When “Denial” Means “Acceptance” – The Wonderful World of PA Workers’ Compensation

In many situations in life, things make sense.  This is not always true in law.  For example, a reasonable person may conclude that a “Notice of Denial” would be issued when a claim is “denied.”  How silly that person would feel to know that Pennsylvania Courts find it perfectly acceptable for a “Notice of Denial” to be used to accept a claim, even though the form itself specifically prohibits such a use.

Church v. Workers’ Compensation Appeal Board (Cook Landscaping) involved a worker who suffered a herniated disk in his lumbar spine while performing his job in 2004.  A Notice of Temporary Compensation Payable (NTCP) was issued accepting the injury as as a “herniated disc.”  An average weekly wage of $973.81 and a compensation rate of $649.21 was listed.  Subsequently, a second NTCP was issued, marked “corrected,” and adjusted the average weekly wage and compensation rate.  Temporary total disability benefits were paid for approximately 10 weeks under the two NTCPs.

After the 10 or so weeks, the injured worker returned to his job.  The workers’ compensation insurance carrier filed a Notice Stopping Temporary Compensation (NSTC) and a Notice of Workers’ Compensation Denial (NCD), indicating that, although an injury took place, Claimant was not disabled as a result of the injury and further indicating that all medical treatment related to the work injury would be reviewed for payment.  Having no medical insurance, the injured worker went several years without treatment for his low back, though he continued to have pain.

In 2011, the injured worker filed first a Petition for Reinstatement, seeking to have benefits awarded back to 2004, then amended to include a Petition for Penalties.  The workers’ compensation insurance carrier filed a Petition for Joinder (alleging that the condition of the injured worker worsened by subsequent employment), as well as a Petition for Termination.  All of the Petitions were denied by the Workers’ Compensation Judge (WCJ).  The testimony of the injured worker, and his physician, were found not credible.  The physician offered by the workers’ compensation insurance carrier was found credible, other than on the opinion of full recovery (A WCJ can find any or all of a witnesses’ testimony credible).  This was all affirmed by the Workers’ Compensation Appeal Board (WCAB).

Upon further appeal, the Commonwealth Court of Pennsylvania also affirmed.  First, the Court rejected the injured worker’s argument that first NTCP had to be revoked and therefore, there was still an open NTCP.  The Court related that amending or correcting an NTCP does not require a separate Notice Stopping Temporary Compensation.

The Court, in passing, noted that both the WCJ and the WCAB found the NCD was actually a Medical Only NCP.  On the plus side, this allowed the injured worker to file the Petition for Reinstatement in a timely fashion (had the argument of the insurance carrier been granted, the injured worker would have had to file a Claim Petition, for which the permissible time had already run).

There are two major problems with this finding by the Court.  As noted above, and even noted in the decision rendered by the Court, the NCD specifically prohibits using this document in such a manner.  As such, the NCD, in this author’s opinion, was void and of no legal meaning.  By acknowledging an injury in the NCD, and denying the claim, the document, again to this author, came dangerously close to fraud.  How this was just glossed over is troubling.

All the workers’ compensation insurance carrier had to do, back in 2004, was file a Petition for Suspension.  Instead, the company cheated and denied a claim it has no reason, or right, to deny.  The company should not gain from such subterfuge.

Moreover, this was not a “Medical Only” anything.  Some 10 weeks of temporary total disability benefits were paid.  The mere fact the benefits were paid under a NTCP does not mean the period of disability never happened.  By issuing the NSTC and NCD, the insurance carrier attempted to simply ignore there was a period of disability.  Again, how this was bypassed remains troubling.

Admittedly, much of this is “dicta,” unessential to the final decision.  The WCJ did not believe the injured worker, or his doctor, which is usually fatal to a workers’ compensation case, and was so in this situation.  The injured worker could not show that his disability was as a result of his work injury.