Most frequent questions and answers
Often, a worker develops a lingering illness which is difficult for the family physician to diagnose and he is treated with medications that alleviate the symptoms but general malaise and weakness continue.
If the family physician did not inquire into the details of the patient’s occupational duties and environment, the worker may continue to be exposed to harmful substances when the best treatment should have been removal from the exposure. Under the above circumstances, pulmonologists or occupational medical specialists should be consulted and workers compensation benefits would be available if it can be determined that the illness or injury resulted from the exposure.
It is never too soon to consult an attorney after sustaining a work related injury, even if for no other reason that to have the workers’ compensation system explained to you, and what to expect from the process. There is a substantial likelihood that the insurance company will eventually challenge a workers’ right to compensation benefits, and the insurance company begins preparing a litigation strategy to get an injured worker off compensation from the time that the adjuster opens the file.
Not only is it critical for the injured worker to consult an attorney as soon as possible, it is recommended that you contact an attorney experienced in workers’ compensation law.
You most certainly do need an attorney, regardless of how nice a person the insurance claims adjuster appears to be. The problem with taking the advice of an insurance adjuster is that the adjuster’s motivation for making decisions is to keep costs down and profits up. This goal is in direct conflict with the injured workers’ best interests, which is to obtain the best medical care and ongoing wage loss benefits for as long as the injured worker is unable to return to work. An insurance adjuster is trained to reduce the cost of the claim any way possible, even to the extent of violating the provisions of the Workers’ Compensation Act.
Although the Pennsylvania Workers’ Compensation Act provides for penalties for insurance company misconduct, those provisions do not seem to keep violations at a minimum.
Most workers’ compensation attorneys in Pennsylvania provide free initial consultations and will not charge a fee until the Employer/Insurance company has filed a petition to suspend, modify, and/or terminate your benefits. In addition, an attorney may not collect a contingency fee without first submitting the fee for approval before a workers’ compensation judge.
An injured worker in Pennsylvania must go to one of his/her employer’s designated physicians for the first ninety (90) days provided that the Employer has provided a list of at least six designated health care providers, “no more than four of whom may be coordinated care organizations, and no fewer than three of whom shall be physicians.” It is the duty of the Employer “To provide a clearly written notification of the employee’s rights and duties” regarding his/her rights to medical treatment, and to “Ensure that the employee has been informed and that he/she understands these rights and duties” in writing with the “Employee’s written acknowledgment of having been informed and having understood his rights and duties.” If you believe that your Employer has failed to comply with these provisions, contact a workers’ compensation attorney about the possibility of being able to treat with a provider of your own choosing within this ninety day period.
Yes. There is no requirement under the Pennsylvania Workers’ Compensation Act for the insurance company to “pre authorize” any type of medical treatment. The insurance company is only required to pay for reasonable and necessary medical treatment after the treatment has been given by the provider and the bill has been properly submitted to the insurance company. The bill must be paid within thirty (30) days after the medical provider has submitted the bill on a Bureau form and with a medical report setting forth the reason and necessity of the treatment.
You have two options. The first is to choose another doctor who will treat you without requiring pre-authorization from the insurance company. The second is to file a prospective Petition for Utilization Review Determination which could take a few months to process. The Bureau selects a physician to review the proposed treatment after contacting the treating physician and discussing the proposed treatment with him/her. Your treating physician may have copies of these forms and may help you fill them out, or you can get them at your county’s Workers Compensation Judge’s offices. An attorney can also file this form for you.
No. Under the Pennsylvania Workers’ Compensation Act, the Employee is precluded for suing the Employer for pain, suffering, disability, or for causing an Employees injury. The only benefits that the injured worker can recover is wage loss benefits and medical expenses for the work related injury only.
No. The Employer is granted immunity from negligence claims by its employers. The good news is that the Employee can recover wage loss and medical benefits even if the worker himself carelessly or recklessly causes his own injury and disability. It is a give and take situation designed to ensure that as few people as possible are without any means to provide for themselves and their families, even the careless.
Truth of the matter is, there is no such thing as an “Independent” Medical Evaluation. Most treating physicians favor their patients over the insurance company, and the “independent” medical evaluating physicians receive substantial compensation for their evaluations, medical reports, and testimony, and therefore, favor the insurance company. The “independent” evaluations are in fact, “Defense Medical Evaluations.” It is strongly recommended that you consult an attorney before attending one of them.