Insurance Insights ~ May 1999
CONTENTSNew Office HoursIs Workers' Comp Still Confusing?Don't Think a Flood Could Happen to You? |
PAST ISSUESof Insurance Insights |
Providing our policyholders with the best service possible is one of the keystones at the foundation of our agency. To further enhance the service we provide, G. C. Weimer Insurance Agencies is establishing new office hours.
Beginning April 12, 1999, hours of operation will be:
As always, other appointment times are available on request.
We encourage you to give us your opinion of these changes, as well as other ways our agency may improve our service to you, our customer.
Most, if not all of our commercial customers have had a Workers’ Compensation policy review performed in the past twelve months. With those reviews, the major points of this article have been examined. During a recent employee meeting, questions were raised regarding Benefits, Physicians Panels, and coverage.
The Department of Labor and Industry, Bureau of Workers’ Compensation publishes an excellent brochure titled, " Workers’ compensation and the Injured Worker". Say what you will about "government agencies", these folks put together a very useful tool. They explain it much better than we could. The following are excerpts from this brochure. Remember that this is only a general information guide and is not official interpretations of the law.
Workers' Compensation & the Injured Worker is published by the Department of Labor & Industry, Bureau
of Workers' Compensation. Johnny J. Butler, Secretary of Labor & Industry, Donald A. Smith, Jr., Deputy Secretary for Compensation & Insurance, Richard A. Himler, Bureau Director, Bryan Mahoney, Information Officer, Kathleen M. Dupin, Editor
If you are unable to work because of a job injury or a work-related illness, Pennsylvania’s Workers’ Compensation Act (Act) provides for your medical expenses and wage-loss compensation benefits until you’re able to go back to work. Additionally, death benefits for work-related deaths are paid to your dependent survivors. Benefits are paid by private insurance companies or the State Workers’ Insurance Fund (a state-run workers’ compensation insurance carrier) or by employers themselves if they are self-insured.
Nearly every Pennsylvania worker is covered by the Pennsylvania Workers’ Compensation Act. Employers must provide workers’ compensation coverage for all of their employees, including seasonal and part-time workers. Non-profit corporations, unincorporated businesses, and even employers with only one employee must comply with the Act’s requirements.
Other compensation laws cover some Pennsylvania employees, including: Federal civilian employees, railroad workers, longshoremen, shipyard and harbor workers. Some others who may not be covered are volunteer workers, agricultural laborers, casual employees, domestics and employees who have been granted a personal religious exemption from the Act. Certain types of executive officers of for-profit and not-for-profit corporations may elect exemption from the Act. A worker should seek further information if there is any doubt as to coverage.
If your work causes an injury, illness or disease, you may be entitled to workers’ compensation. No compensation shall be paid when an injury or death is intentionally self inflicted, or is caused by an employee’s violation of the law including, but not limited to, the illegal use of drugs. An injury or death caused by intoxication also may not be covered.
Coverage begins on the date of hire. Medical benefits are payable from the first day of injury; payment of lost wages are addressed in the Wage Loss Benefits section.
Prompt reporting is the key. Report any injury or work-related illness to your employer or supervisor immediately. You must tell your employer that you were injured in the course of employment and inform your employer of the date and place of injury. Failure to notify the employer can result in the delay or denial of benefits. Once you have lost a day, shift or turn of work, your employer is required to report your injury to the Bureau of Workers’ Compensation (bureau) by filing an Employer’s Report of Occupational Injury or Disease.
If the injury is very serious – one where you won’t be able to work for a year or more –you may be eligible for additional disability benefits from Social Security. For information, contact the nearest office of the Social Security Administration.
If you require an accommodation to participate in a hearing due to a physical impairment, or need a translator*, or a sign language interpreter without cost, call or write the Judge's office assigned to your case and describe the accommodation. The Bureau Headquarters’ Administrative Division Chief can also be contacted at:
Bureau of Workers' Compensation
1171 S. Cameron St., Room 324
Harrisburg, PA 17104-2501
(717) 783-5421
TTY (800) 362-4228 (for hearing and speech impaired only)
*Costs of language translators are the responsibility of the user.
Occupational diseases under the Act are covered if caused by or aggravated by employment. Your disability must occur within 300 weeks of your last employment in an occupation where you were exposed to the hazard. For certain lung diseases, you must have worked in an occupation with a silica, coal or asbestos hazard for at least two years during the ten years prior to your disability.
Wage-loss benefits are equal to approximately two-thirds of your average weekly wage, up to a weekly maximum. Workers’ compensation wage-loss benefits can be offset for 50% of Social Security "old age" benefits, the employer-paid portion of a retirement pension, severance pay, unemployment compensation or earnings the employee receives.
There are several different ways of calculating the average weekly wage under the Act. The minimum compensation rate is the lower of 90% of the workers’ average weekly wage or 50% of the statewide average weekly wage.
The law does not allow for a cost-of-living increase.
Wage-loss benefits are available if it is determined that you are totally disabled and unable to work or partially disabled and receiving wages less than your pre-injury earnings. Please see the "Total and Partial Disability Benefits Status" sections for further information as to disability status.
Applies to injured workers for a period during which they are considered totally disabled and unable to work. After 104 weeks of such status, the employer/insurer can require a medical examination to determine if the employee is at least 50% impaired based upon his/her work injury according to American Medical Association standards. If the 50% threshold is not met, the employee’s status can change to partial disability.
This benefit status is for a maximum of 500 weeks. If, while on partial disability status, you obtain a qualified impairment rating physician’s determination of impairment that is equal to or greater than 50%, you may file a Petition for Reinstatement of total disability status.
Partial disability of up to 500 weeks of benefits are paid if you can return to work at a lower paying job within work-related restrictions or you are found not totally disabled.
Wage-loss benefits are payable when you report the injury promptly, miss more than seven days of work and your claim is accepted by the insurance carrier.
You must be disabled more than seven calendar days (including weekends) before workers' compensation payments for disability are payable. Benefits are then payable beginning with the eighth day after injury.
You will receive retroactive payment for the first seven days if you are off work 14 days.
You should receive your first compensation check within 21 days of your absence from work. After that, you will receive a check regularly as you received your wages prior to the injury.
Payments of temporary compensation may be made by your employer or the insurance carrier for up to 90 days, even if your claim is not accepted by your employer or its insurance carrier. If your employer or their insurance carrier advises you that it will not continue your temporary compensation check past 90 days, you have the right to file a Claim Petition with the bureau for a hearing if you believe you are entitled to benefits.
Wage-loss benefits can be stopped by an employer/insurer who has evidence that you have returned to work at wages equal to or more than your earnings level prior to the injury and after providing a timely notice of that fact. In addition, if you are receiving temporary compensation benefits during the 90 days following the report of injury, the insurance carrier/employer may notify you they are stopping benefits because they are not accepting the claim of a work-related injury.
Other reasons that benefits may be stopped are: a workers’ compensation judge stopped benefits after a hearing; the employee signs either a Supplemental Agreement or an Agreement to Stop Workers’ Compensation (commonly referred to as a Final Receipt); the 500-week period of partial disability status expires.
In the event of a work-related illness or injury, you are entitled, if covered under the Act, to the payment of related reasonable surgical and medical services rendered by a physician or other health care provider.
Medicine, supplies, hospital treatment and services, orthopedic appliances, and prostheses are also covered for as long as they are needed. (To assure payment of medical services, see the "Choice of Doctor" section.) Even if you have lost no time from work, health care costs for a work-related injury or illness are payable up to 113% of the Medicare reimbursement rate, as updated by law. Reimbursement for prescription drugs and professional pharmaceutical services is limited to 110% of the average wholesale price of the product. However, an employee may not be charged the difference between the health care provider’s charge and the amount paid by the employer or its insurance carrier. In other words, there can be no "balance billing" to you.
If your employer has posted a list of six or more physicians or health care providers in your workplace, then you are required to visit one of them for initial treatment. You are to continue with that provider or another on the list for a period of 90 days following the first visit.
Employers are responsible for advising workers of their rights and duties under Section 306(f.1)(1)(i) of the Act (medical benefits).
If an employer’s provider prescribes invasive surgery, you are entitled to a second opinion which will be paid for by your employer/insurer. Treatment recommended as a result of the second opinion must be provided by a listed provider for 90 days.
If during the 90-day period you visit providers other than those on the list, your employer or your employer’s insurance carrier may refuse to pay for such treatment. After that time period, as well as in situations where your employer has not posted a list or has posted an improper list, you may seek treatment with any physician or other health care provider. You must notify your employer of the provider you have selected. So long as the treatment is related to the injury and is necessary and reasonable it will be paid for by your employer or the employer's insurer. During treatment, the employer or the employer’s insurer is entitled to receive monthly reports from your physician or provider.
Once you begin receiving workers’ compensation benefits, the employer/insurer has the right to ask you to see their doctor for examination. If you refuse, the employer is entitled to request an order from the workers’ compensation judge requiring you to attend an examination. Failure to then attend may result in a suspension of your benefits.
If you have lost the permanent use of all or part of your thumb, finger, hand, arm, leg, foot, toe, sight, hearing, or have a serious and permanent disfigurement on your head, face or neck, you may be entitled to a specific loss award.
If the injury results in death, surviving dependents may be entitled to benefits.
If you think you haven’t received benefits due you, contact your employer or your employer’s insurance carrier. The insurance carrier is allowed 21 days from your notice to the employer of your disability to decide to accept or deny your claim or to make payments of temporary compensation for up to 90 days.
Cooperative communication with your insurance carrier is recommended. If the problem is not resolved, it may be necessary for you to file a petition with the bureau. Forms can be obtained through the Claims Information Helpline (800-482-2383). The bureau is responsible for resolving disputes by assigning petitions to workers’ compensation judges who decide each case after holding hearings on the issues.
Notice of an occupational injury or disease must be given to the employer within 120 days of the injury or disability. If your request for workers’ compensation benefits is denied by your employer or your employer’s insurance carrier, you have three years from the date of injury to file a Claim Petition.
In occupational disease cases, injury/disability must occur within 300 weeks from the date of last employment in an occupation in which you had exposure to a hazard, and a petition must be filed no later than three years from the date of injury/disability. Failure to file a petition on a timely basis may result in forfeiture of your right to benefits.
If your benefits were terminated, you may file a Petition to Reinstate workers’ compensation benefits within three years after the date of your most recent workers’ compensation check.
If your benefits were suspended, you may file a petition to have benefits resumed. This petition must be filed within 500 weeks from the date of suspension.
Payment of medical benefits by your employer does not mean that your claim has been accepted or reopened.
You may represent yourself in workers’ compensation proceedings, but a non-attorney cannot represent you. However, you should be aware that workers’ compensation litigation is complex and your employer or your employer’s insurance carrier will be represented by an attorney. If you hire an attorney, you should discuss fee and cost arrangements. The fee agreement must be approved by a workers’ compensation judge or the Workers’ Compensation Appeal Board. Your local Bar Association or the Pennsylvania Bar Association can help you find an attorney: (800) 692-7375.
If you file a petition with the bureau, you can request an informal conference to try to resolve your issues. If you are not represented by an attorney at the informal conference, your employer is not entitled to be represented either. Informal conference forms are available from the Claims Information Helpline.
Workers’ compensation judge decisions can be appealed to the Workers’ Compensation Appeal Board and then to the Commonwealth Court. You will be informed of appeal rights upon receiving the workers’ compensation judge’s decision.
Under the Act, any worker who has filed a petition for total or partial disability benefits or who is receiving such benefits is required to report, in writing to the insurer, any information which is relevant in determining entitlement to, or amount of, compensation including, but not limited to, information regarding the receipt of wages from another employer or from self-employment. The worker is obligated to cooperate with the carrier in an investigation of employment, self-employment, wages and physical condition.
All workers’ compensation reports and forms must be honestly completed to avoid violating Pennsylvania fraud provisions.
If you are an employee, startup business or an existing business hiring for the first time, this should have answered most of your questions. If you still have any unanswered concerns, contact G. C. Weimer Insurance Agencies or:
Commonwealth of Pennsylvania
Department of Labor and Industry
Bureau of Workers Compensation
1171 South Cameron Street, Room 324
Harrisburg PA 17104-2501
As insurance agents we hear the same response from clients when we discuss flood insurance. "I’m not in a flood zone!", "I’m not in a high-risk flood zone!", "We’ve never been flooded before!", or "It’s to expensive!".
The cold, hard fact is your homeowner’s policy does not cover losses due to flooding. You can purchase flood insurance if your community participates in the National Flood Insurance Program (NFIP). You should consider purchasing flood insurance even if you are in an area that is not considered flood-prone. Did you know one-third of all NFIP claims come from outside high-risk flood areas? A flood is the most common form of natural disaster. Homes located in a high-risk flood zone have a 26% chance of being flooded during the life of a 30-year mortgage compared with only a 4% chance of having a fire.
Federal disaster grants often are not enough to cover the damage done by a flood. The average grant is less than $2500.00 and in the past, the maximum grant has only been $12200.00. Disasters must be formally declared by the President before most forms of Federal assistance can become available to you. Ninety percent of all disasters are never declared!!!
Unfortunately, many property owners do not find out until it is too late that property policies don't cover flooding. Don't wait until disaster strikes!!! Contact your insurance agent to inquire about this necessary coverage.
INSURANCE INSIGHTS is an electronic newsletter published monthly by G. C. Weimer Associates, Inc. Information contained herein is accurate to the best of our knowledge and belief as of 5/1/99. If you have a topic of interest for a future issue, e-mail us at info@gcwinsure.com.
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