Pennsylvania Workers’ Compensation Lawyer Blog

Utilization Review is the process through which either party, though usually the workers’ compensation insurance carrier, can challenge whether medical treatment is reasonable and necessary. We have addressed this topic on several occasions. When a Utilization Review Determination is received, the party who lost can appeal (by filing a Petition for Review of Utilization Review Determination), and then the matter is heard before a Workers’ Compensation Judge (WCJ).

What if, though, neither Claimant nor Claimant’s attorney are even aware of the Utilization Review Determination? Certainly the insurance carrier cannot use the Determination to not pay for treatment, despite not providing a copy, right? Apparently they can, says Commonwealth Court of Pennsylvania.

In Marek v. Workers’ Compensation Appeal Board (Logistics Express, Inc.), Claimant and Claimant’s attorney only became aware of the Utilization Review Determination when payment for medications was allegedly denied based on a Utilization Review Determination. Claimant’s attorney then even obtained records from the Bureau of Workers’ Compensation, and no Utilization Review Determination was on file. Having no other alternative, Claimant’s attorney filed a Petition for Penalties, for the non-payment of the medications.

We have talked before about the fact that a work injury in PA generally cannot take place during the commute to or from work to be compensable under the Pennsylvania Workers’ Compensation Act. One area where this issue is frequently tested is when an employee is injured in a parking lot. In this kind of case, one must prove that the injured worker is on the premises occupied or under the control of the employer (or upon which the employer’s business or affairs are being carried on), that he or she is required by

the nature of the employment to be present on the employer’s premises, and that he or she sustains an injury caused by the condition of the premises or by operation of the employer’s business or affairs thereon.

For example, the Commonwealth Court of Pennsylvania recently issued a decision in PPL v. Workers’ Compensation Appeal Board (Kloss). Here, the employer offered its employees cheaper parking at one of two parking lots, or offered a similar subsidy for using public transportation. The employer did not own either of the two parking lots, and neither parking lot was restricted to the use of PPL’s employees. The employees of PPL were offered these subsidies, but were not required to accept them, or park in any particular place. Note, however, that PPL did construct a skyway to walk from one of the parking garages to PPL’s building.

Sometimes the dispute in the litigation of a Claim Petition in Pennsylvania is a medical one – whether the injury was caused by the work duties (often seen in a repetitive trauma case, like carpal tunnel syndrome, in a heart attack case, or when degenerative changes are aggravated by work). Other times, though the dispute is whether the injury took place within the “scope and course” of employment. Interestingly, though this is occasionally a threshold issue in a workers’ comp case in PA, the words “scope and course” do not even appear in the Pennsylvania Workers’ Compensation Act – the entire concept of “scope and course” is derived from decisions by the appellate courts in PA.

We have seen cases on this topic when an employee takes a “break” from his or her actual job duties. Another time the concept of scope and course becomes important is when the employee is injury in the employer’s parking lot, before or after his or her shift. Such a case was recently decided by the Commonwealth Court of Pennsylvania in Ace Wire Spring and Form Company v. Workers’ Compensation Appeal Board

(Walshesky).

Whether one was actually in the scope and course of his or her job at the time of a work injury is not an uncommon reason for litigation. This is an issue we have addressed on our blog in the past.

Recently, the Commonwealth Court of Pennsylvania tackled this issue in Wetzel v. Workers’ Compensation Appeal Board (Parkway Service Station). Here, the worker was a manager at a gas station. He had arrived early for his shift to go over a problem with the cash register. Once that issue was completed, the worker was stocking some shelves until his shift was actually started. During this time, a thief came in and attempted to grab money from the register. The worker chased the thief outside. When the thief got in his car, the worker drew a gun and ordered the thief to stop. Unfortunately, the thief elected to instead run over the worker with his car. The worker suffered very serious injuries, which led to his death several months later.

A Claim Petition was filed on behalf of the worker (not a Fatal Claim Petition, because the worker had no wife, children or eligible dependents). The workers’ comp insurance carrier defended the Claim Petition by alleging that carrying a gun was a violation of a positive work order, and also that the worker was no longer in the scope and course of his employment at the time he was injured. The Claim Petition was granted by the Workers’ Compensation Judge (WCJ), but this decision was reversed by the Workers’ Compensation Appeal Board (WCAB), which concluded that attempting to apprehend the thief was outside the scope and course of the job.

We have previously discussed Impairment Rating Evaluations (IREs) in our blog. An IRE is a tool the PA workers’ comp insurance carrier can use to start the clock ticking on the maximum 500 weeks of partial disability available to an injured worker. While an IRE can change the status of an injured worker, from total to partial disability, the amount of the compensation benefits is not changed. A threshold issue in an IRE is whether the injured worker has reached Maximum Medical Improvement (MMI); until this finding is made, an impairment rating cannot be determined.

Since whether the injured worker has reached MMI is a threshold issue for a workers’ comp insurance carrier litigating an IRE in PA, one would think there cannot be a successful IRE without such a finding. One might be wrong.

In Arvilla Oilfield Services, Inc. v. Workers’ Compensation Appeal Board (Carlson), the injured worker suffered a labral tear in his right hip, and also hurt his low back and right shoulder in the accident at work. There was surgery on the hip, followed by a total hip replacement. In addition to other litigation, the workers’ compensation insurance carrier filed a Petition for Modification to change the disability status of the injured worker, based on an IRE.

We previously discussed the decision in Keene v. Workers’ Compensation Appeal Board (Ogden Corp.). Here, the Commonwealth Court of Pennsylvania reversed the Workers’ Compensation Appeal Board (WCAB), which had reversed the Workers’ Compensation Judge (WCJ). Essentially, the Court had found that the workers’ comp insurance carrier had failed to prove the injured worker had “voluntarily removed herself from the labor market.”

Subsequently, after the Supreme Court of Pennsylvania decided the City of Pittsburgh v. Workers’ Compensation Appeal Board (Robinson) case in 2013, the Supreme Court vacated the decision of the Commonwealth Court in Keene, and remanded back to the Commonwealth Court to reconsider the decision in light of the Robinson case.

Upon remand, in a recent decision, the Commonwealth Court of Pennsylvania again reversed the WCAB, and again found the workers’ comp insurance carrier had failed to prove the injured worker had “voluntarily removed herself from the labor market.” This result is not surprising when one considers that the decision in Robinson also found that the injured worker had not “retired.” Indeed, it seems a bit odd that the Supreme Court even vacated the decision in Keene to begin with – the previous decision seemed perfectly consistent with Robinson anyway. Regardless, the result is again comforting to injured workers, as it is more difficult for a workers’ comp insurance carrier to stop benefits merely by alleging that an injured worker retired or voluntarily left the labor market.

You probably knew that almost any injury at work which takes place in PA can lead to benefits under the Pennsylvania Workers’ Compensation Act (other than those employees who work for the Federal Government, U.S. Military, or in the maritime or railroad industries). But, did you know that, under certain circumstances, one can receive PA workers’ comp benefits for an injury which takes place in a State other than Pennsylvania?

This is called “extraterritorial jurisdiction,” and can happen when one of three situations apply. Either the injured worker’s employment is “principally localized” in Pennsylvania, the injured worker is working under a contract of hire made in PA in

employment not principally localized in any state, or the injured worker is working under a contract of hire made PA in employment principally localized in another state whose

A frequent topic of blog entries here is the Uninsured Employers Guaranty Fund (UEGF), which steps in for an employer who (in direct violation of Pennsylvania law) fails to carry PA workers’ compensation insurance. There are many hoops through which an injured worker must jump successfully to obtain benefits from the UEGF.

The PA Workers’ Compensation Act was amended in 2007 to create the UEGF. Under this scheme, when an injured worker knows his or her employer does not have Pennsylvania workers’ comp insurance, he or she must first file a Notice of Claim against the UEGF, then file a Claim Petition against the UEGF. There are time limitations within this process which can derail an otherwise compensable claim, making this area very dangerous for the injured worker who does not have an attorney.

For example, under the Act, an injured worker has 45 days from when he or she “knows” that his or her employer failed to carry workers’ comp insurance. This time limit can be devastating to a case, as was the situation in Pennsylvania Uninsured Employers Guaranty Fund v. Workers’ Compensation Appeal Board (Lyle and Walt & Al’s Auto & Towing Service). Here, the injured worker, a mechanic, suffered a compression fracture of his thoracic spine while doing his job on July 14, 2008. The injured worker filed the Notice of Claim against the UEGF on October 7, 2008, a few days after receiving a letter from the PA Bureau of Workers’ Compensation, suggesting his employer may have not had insurance coverage.