When an employee is injured in the course and scope of their employment, they are generally able to collect workers’ compensation benefits under Pennsylvania State law. However, there are four major categories of workers’ compensation benefits, and which one(s) you are eligible for will depend on the specifics of your case. These categories are: Medical expenses, wage loss benefits, specific loss benefits, and death benefits. The vast majority of claims will involve medical expenses and wage loss benefits. Specific loss and death benefits are reserved for special circumstances.
Workplace injuries often result in medical expenses which are then paid for by your employer’s insurance company. These expenses cover things such as doctor visits, surgery, hospital expenses, prescription medications, diagnostic tests, and injections. For doctor visits specifically, keep in mind that there may be limitations on which doctors you can see within the first 90 days after your injury if you want your employer’s insurance to pay for it. These expenses may also include medical devices, physical therapy, acupuncture, massages, and work hardening, but insurance companies often challenge payment of these costs.
There are no arbitrary or set time limits for how long an injured worker may receive medical expense payments. These payments from the insurance company can begin immediately once they have received a bill — as long as there is a timely notification from the treating physician and the billing is done properly. The payments can then continue until they are no longer needed or are proven to no longer be reasonable, necessary, or related to the work injury.
What Medical Expenses does Workers’ Compensation Cover?
Learn more about what the term “medical expenses” includes and how to qualify for coverage.
Wage loss benefits can be separated into two main types: Temporary total disability and partial disability.
Temporary total disability (TTD) benefits allow an injured worker to claim a portion of their pre-injury average weekly wage based on the State’s compensation rate calculation. The amount of compensation and how it is calculated depend on your pre-injury average weekly wage. Additionally, these benefits can be unlimited in duration as long as you can prove disability due to your work injury. For example, as long as you can keep proving that your back injury sustained at work is preventing you from working, you may be compensated for your lost wages.
Partial disability benefits are generally paid out to injured employees who are still able to work in a lesser capacity after their workplace injury. If you make less money in your new role than you did in your old one, partial disability benefits are there to help make up the difference. How much you receive is based on the State’s compensation rate calculation, which generally speaking means ⅔ of the difference between your pre- and post-injury average weekly wages.
Partial disability benefits are limited to 500 weeks per claim. There are two main methods for changing disability benefits from total to partial. The first one is when you are working with a partial wage loss. The second is an IRE. If you are out of work for 104 weeks, you may be required to undergo an IRE to measure the percentage of your physical impairment based on the condition of your whole body. Anyone who is found to have less than 35% of whole body impairment, which is most injured workers, may have their benefits switched from total to partial, thus imposing the 500 week limit. (Note, there are current ongoing challenges to the constitutionality of the IRE provisions.)
Specific loss can refer to the loss of a body part, the loss of use of a body part for all practical intents and purposes, or scarring and disfigurement to the face, head, and neck. Compensation received for specific loss injuries is based on the application of a statutorily established number of weeks based on the type of your specific loss times your specific compensation rate based on your average weekly wage. There may also be an additional number of weeks of benefits for a “healing period” associated with your injury. Generally, these benefits are paid out weekly over time, rather than in a lump sum. Lump sum payouts can be voluntarily negotiated by the parties.
The more severe the loss, the larger the statutory award for benefits. For example, losing an arm will award more weeks of compensation than losing a finger. Even different fingers are worth different amounts. Body parts which are covered by specific loss include legs, feet, toes, arms, hands, fingers (and thumbs), ears, and eyes. Notably, body part loss includes both amputation and loss of the use of the body part for all practical intents and purposes. This means that even if your body part has not been severed, if you can no longer use it, such as if it has been crushed, it may still count as a specific loss depending on the severity of the injury and how much function is retained in that body part.
Hearing loss is another type of specific loss injury. Work related hearing loss can either be associated with a traumatic (single) event or occupational exposure. However you will not only need to prove that you suffer from hearing loss, but that the hearing loss is a direct result of your working conditions. An audiogram will be used to prove your hearing loss, and the loss must exceed 10% for your claim to be compensable. The amount of compensation you will receive is based on your percentage of hearing loss attributed to work. These claims can be difficult to prove, as hearing loss is commonly associated with aging and other non-work related factors.
Scarring and disfigurement to the head, face, and neck counts as a specific loss as well. Compensation depends on the size of the scar (or extent of the disfigurement) and how noticeable it is (the color, placement, etc.). The award is somewhat within the discretion of the Workers’ Compensation Judge who views your disfigurement.
Death benefits are paid to the dependent heirs of the decedent, and or the spouse until they remarry or enter into a meretricious relationship. Dependent children are those who relied on the decedent and their income; they are usually minors, but this is not always the case. Dependent parents or other family members may also be entitled to benefits in the absence of a spouse or children.
There are two parts which make up death benefits. The first part covers funeral expenses, and is an amount adjusted over time depending on the date of death. The second part is based on a statutory formula using the decedent’s average weekly wage and the type of survivor.
The four major categories of workers’ compensation benefits are medical expenses, wage loss benefits, specific loss benefits, and death benefits. While the first two types of benefits are present in most claims, the latter two are only present under specific circumstances. My name is Geoffrey Hillsberg, and I have been solely practicing workers’ compensation law in the state of Pennsylvania since 1995. If you or someone you love has been injured while working, contact my law office today. I will fight for your right to compensation for your injuries.
The advice offered above is general in nature and may not be applicable to every case. Consultation with an attorney is highly recommended. Reliance on this advice does not represent the formation of an attorney-client relationship in the absence of a fee agreement with Mr. Hillsberg.
Fill out the form with a brief description of your situation or call me at (610) 566-0600 and I’ll be in touch to schedule a free consultation.