By Dennis L. Plank, Attorney
Workplace accidents are seldom expected, but they happen nevertheless. And they are more common than most people think. In Pennsylvania, more than 170,000 workplace injuries were reported in 2019. While some workplace injuries can seem minor, many stop workers from performing their duties and cause ballooning medical bills and lost wages.
Every state – including Pennsylvania –requires employers to carry workers’ compensation insurance to give injured employees medical and wage benefits. Unfortunately, actually acquiring those benefits is rarely easy. Lancaster County workers with work-related injury or illness can face a confusing and complicated flurry of legal jargon, making it even harder. An experienced workers’ compensation attorney can help them secure the compensation that they deserve, but it helps to understand the legal terms they will need to know:
Also referred to as an “admitted claim,” an accepted claim is a claim considered valid by an employer’s insurance company. However, accepted claims are not a guarantee of immediate benefits. There are sometimes problems or delays.
Independent Medical Evaluation (or IME)
When there is a dispute over a doctor’s recommended treatment plan or the cause of an injury, a worker may require an independent medical evaluation. IMEs are medical examinations by doctors agreed upon by both the employee’s workers’ compensation attorney and the insurance company. Such assessments will have a serious impact on the outcome of the claim, and the injured employee should have an experienced workers’ comp lawyer who can make sure the doctor selected will not unfairly favor the insurance company.
When a physician determines that an injured employee cannot return to their previous job, an employer may be able to offer alternative work. This is sometimes referred to as modified or “light-duty” work. However, the alternative work must meet the employee’s medical restrictions. If the employer is acting in good faith, it is typically unwise for workers to refuse modified work since it can jeopardize their benefits.
The acronym AOE/COE stands for “arising out of employment” (AOE) and occurring in the “course of employment” (COE). These terms refer to the fact that injuries must occur during working hours, and during a work-related activity to qualify for workers’ compensation.
Benefit structure refers to the part of the workers’ compensation insurance policy defining what compensation employees may receive after sustaining injuries from work. These benefits depend heavily on the injury’s nature and severity and can cover vocational rehabilitation services, medical expenses, temporary disability benefits, permanent disability benefits, and death benefits.
Classification codes are a three- or four-digit number assigned to various businesses and professions based on the risk of injury and the base premium cost of workers’ compensation insurance. Most industries with any significant risk of worker injury have standard classification codes. The code system ensures a fair breakdown of insurance costs, with more high-risk businesses paying higher premiums.
Compromise and Release
Compromise and release refers to a kind of workers’ compensation settlement where the injured employee and the employer’s insurer agree on a single lump-sum payment. This type of agreement also clears the insurance company from all further liability and future payments regarding the workers’ illness or injury.
Cumulative trauma describes illness or injury resulting from repeated activity or exposure while working and is not caused by one specific accident. Cumulative trauma can include respiratory problems from repeated exposure to chemicals or carpal tunnel syndrome from strenuous typing over time.
Declaration of Readiness
Declaration of readiness is a form that requests a judge hear a workers’ compensation case.
Delay letters are sent from a claims administrator explaining the reason for a delay in workers’ compensation claim and any further information the worker may need to move the claims process forward.
A duty description – or job description – is a formal explanation of the job functions performed by an employee.
Impairment ratings in Pennsylvania determine how disabled a worker is from their workplace injury. If an AME finds that a worker is disabled less than a certain percentage, their workers’ compensation benefits can be reduced.
Independent contractors do paid work for employers, but unlike an employee, they use their own equipment and make their own hours. Under Pennsylvania law, independent contractors are ineligible for workers’ compensation coverage.
When a law or contract is “in force,” that means it is in effect, and it must be obeyed.
Maximum Medical Improvement
When a doctor has evaluated an injured worker and finds they are unlikely to recover further, they have reached maximum medical improvement.
The Occupational Safety and Health Administration (OSHA) is a federal agency responsible for setting and enforcing workplace safety standards to reduce the risk of injury and illness. Those standards range from requiring employers to provide proper safety equipment like gloves or hazmat suits to establishing chemical exposure limits. OSHA provides safety seminars and trainings and onsite consultations that identify potential workplace hazards. Penalties for employers neglecting OSHA standards can include legal action, fines, and suspension of business.
Judges can award penalties to an injured worker if a company violates the Pennsylvania Workers Compensation Act. These violations can include failure to investigate a claim, not paying medical bills, or terminating regular checks without a valid reason. Judges can award workers up to 50% of the penalty, plus interest, for unreasonable or excessive delays.
Permanent Alternate Position
Unlike a temporary alternate position for a worker recovering from injury, a permanent alternate position is a long-term job that an employee can perform under prescribed medical restrictions. Permanent alternate positions are usually assigned once a doctor determines the employee has a permanent work-related disability, making it impossible for them to return to their original job.
Permanent Partial Disability (PPD) Benefits
When a worker suffers a permanent partial disability and returns to their job for less pay or fewer hours, PPD benefits pay two-thirds of the lost wages. Workers can collect these partially lost wage benefits for a maximum of 500 weeks.
Permanent Total Disability (PTD) Benefits
When a work-related injury or illness stops a worker from returning to any kind of employment, PTD benefits pay two-thirds of their average salary at the time of injury up to a certain maximum, along with medical bill payment, for the remainder of their life. If the worker also receives Social Security disability benefits, the total of both of these benefits can’t exceed 80% of their earnings.
Under Pennsylvania law, injured workers cannot usually file a lawsuit against an employer if they provide workers’ compensation insurance. However, there are notable exceptions. If the employee can demonstrate the employer engaged in willful misconduct like fraud, misrepresentation, or misleading investigators, then lawsuits are a viable option.
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