more than seven days, which includes weekends. Benefits for lost wages are payable on the eighth day. Once you have been out of work for 14 days, you will receive payment for the first seven days. As long as you had reported your injury promptly, missed more than seven days of work and your claim was approved, you should receive your first check within 21 days of your absence from work. From that point on, you would receive a regular check.
Am I Entitled to an Insurance Company Lump Sum Benefit?
If you are receiving benefits, you may be entitled to a lump sum settlement from the insurance company. However, qualifying for a lump sum benefit does not mean it is your best option. When you accept a lump sum, you settle your claim and give up your right to all workers’ compensation benefits. Only experienced workers’ compensation lawyers can tell you how much your case is worth, and make sure the insurance company pays you everything you are entitled to receive.
Signing supplemental agreements, final receipts or compromise and release agreements may have the effect of signing away your right to future wage-loss or medical benefits. Signing any of these documents may also affect your receipt of or future entitlement to other benefits, such as Unemployment Compensation, Social Security Disability and Medicare. Always consult with an experienced workers’ compensation lawyer before settling or signing any documents.
How Do I Know the Insurance Company Is Paying Me Everything I Am Entitled To?
If you reported a work-related injury, you might be wondering why you had not received a compensation check in the mail yet. Keep in mind your employer and their insurance company have 21 days to send you compensation. As long as your employer has accepted liability, and you have been out of work for more than seven days, you should receive compensation checks weekly or biweekly (the same way you were paid at work). Most people receive about two-thirds of their regular pay up to a weekly limit. For example, the maximum weekly compensation rate for an injury occurring in 2019 is $1,049.
It is important to note your employer will also consider other earnings such as Social Security benefits, severance pay or unemployment benefits when determining your workers’ compensation amount.
If you suffered a permanent injury, your compensation may be different than someone who expects to recover within time, and you may be entitled to a specific loss award in addition to disability compensation.
If you receive a bill for medical services you used to treat your work-related injury, you need to contact your employer. Generally you are not responsible for paying any of the medical expenses related to the injury. If a medical provider suggests surgery for your injury, you have a right to seek a second opinion, which your employer will pay for.
There are a few exceptions when it comes to medical benefits. Your employer is not required to pay your medical bills if your employer has posted six or more physicians or health care providers, and you go to a provider who is not on that list.
If your employer does not provide a list of health care providers, you are free to seek medical care from whomever you wish. Otherwise, you are required to seek medical assistance from one of the listed providers or you may be responsible for your medical bills. Either way, you must notify your employer of the health care provider you choose, and they have a right to receive reports from your physician. Your employer also has the right to periodically ask you to see a doctor of their choice for an exam once you begin to receive benefits.
Your employer must pay your medical bills for a work-related injury as stated under the Act. However, this does not mean they have accepted your claim, and they still may deny liability and refuse to pay lost wages.
What If I Am Not Receiving Fair Compensation?
Employers or insurance companies do not always follow the rules. Sometimes, they make mistakes or miscalculate the correct payment amount. Regardless of the cause, your employer’s insurance company may not pay you the full amount they owe you, whether it be compensation for partial disability, full disability or your medical bills.
If you have any questions or concerns about your benefits and believe you are not receiving fair compensation for your work injury, you have a right to take legal action. The first step is to contact a lawyer who has experience handling workers’ compensation cases and who has a track record of success. Workers’ compensation cases are often complex and require a thorough knowledge of workers’ compensation laws in Pennsylvania. An experienced attorney can help you obtain what it is rightfully yours.
At KBG Injury Law, we take your injury seriously, and we understand you depend on compensation to support yourself or your family. It is difficult enough to pay bills while waiting for a notice to arrive in the mail. We strive to end the frustration for you and help you recover the results you deserve.
Workplace injuries can happen to anyone, and so can unethical insurance practices. To learn more about your rights as an injured employee and the compensation owed to you, contact us today or request a free consultation.