Articles Posted in Worker Comp Generally

There is a common misconception that the workers’ compensation insurance carrier controls medical treatment whenever a worker is injured in Pennsylvania.  This is addressed in broad strokes on our website.  The truth is, a workers’ compensation insurer in PA may control medical treatment for the first 90 days of an injury, only if certain requirements are met (and very often, they are not).  Even then, there are situations where the injured worker is not bound by the insurer’s desired healthcare providers.  As with many aspects in the complex world of PA workers’ comp, it pays for an injured worker to know his or her rights.

An employer may post a “panel” of healthcare providers for an injured worker to use in the case of a work injury.  For a panel posting to be valid, it must include at least six healthcare providers (at least three of which must be physicians).  No more than four of the healthcare providers can be part of a coordinated care organization.  Though it may seem obvious, the providers must be geographically accessible for the injured worker.  The panel listing must contain the name and specialty of each provider, the address and phone number, and any ownership relationship.

Those requirements are just pertaining to the content of the panel posting.  For a panel posting to be valid and binding, more is required.  The panel must be “conspicuously” posted in an employee-accessible area (such as a breakroom, locker room, first aid station or time clock area).  Additionally, employees must receive a written copy of the panel at the time he or she is hired, as well as either immediately after, or as soon as possible after, an injury.

While many folks know what happens when an Employer violates Pennsylvania law and fails to carry PA workers’ compensation insurance (this is governed by the Uninsured Employers’ Guaranty Fund [UEGF]), few know what happens when a PA workers’ compensation insurance carrier goes bankrupt or ceases to exist.  This is where the Security Fund (Fund) steps in and pays the appropriate compensation.

Much like the UEGF, it is well settled that the Fund is not an “insurance company,” and therefore immune from penalties for a violation of the Act.  The Fund also cannot be assessed counsel fees for maintaining an unreasonable contest.  But, the Fund, like the UEGF, is responsible for paying for wage loss and medical treatment related to a work injury, and for the reimbursement of reasonable costs of litigation incurred by the injured worker in procuring such benefits.

On this blog, we discussed the landmark Lorino case, where the Supreme Court of Pennsylvania held that a Workers’ Compensation Judge (WCJ) can order a payment to an injured worker’s attorney of a counsel fee, even in there was a reasonable contest, and that such a fee is considered a litigation cost.

As we have discussed previously on this blog, physical injuries in Pennsylvania are treated differently than mental ones.  Provided that a physical injury was suffered in the scope and course of the job, benefits should be payable.  Mental injuries, though, have a different and additional requirement – the injury must have resulted from “abnormal working conditions.”

There should not be much surprise, then, that many cases have dealt with whether a particular fact pattern reaches the standard of “abnormal working conditions.”  This determination is very dependent on the exact facts of each case.  And, of course, what would be expected in that particular job.  What a police office, fire fighter or EMT might expect on a normal day at work is very different from that of an accountant, warehouse worker or a secretary.

Recently, the Commonwealth Court of Pennsylvania dealt with this issue in Ganley v. Upper Darby Township (Workers’ Compensation Appeal Board).  Here, the injured worker was a firefighter/EMT, who was forced to perform CPR on infants twice in less than two years (with neither infant surviving).  As a result of those events, the injured worker suffered post-traumatic stress disorder (PTSD).

The Pennsylvania Workers’ Compensation Act (Act) is very specific – a workers’ comp insurance carrier is responsible for the payment of all reasonable and necessary medical expenses, which are related to a work injury.  As always, the devil is in the details.  For example, is the payment of medical bills something which can only be addressed by Fee Review and not by a Workers’ Compensation Judge (WCJ)?

As the Commonwealth Court of Pennsylvania indicated in the recent case of Day-Timers, Inc. v. Rhonda Horton (Workers’ Compensation Appeal Board), a WCJ does, indeed, have jurisdiction to address the nonpayment of medical bills.  But, initially, let’s examine the confusion.

Under the Act, a PA workers’ compensation insurer has 30 days to either pay a medical bill related to a work injury, or file for Utilization Review (UR), which challenges whether such treatment was reasonable and necessary.  If a healthcare provider is not satisfied with the timing or amount of the payment for medical treatment, the provider has the ability to file for Fee Review.  This statutory scheme could lead an insurance carrier to argue that an injured worker cannot file a Petition for Penalties, for the nonpayment of a medical bill, since that is a subject solely for Fee Review.

Back in 2008, we discussed the decision of the Commonwealth Court of Pennsylvania in the matter of Weney v. Workers’ Compensation Appeal Board (Mac Sprinkler Systems, Inc.) [Note that the formatting, with the WCAB listed as the party and the Employer in parentheses, has been reversed since this decision].  This decision terrified attorneys who represent injured workers in Pennsylvania.

Essentially, Weney stood for the proposition that if a work injury is in litigation, and there is an aspect of the injury that was either raised, or should have been raised, the injured worker is barred from trying to bring it up in a subsequent litigation (what the court calls “technical res judicata”).  The consequence of barring a condition from being added in the future, even if it was never even litigated in the past, is both a great fear and a terrible injustice to us in the workers’ comp Claimant bar.

However, the Commonwealth Court of Pennsylvania does recognize limits to this concept.  This was addressed by the Court in the recent case of Michael N. Lewis, Sr. v. City of Philadelphia (Workers’ Compensation Appeal Board).  The injured worker here was a police officer, who in 2017, sustained injuries to his hand/wrist, low back, chest wall, and thoracic spine while attempting to subdue a burglary suspect.  The injury was properly accepted by issuance of a Notice of Compensation Payable (NCP).

We are excited to relay the news that the Pennsylvania Bureau of Workers’ Compensation, Office of Adjudication, has announced that there will be three new additions to the workers’ comp bench.  Two will be serving the Philadelphia Workers’ Compensation Hearing Office and one will be in the Williamsport Workers’ Compensation Hearing Office.

Erica Burry, Esquire and Robert Rachlin, Esquire, will each begin training in June, 2025.  Each will then be hearing cases in the Philadelphia hearing office.  Meaning, Robert Rachlin, Esquire, will also begin his training in June, 2025, but will be assigned to preside over cases in the Williamsport hearing office.

We welcome these additions to the PA workers’ compensation bench, and wish them well in their careers as Workers’ Compensation Judges!

Back in November, 2023, we discussed the case of M.R. Schmidt v. Schmidt, Kirifides and Rassias, PC (Workers Compensation Appeal Board).  As you may recall, this case addressed an issue regarding payment for CBD oil used in conjunction with treatment for a work-related injury.  The Workers’ Compensation Judge (WCJ) ordered such bills paid, though the Workers’ Compensation Appeal Board (WCAB) reversed that decision.  The Commonwealth Court of Pennsylvania then reversed the WCAB, determining that the initial decision authored by the WCJ was correct.

Since that time, the matter was appealed to the highest Court in the State, the Supreme Court of Pennsylvania.  Recently, that Court issued an opinion which affirmed the decision of the Commonwealth Court of PA (saying the WCJ was correct in requiring coverage for the CBD oil).

The Court was very specific in its opinion, stating, “we hold that any item that is part of a health care provider’s treatment plan for a claimant’s work-related injury falls within the purview of the broad-encompassing phrase ‘medicines and supplies’ as provided in Section 306(f.1)(1)(i). We further hold that, in such circumstances, the cost containment provisions of the (Pennsylvania Workers’ Compensation Act) and the attendant Pennsylvania Department of Labor regulations, both of which apply to a health care provider, do not apply to a claimant.”

Workers’ compensation benefits in Pennsylvania consist of three types (aside from fatal claim benefits, which are not really relevant for this discussion).  These are described in detail on our website.  There are wage loss benefits (also known as “indemnity”), medical benefits and “specific loss” benefits.  Specific loss benefits are paid for permanent loss of use of a body part and/or disfigurement claims (usually scarring, either from the injury or resultant surgery).  The rate paid to an injured worker in wage loss benefits and specific loss benefits, for many years, has been calculated using the same formula.  A recent decision by the Supreme Court of Pennsylvania has now overruled existing case law, changing the formula in specific loss cases.

Under Section 306(a) of the Pennsylvania Workers’ Compensation Act (Act), the rate for temporary total disability (TTD) benefits is calculated using the Average Weekly Wage (AWW) of the injured worker.  The benefit rate is two-thirds of the AWW, up to the statutory maximum (which is set every year).  If the benefit rate as calculated is less than half of the maximum rate, then the appropriate benefit rate is the lesser of 1) One half of the maximum rate; or, 2) 90% of the AWW.  Note that the AWW and benefit rate are often miscalculated by the workers’ comp insurance carrier and should always be reviewed by an experienced workers’ compensation attorney.  Under old case law, the same benefit rate paid for TTD was used for specific loss.

That all changed when the Supreme Court of Pennsylvania issued a decision in the case of Jackiw v. Soft Pretzel Franchise (Workers’’ Compensation Appeal Board).  The language in the Act for specific loss benefits, in Section 306(c), says that the benefit rate for specific loss, “ . . .    shall not be more than the maximum compensation payable nor less than fifty per centum of the maximum compensation payable per week for total disability as provided in subsection (a) of this section, but in no event more than the Statewide average weekly wage.”  The reference there to Section 306(a) is what created the prior case law, saying the rate was the same for each type of benefit.

As we previously mentioned on our Blog, Senate Bill 1232 was created to require insurance carriers to offer direct deposit of PA workers’ compensation benefits to injured workers across the State of Pennsylvania.  Hopefully, this will allay the difficulties that many injured workers have with receiving their workers’ comp checks by regular mail.  Governor Josh Shapiro signed Act 126 of 2024 (as SB 1232 became) into law on October 29, 2024.

By the terms of Act 126, insurer carriers (and self-insured employers) have one year to offer the payment of workers’ compensation benefits by direct deposit (so, by October 29, 2025).  Failure of the insurer to offer direct deposit beyond that date would likely be considered a violation of the Pennsylvania Workers’ Compensation Act, punishable by an award of penalties.

Act 126 discusses the creation of a form, which would be completed by the injured worker to start, stop or change the direct deposit.  Recently, the Pennsylvania Bureau of Workers’ Compensation released the first version of this form (LIBC-215).

As we have discussed in this blog previously, changes to an accepted work injury in PA come in two types – “corrective” and “consequential.”  The difference between these two situations can make or break a case, as recently illustrated by the Commonwealth Court of Pennsylvania in their decision in the Grow v. PECO Energy Company (Workers’ Compensation Appeal Board) matter.

A “corrective” amendment is when the condition was present at the time of the work injury.  In this situation, the injured worker need not file a Petition to Review, and the corrective amendment can be made by a Workers’ Compensation Judge (WCJ) in the litigation of any type of petition.  A “consequential” amendment, however, requires the filing of a Petition to Review.  This is used when the new condition is due to the accepted work injury, but takes place after the time of the injury (ie: as a consequence of that injury).  Significantly, a Petition to Review can only be filed within three years of the date of the last payment of workers’ compensation benefits.

Looking at the Grow case, the injured worker hurt his neck while working on November 4, 2013.  The injury was accepted by the workers’ comp insurance carrier, using a Notice of Compensation Payable (NCP), which described the work injury as “contusions and fractures at C3-C4.”  As a result of the work injury, disc fusion surgery was performed.  To his credit, the injured worker went back to work on January 10, 2014, and the workers’ comp benefits were suspended.

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