Many clients walk in the door without an active workers’ compensation claim. Not all of these situations look the same. This can come in the form of a denied comp claim. In this situation, the insurance company is aware that you sustained an injury, but they have chosen to deny you coverage. It could also be that the Employer is paying ongoing wages and medical bills, but nothing was ever reported to the insurance company. In this situation, you do not have active insurance coverage with them. The Employer may do that for a variety of reasons, but we do not dissect those reasons here. At the end of the day, whatever your situation, if you do not have an active and open workers’ comp claim with the insurance company, you are going to need to file for benefits. What do you need to do to get workers’ compensation? This article focuses on the necessary steps and time period for filing for workers’ compensation benefits in Pennsylvania.
There are multiple steps to filing a workers’ compensation claim in PA. It is important to follow each one of these steps. If you do not satisfy each step, you may not be able to file a claim. Even if you are able to file a claim, a judge will ultimately be deciding your case. You will want to make sure you did everything properly from the start. It is important to note that the process of filing for a workers’ compensation claim is not the same as putting your Employer on notice. Putting your Employer on notice is part of the process. It is an important part for filing a claim, but not the only part. It is also important to note that workers’ compensation laws are state specific. So, what is required in PA, may not be required in NJ. This article only focuses on how to obtain workers’ compensation benefits in PA. Let’s start at the beginning of the process…
The first step is, of course, the work injury itself. This is the catalyst that sets off the rest of the process. Once you suffer your work injury, the next crucial part is when to report your injury to your Employer. This is discussed in a different informative post, “When to Tell Your Employer You Were Hurt at Work”, but *spoiler alert* it is best to immediately report the injury. You can report your injury a variety of ways, but it is important to document that you reported it and include that you were actually injured from the incident. This is called putting your Employer on notice. If you do not provide notice about your work injury, you cannot win a claim for benefits in Pennsylvania.
Important things to note about providing notice: You must give notice of your injury within 120 days of when the injury happened. That means you MUST give notice to your Employer within 4 months of when you got hurt. Otherwise, your claim is barred. This can be extended in certain circumstances like if you did not know or should not have known you sustained an injury. This would be a case where you are not aware yet that your condition has resulted from your work activities/environment. This is typically limited to exposure and repetitive trauma cases. Exposure case would be something like asbestos. Repetitive trauma would be if you work heavy labor and do not have a specific traumatic incident but experience cumulative wear and tear from your daily job activities. In these cases, your last day of trauma/exposure is your “date of injury” since each day of work is a new “injury” to your body. Each day at work is a new day you are exposed to a harmful environment or performing activities causing injury to your body. There are times that your “date of injury” could also be the date of your diagnosis by your doctor. This usually happens when you do not stop working so you do not have a last day of trauma/exposure. The important thing to remember is do not delay- report your injury soon after it happens or as soon as you think your job duties/environment are causing your health issues.
There are times you do not need to worry about providing notice to your Employer about your injury. Those would be situations where the Employer was present and had actual notice of the injury. An example of this would be if your supervisor was present when the ladder you were on fell, and your Employer drove you to the hospital. Clearly, the supervisor is aware that not only did an incident happen, but also that you sustained an injury since the Employer had to drive you to the hospital for medical treatment. If the supervisor had not been present, it would be your duty to call someone in charge to notify him or her that the ladder fell, and you hurt yourself. You must be clear that not only did something happen but also that you sustained a work injury from the incident.
After you report your injury to your Employer, the duty now falls on your Employer to report this to their workers’ compensation insurance company, also known as “the carrier”. This is when the claims process begins. (To be clear, though the insurance company is providing you coverage, their client is your Employer. This is not your typical insurance situation where you pay the premiums and you are the client for the carrier. Keep that in mind when dealing with the carrier.) Once the insurance company is aware of your injury, they will begin their “investigation” into the matter. This usually looks like them calling the Employer to hear about what happened from the Employer’s point of view. The carrier will request wage records from the Employer. They may possibly obtain medical treatment records from any doctor or hospital that you have seen since your injury. They may even call you to obtain a recorded statement about the incident. This is all normal and part of the initial process for filing for workers’ compensation benefits in Pennsylvania.
After your Employer notifies the carrier, the insurance company has 21 days from the date you notify your Employer that you were injured on the job to file an acceptance or a denial on your case. The 21 days starts to run from the date of notice of the injury whether you are disabled from the job or not. The insurance company has a few options. They can straight out deny your case. They can temporarily accept your case for both wage loss and medical benefits. They can temporarily accept your case for medical benefits only. If they temporarily accept your case, they have 90 days to change their minds if they want to. If they do not change anything at the end of those 90 days, your case automatically is accepted, and you have an open workers’ compensation claim. At that point, the carrier cannot simply change their minds and deny your case. They must bring the case to the courtroom and ask the Judge to stop your workers’ compensation. This is true in Pennsylvania, but not all states. During this time, the first 90 days, the insurance carrier can pay wages and medical benefits and then deny your case at the end. It is important to stay on top of the documents the insurance carrier is issuing so you know the status of your claim. It is also important to keep up with your medical treatment during this time.
Let’s say the insurance company does not accept your workers’ compensation claim for whatever reason. Or they decided to deny your claim during the first 90 days. You must now file what is called a Claim Petition with the court if you want to fight for your benefits. You have 3 years from the date of your injury to file a Claim Petition. This has been refined to actually mean from the date of your disability. So, if you were hurt on February 1, but you did not start missing time from work due to your injury until February 22, February 22 is when the 3-year clock starts ticking. If you do not stop working and have a repetitive trauma injury, you have 3 years from the date of your medical diagnosis since you do not have a last day of work. This means that even if the insurance company denies you coverage, you can contact a lawyer and file a petition within 3 years for a Judge to hear your case as to why you deserve benefits. If you file a Claim Petition even just one day after the 3-year time limit, you are out of luck and will be barred from bringing a claim for benefits. If the Employer is paying medical benefits but not wage loss benefits, this does not extend your 3-year time limit. You are still responsible for filing a Claim Petition within 3 years.
There are some things that do delay the 3-year clock from starting to tick. If you receive payments from your Employer in the form of wages or medical benefits instead of the carrier paying you workers’ compensation benefits will toll the 3-year limit. So, this would be if you were not working but your Employer continued to pay you while you were out of work and covered your medical bills. This is when the Employer pays you, not the insurance company. If your Employer intentionally lulls you into a false sense of security that your workers’ comp claim has been accepted that can also toll the 3-year limitation. This only happens if your Employer intentionally deceives you, so you believe your claim has been accepted by the carrier, so you do not think you need to file a Claim Petition. Something that is especially important in Pennsylvania due to the close proximity of New Jersey, Delaware, and Maryland, is that if another state is paying your workers’ compensation benefits under their jurisdiction, this will also toll the Pennsylvania 3-year limitation. This is usually found in cases with delivery drivers and truck drivers who travel to other states for work. It applies to any case where another state is paying you compensation benefits. And finally, if for some reason you did not know about your injury and cannot be held to reasonably should have known about it, that will toll the limitation. This usually occurs in exposure cases. This would be if you have been exposed to a harsh environment or toxins but were not aware that they were making you sick. If you later realize that your work environment caused your injuries, it is the date you came to this realization that starts the 3-year clock. If you reasonably should have known that the environment was causing your health issues, the date you are held to “reasonably should have known” is when the clock starts. A situation like that would be if there were known harmful toxins at your work, you became sick, and your doctor told you it is probably from your work. At that point, it would be reasonable for you to know that your work caused your injuries since a medical provider told you.
There are important steps and dates you need to make sure you do not miss. You should talk to a lawyer even if the insurance company is currently paying your medical bills and wages. It will be easier for a lawyer to help you from day 1 instead of coming in late to the game and try to play catch up. Take care of yourself and your benefits from the start.
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