Pennsylvania Workers’ Compensation Lawyer Blog

When a PA workers’ compensation insurance carrier wants to “terminate” the workers’ comp benefits of an injured worker, the insurance company must prove that the injured worker has fully recovered from his or her work injury. What constitutes the “work injury” is usually what is described on the Notice of Compensation Payable (NCP)[the document used by the insurance carrier to accept a claim]. While this is the rule, there are always exceptions.

A recent decision rendered by the Commonwealth Court of Pennsylvania, Julio Paz Y Mino v. Workers’ Compensation Appeal Board (Crime Prevention Association), dealt with the exception to the rule. After Mr. Mino was injured, an NCP was issued, describing the injury as lumbar sprain and strain. A Petition to Terminate was filed by the workers’ comp insurance carrier. The Workers’ Compensation Judge (WCJ) denied this Petition, finding the testimony of the injured worker’s doctor more credible than the doctor who performed the Independent Medical Examination (IME) for the insurance company. Though the WCJ did not formally state he was amending the NCP (nor was a Petition to Review, the Petition used to amend an NCP, filed), he noted the diagnosis rendered by the injured worker’s doctor, specifically, an aggravation of pre-existing lumbar stenosis and a lumbar radiculopathy.

The workers’ compensation insurance carrier then filed a second Petition to Terminate (Persistent little devils, eh?). Since the first WCJ did not formally amend the NCP, the second WCJ did not include the entire diagnosis found by the first WCJ. In so doing, the second WCJ found that Claimant had fully recovered and granted the Petition to Terminate.

In PA Workers’ Compensation, when the workers’ comp insurance carrier feels the treatment rendered to an injured worker is no longer “reasonable” or “necessary,” the relief is for the insurance company to file for Utilization Review (UR). When a UR is requested, the PA Bureau of Workers’ Compensation randomly assigns a Utilization Review Organization (URO) to review the treatment and decide if it is “reasonable and necessary.” Once a UR is requested, until treatment is found to be reasonable and necessary, the workers’ comp insurance carrier does not have to pay for the treatment under review.

When a UR is requested, the workers’ comp insurance carrier must specifically state both the provider under review and the treatment being challenged. A UR only pertains to the provider named, and the treatment as issue. In other words, if a UR finds treatment with a specific orthopedic surgeon not reasonable or necessary, the workers’ comp insurance carrier no longer is responsible for the treatment of that doctor; however, that does not mean the workers’ comp insurance carrier is not responsible for treatment with a different orthopedic surgeon. The workers’ comp insurance carrier would have the obligation to file another UR request, and the process would start all over.

But, what if the provider is not a physician at all, but a physical therapist working under the direction of a physician at the same facility? This was the issue presented to the Commonwealth Court of Pennsylvania in MTV Transportation v. Workers’ Compensation Appeal Board (Harrington).

Generally speaking, employees in Pennsylvania are not entitled to workers’ compensation benefits when the employee is injured commuting to work (known as the “Coming and Going” rule).

There are four notable exceptions to this rule. They are that the injured worker: (1) has an employment agreement which includes commuting to and from work; (2) has no fixed place of employment; (3) is hurt while on a “special assignment” for employer; or, (4) is furthering the business of the employer.

The Supreme Court of Pennsylvania, in Peterson v. Workmen’s Compensation Appeal Board (PRN Nursing Agency), decided in 1991, has already told us that an employee of a temporary agency has no fixed place of employment. In that case, the Supreme Court said, “[a] temporary employee, who is employed by an agency, never has a fixed place of work.” The Supreme Court then concluded, “when [an] agency employee travels to an assigned workplace, the employee is furthering the business of the agency. Therefore, . . . as a matter of law, [Peterson] had no fixed place of work . . . and her injury occurred while she was in furtherance of her employer’s business.”

As discussed in previous blog entries, back in the old days (before the 1996 changes to the Pennsylvania Workers’ Compensation Act), if a workers’ comp insurance carrier wanted to cut a claimant’s worker’s compensation benefits, the carrier had to refer the person to an actual job lead. If the job lead did not result in employment, workers’ compensation benefits continued.

In 1996, the system was changed to one more like that used for Social Security Disability. Rather than sending the injured worker to an actual job opening, at an actual employer, a vocational specialist, hired by the insurance carrier, gathers theoretical information and compiles an Earning Power Assessment (EPA, also known as “Labor Market Survey,” (LMS)).

The workers’ comp insurance carrier then can take this EPA/LMS to a Workers’ Compensation Judge (WCJ), and ask that the injured worker’s compensation benefits be modified, based on the jobs shown to be “available” in the general geographic area in which the injured worker resides.

We have seen in recent decisions rendered by the Commonwealth Court of Pennsylvania a trend toward punishing injured workers in PA who take any type of disability or retirement package, almost, seemingly, without regard for the reasons.

In fact, earlier this month we posted a blog entry regarding Duferco Farrell Corp. v. Workers’ Compensation Appeal Board (Zuhosky), where the Court followed this very trend. So, the decision rendered by the Court recently in Polis v. Workers’ Compensation Appeal Board (Verizon Pennsylvania, Inc.), was received as a pleasant surprise.

Here, Mr. Polis had injured his knee (and had surgery for the knee). Eventually, Mr. Polis went back to work, at a light duty job. After some period of time, the employer discontinued the light duty work, leaving Mr. Polis without a position within his physical restrictions. As we commonly see in these situations, Mr. Polis investigated what options were available to put food on his family’s table.

As discussed in previous blog entries, for several years now, the Courts in PA have caused decisions by Pennsylvania’s injured workers to have drastic consequences beyond what an injured worker could reasonably expect.

Because of the decision in Pennsylvania State University v. Workers’ Compensation Appeal Board (Hensal), rendered by the Commonwealth Court of Pennsylvania in 2008, the simple act of filing for a pension can easily lead to a loss of workers’ comp benefits for an injured worker.

Well, don’t look now, but Commonwealth Court has struck again. Now, an injured worker who testified credibly that he is NOT retired, that he had NOT filed for a retirement pension from his employer (even though one was available), that he would go back to work if a job was available within his physical restrictions and that he filed for Social Security Retirement benefits only after the workers’ comp insurance carrier refused to reinstate his benefits, has been found by the Court to have voluntarily removed himself from the labor market, ending his entitlement to PA workers’ compensation indemnity (wage loss) benefits.

This being a free Country, a workers’ compensation insurance company in PA cannot “force” an injured worker to get any medical treatment. However, the Pennsylvania Workers’ Compensation Act permits the suspension of workers’ comp benefits if an injured worker refuses “reasonable” medical treatment (Known as a “Forfeiture” Petition). Often in those cases, the issue is whether the treatment at issue (anything from carpal tunnel release, to lumbar fusion, to total knee replacement, to epidural steroid injections) is actually “reasonable” in any particular case.

An interesting aspect of this issue was recently examined by the Commonwealth Court of Pennsylvania in Bereznicki v. Workers’ Compensation Appeal Board (Eat ‘N Park Hospitality Group). In that case, the question was whether the proposed treatment had to actually be intended to return the injured worker to gainful employment. In a decision surprising to many, the Court held that the treatment did NOT have to be designed to return the injured worker to gainful employment to lead to a suspension of benefits.

The concept of a “Forfeiture Petition” makes sense; it is designed to keep an injured worker from refusing treatment which would put the injured worker back on the job (in reality, however, I doubt many folks would truly refuse treatment that would make them better, but the insurance industry seems to disagree with me). But, to me, that is the point – the fact the injured worker could return to work.

Under the Pennsylvania Workers’ Compensation Act, an insurance carrier cannot just stop, or even change, payments of workers’ comp benefits. Any change made by the workers’ compensation insurance carrier in PA, without permission of the injured worker, or a Workers’ Compensation Judge (WCJ), may be met with an assessment of penalties. This leads us into an examination of how an insurance carrier can try to reduce such benefits.

When a workers’ comp insurance carrier receives evidence that the medical condition of an injured worker has changed, the carrier must file a Notice of Ability to Return to Work. The law tells us that this document must be filed before the workers’ compensation carrier can file a Petition to Modify or Suspend (workers’ comp benefits), based on some wage-earning capacity.

In the case of an injured worker actually going back to work, the insurance carrier has a period of time to file a Notification of Modification or Suspension. This document sets forth the allegations regarding the wages now being earned by the injured worker. If this document is not challenged in court by the injured worker, the effect is the same as if the injured worker agreed to the terms recited within the document (as if the injured worker had agreed to those terms in a “Supplemental Agreement.”). If the workers’ compensation insurance carrier does not file the Notification of Modification or Suspension in a timely fashion, then the insurance carrier must file a Modification, or Suspension, Petition and litigate the matter before a WCJ.