When a PA workers’ compensation insurance carrier wants to “terminate” the workers’ comp benefits of an injured worker, the insurance company must prove that the injured worker has fully recovered from his or her work injury. What constitutes the “work injury” is usually what is described on the Notice of Compensation Payable (NCP)[the document used by the insurance carrier to accept a claim]. While this is the rule, there are always exceptions.
A recent decision rendered by the Commonwealth Court of Pennsylvania, Julio Paz Y Mino v. Workers’ Compensation Appeal Board (Crime Prevention Association), dealt with the exception to the rule. After Mr. Mino was injured, an NCP was issued, describing the injury as lumbar sprain and strain. A Petition to Terminate was filed by the workers’ comp insurance carrier. The Workers’ Compensation Judge (WCJ) denied this Petition, finding the testimony of the injured worker’s doctor more credible than the doctor who performed the Independent Medical Examination (IME) for the insurance company. Though the WCJ did not formally state he was amending the NCP (nor was a Petition to Review, the Petition used to amend an NCP, filed), he noted the diagnosis rendered by the injured worker’s doctor, specifically, an aggravation of pre-existing lumbar stenosis and a lumbar radiculopathy.
The workers’ compensation insurance carrier then filed a second Petition to Terminate (Persistent little devils, eh?). Since the first WCJ did not formally amend the NCP, the second WCJ did not include the entire diagnosis found by the first WCJ. In so doing, the second WCJ found that Claimant had fully recovered and granted the Petition to Terminate.
On appeal, the Workers’ Compensation Appeal Board (WCAB) affirmed. The Commonwealth Court of Pennsylvania, however, reversed. The Court found that there was no requirement that the NCP be formally amended, or that a Petition to Review be filed in this situation (see previous blog entry on Cinram case). The WCJ made findings, which were not appealed. Since the IME physician did not state that the injured worker had fully recovered from all of the diagnoses found by the first WCJ, the Petition to Terminate must fail.
Note, too, that the Court also dealt with an issue concerning an overpayment of benefits to the injured worker. The WCJ and the WCAB found that the workers’ compensation insurance carrier was entitled to a credit for the overpayment. The injured worker claimed that there should not be a credit because the overpayment came from an administrative error, rather than a miscalculation. On this issue, the injured worker did not fare as well. The Court found the injured worker would be “unjustly enriched” by the extra payments, regardless of whether the error was administrative or a miscalculation. The workers’ compensation insurance carrier was given a credit for these payments. What is unclear is whether this credit can only be taken from future workers’ compensation benefits, or whether repayment can be sought from the injured worker (if there are no future benefits).