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Questions and Answers
What does the term 'Cumulative Trauma' specifically refer to?
What does the term 'Cumulative Trauma' specifically refer to?
What does 'Denied Claim' imply in a workers' compensation context?
What does 'Denied Claim' imply in a workers' compensation context?
What is the purpose of a 'Declaration of Readiness'?
What is the purpose of a 'Declaration of Readiness'?
How is the 'Date of Injury' defined in cases of cumulative trauma?
How is the 'Date of Injury' defined in cases of cumulative trauma?
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What role does an 'Impairment Rating' serve in Pennsylvania workers' compensation?
What role does an 'Impairment Rating' serve in Pennsylvania workers' compensation?
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What does Maximum Medical Improvement (MMI) signify in the context of workers' compensation?
What does Maximum Medical Improvement (MMI) signify in the context of workers' compensation?
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Which of the following statements is true regarding a Compromise and Release Agreement?
Which of the following statements is true regarding a Compromise and Release Agreement?
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What is the primary purpose of an Independent Medical Examination (IME)?
What is the primary purpose of an Independent Medical Examination (IME)?
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How can a worker's compensation benefits be modified?
How can a worker's compensation benefits be modified?
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Why might an employee risk their workers' compensation benefits by refusing modified work?
Why might an employee risk their workers' compensation benefits by refusing modified work?
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What is indicated by a law or contract being 'in force'?
What is indicated by a law or contract being 'in force'?
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What is the purpose of a Mail Audit in the context of workers' compensation insurance?
What is the purpose of a Mail Audit in the context of workers' compensation insurance?
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In Pennsylvania, which group is not eligible for workers' compensation coverage?
In Pennsylvania, which group is not eligible for workers' compensation coverage?
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What process allows an injured worker to appeal a denied claim based on disagreements with the employer's assessment?
What process allows an injured worker to appeal a denied claim based on disagreements with the employer's assessment?
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What does a compromise and release settlement entail?
What does a compromise and release settlement entail?
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Which of the following is a reason an employer might challenge a workers' compensation claim?
Which of the following is a reason an employer might challenge a workers' compensation claim?
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What does the classification code in workers' compensation insurance indicate?
What does the classification code in workers' compensation insurance indicate?
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What does the term 'maximum medical improvement' (MMI) refer to in workers' compensation?
What does the term 'maximum medical improvement' (MMI) refer to in workers' compensation?
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Which of the following benefits may not be covered under the benefit structure of a workers' compensation policy?
Which of the following benefits may not be covered under the benefit structure of a workers' compensation policy?
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In what scenario might an injured worker receive a refund from their workers' compensation premium?
In what scenario might an injured worker receive a refund from their workers' compensation premium?
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Why might an employee's lawyer be crucial during the claim process?
Why might an employee's lawyer be crucial during the claim process?
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What can an employer do if they believe a workers' compensation injury did not occur in the workplace?
What can an employer do if they believe a workers' compensation injury did not occur in the workplace?
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What type of benefits is NOT typically included in the workers' compensation benefit structure?
What type of benefits is NOT typically included in the workers' compensation benefit structure?
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What is the purpose of an Agreed Medical Evaluation (AME)?
What is the purpose of an Agreed Medical Evaluation (AME)?
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Which entity is responsible for deciding appeals in Pennsylvania workers' compensation cases?
Which entity is responsible for deciding appeals in Pennsylvania workers' compensation cases?
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In the context of workers' compensation, what does 'AOE/COE' stand for?
In the context of workers' compensation, what does 'AOE/COE' stand for?
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Which of the following best describes the term 'alternative work' in workers' compensation?
Which of the following best describes the term 'alternative work' in workers' compensation?
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What is the main function of the Workers' Compensation Appeal Board?
What is the main function of the Workers' Compensation Appeal Board?
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What does the term 'compromise and release' generally refer to in workers' compensation?
What does the term 'compromise and release' generally refer to in workers' compensation?
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What does 'MMI' stand for, and what does it indicate?
What does 'MMI' stand for, and what does it indicate?
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What is a common outcome of the Agreed Medical Evaluation (AME)?
What is a common outcome of the Agreed Medical Evaluation (AME)?
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Under the Americans With Disabilities Act (ADA), what is required from employers?
Under the Americans With Disabilities Act (ADA), what is required from employers?
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Which of the following statements is true regarding an accepted claim?
Which of the following statements is true regarding an accepted claim?
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Study Notes
Pennsylvania Specific Terms
- Accepted Claim: An insurance company considers a claim valid and covered by workers' compensation. It's not a guarantee of immediate benefits.
- Admitted Claim: Another name for an accepted claim.
- Agreed Medical Evaluation (AME): A medical examination by an unbiased doctor agreed upon by both the injured worker's attorney and the insurance company's attorney. Used in disputes over treatment or injury cause.
- Alternative Work: Light-duty or modified work offered if a physician determines the injured worker cannot return to their original job.
- ADA: Federal law that prohibits discrimination against people with disabilities. Employers may have to offer reasonable accommodations, like modified workspaces, due to job injury.
- AOE/COE: "Arising out of and occurring in the course of employment." Injuries must occur during work hours, work property, or work-related activities to qualify for workers' compensation.
- Appeal Board: Decides appeals of work-related injury, death, or illness decisions from judges across Pennsylvania.
- Applicant: The injured worker.
- Auditor: Initially, workers' compensation insurance premiums are estimated from an employer's payroll. At the end of the policy term, an audit confirms payroll and expenses; those who estimated incorrectly get adjustments (refunds or bills).
- Benefit Structure: Outlines compensation amounts based on injury nature. Medical expenses, temporary disability benefits, and permanent disability benefits are often included.
Pennsylvania Specific Terms (Continued)
- Challenge: Disagreement with or dispute of a workers' compensation claim. Employer may dispute injury seriousness, workplace occurrence, timing, etc.
- Claim Form: Used to report a work injury or illness to an employer.
- Classification Code: A three or four-digit number assigned to businesses or professions based on injury risk. The code system ensures fair premium distribution.
- Compensation: Benefits to cover lost wages due to work-related illness or injury.
- Compromise and Release: A settlement in which the injured worker and insurer agree to a lump-sum payment resolving the claim.
- Contractor: A person who performs work or services for someone else under a contract.
- Current Policy Term: The time an active workers' compensation policy is in effect.
- Cumulative Trauma (CT): Illness or injury resulting from repeated activities or exposure on the job (not a single incident.) Examples include respiratory issues or carpal tunnel syndrome.
- Date of Injury (DOI): Date of the accident in cases of specific events or the date when an employee learns an injury is work-related in cases of cumulative trauma.
- Declaration of Readiness: A form requesting a hearing on a workers' compensation case.
- Delay Letter: Explains the reason for a workers' compensation claim delay and the needed steps to address it.
Pennsylvania Specific Terms (Continued)
- Denied Claim: A claim that the insurance company does not recognize as work related and therefore does not cover.
- Dispute: A disagreement.
- Duty Description: Explanation of employee job functions.
- Exposures: The calculation of the potential financial loss based on aspects like payroll.
- General Contractor: Person hired to manage a construction project.
- Hearing: A legal proceeding to determine if a worker should receive workman's compensation benefits.
- Impairment Rating: Determines the level of disability an injured employee has due to work-related injury.
- Independent Contractor: Someone who works for an individual or business but controls their own schedule and equipment unlike employees (typically ineligible for workers' compensation).
- Independent Medical Examination (IME): A medical examination performed by a company doctor to determine the extent of a work-related injury.
- In Force: Currently legally binding.
Pennsylvania Specific Terms (Continued)
- Lump Sum Settlements: Compromise and release agreements to determine future medical or indemnity exposures and settle claims.
- Mail Audit: Insurance company audit assuring premiums accurately reflect risk.
- Maximum Medical Improvement (MMI): Point at which an injured worker has improved as much as medically possible.
- Modification: Increases or decreases in workers' compensation benefits due to a change in total or partial disability level.
- Modified Work/Mod Job: Alternate work options for injured workers who cannot do their regular job duties.
- Notice of Injury: Documents filed after injury notification.
- Notice of Temporary Compensation Payable (NTCP or TNCP): Notice of employer or insurer agreeing to temporarily cover workers' compensation liability on a work-related injury.
- OSHA: Federal agency that enforces workplace health & safety standards.
- Penalty: Judge may impose penalties if an insurance company violates workers compensation act or with unreasonable delays.
Pennsylvania Specific Terms (Continued)
- Permanent Disability Benefits: Compensation for a work-related injury that permanently disables an employee.
- Permanent Modified Position: A longer-term job an employee can do with work restrictions.
- Permanent Partial Disability Benefits: Pays two-thirds of the employee's wage loss difference due to a permanent disability that impacts work hours.
- Permanent Total Disability Benefits: Full wage replacement, but maximum payments are in effect.
- Policy Term: Time period of workers' compensation policy coverage.
- Reinstatement: Resumption of worker's compensation benefits after pause or termination.
- Specific Loss Benefits: Benefits paid for an injury that results in an impairment like vision or hearing loss, or loss of a specific body part.
Pennsylvania Specific Terms (Continued)
- State Workers' Insurance Fund (SWIF): A state-run worker's compensation insurance provider.
- Supersedeas: Temporary halting or stopping of legal obligations.
- Supplemental Agreement: An alteration of a workers' compensation agreement.
- Termination: The agreement between parties ceases.
- Total Disability: Loss of earnings due to a work injury/illness that prevents the employee from performing any substantial job duties.
- TPD: Temporary Partial Disability: If an employee can return to work, but has restrictions, and earns a lower wage.
- TTD: Temporary Total Disability: If an employee cannot work due to injury/illness.
Pennsylvania Specific Terms (Continued)
- Utilization Review Organization (URO): Group authorized to evaluate the need and reasonableness of medical treatments for injured workers.
- WCAB (Workers Compensation Appeal Board): Administrative board reviewing workers' compensation judge decisions.
- WCJ (Workers Compensation Judge): Hearing officer deciding worker's compensation cases.
- Willful Misconduct: Employer actions that qualify as deceit or wrongdoing that allow a worker to file a lawsuit in addition to worker's compensation claim.
Additional Notes
- Addendum #2: Link to PA's WC Administrator
- Addendum #3: Link to PA's WC Administrator's annual report
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Description
Test your knowledge on specific workers' compensation terms used in Pennsylvania. This quiz covers concepts such as accepted claims, agreed medical evaluations, and legal protections provided by the ADA. Enhance your understanding of how these terms apply to workplace injuries and employer obligations.
