Pennsylvania Workers' Compensation Terms & Acronyms PDF

State Specific Terms Pennsylvania 2  PENNSYLVANIA SPECIFIC TERMS Accepted Claim An accepted claim is one that an employer’s insurance company considers valid and covered by worker’s compensation. However, an accepted claim is not a guarantee of immediate benefits. T...

State Specific Terms Pennsylvania 2  PENNSYLVANIA SPECIFIC TERMS Accepted Claim An accepted claim is one that an employer’s insurance company considers valid and covered by worker’s compensation. However, an accepted claim is not a guarantee of immediate benefits. There may be other problems or delays. Admitted Claim Another name for an accepted claim. Agreed Medical Evaluation (AME) In cases where there is a dispute over a doctor’s recommended treatment plan or the cause of an injury, a worker may need an agreed medical evaluation. An AME is a medical examination by an unbiased doctor who is agreed upon by both the injured employee’s worker’s compensation attorney and the insurance company’s attorney. Since such evaluations can have a significant impact on the outcome of a claim, the injured worker should have an experienced workers’ comp lawyer who can ensure the chosen doctor will not favor the insurance company. Alternative Work If a physician determines that an injured worker cannot return to the job he had at the time of his injury, an employer may have the option of offering alternative work. Often referred to as light-duty or modified work, alternative work must meet the employee’s medical restrictions, ADA The Americans With Disabilities Act is a federal law that prohibits discrimination against people with disabilities. If an employee has a permanent physical restriction due to an on-the-job injury, an employer may have to offer them a reasonable accommodation under the ADA, such as a modified workspace or schedule. 3  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) AOE/COE The acronym AOE/COE stands for ‘arising out of and occurring in the course of employment. It refers to the fact that injuries must occur during work hours, on work property, and during work-related activity for them to qualify for workers’ compensation coverage. Appeal Board The Workers’ Compensation Appeal Board decides appeals of decisions from judges throughout Pennsylvania in cases involving work-related injuries, death, or illness. The board decides whether a judge committed an error of law or whether there was sufficient evidence to support the original decision. There are time limits involved in every step of the workers’ comp appeals process, along with paperwork to file, and data and evidence to collect. That’s why anyone filing an appeal should enlist the support of an experienced worker’s comp lawyer. Applicant The injured worker Auditor A workers’ comp insurance premium is initially based upon an estimate of an employer’s payroll. At the end of the policy term, the insurance carrier will request an audit to confirm the payroll, the classification of all employees, overtime, and other expenses, as well as payment to subcontractors. Employers who overestimated their total payroll for the previous year will get a refund or a credit. Those who underestimated will get a bill. Benefit Structure The benefit structure is the part of the workers’ compensation insurance policy that defines what compensation an employee may receive when they sustain injuries on the job. Depending on the nature and severity of the injury, those benefits may include medical expenses, temporary disability benefits, permanent disability benefits, vocational rehabilitation services, and death benefits. 4  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Challenge Challenge means to disagree with or dispute. In the case of a workers’ comp claim, an employer may challenge or attempt to deny a claim if they believe the injury isn’t serious or didn’t occur in the workplace, if there were no witnesses to the injury, if the claim isn’t filed in time, or if there are discrepancies between medical records and the accident report. An employee’s worker’s comp lawyer can help compile the evidence necessary to support a claim. Claim Form The form an employee uses to report a work injury or illness to an employer. Classification Code Any business or profession that could potentially expose an employee to injury has a classification code, a three- or four-digit number assigned based on the amount of risk involved and the base premium cost of workers’ compensation insurance. The code system ensures the fair distribution of insurance costs, with riskier businesses paying higher premiums. Compensation The benefits a worker will receive from a workers’ comp claim to cover lost wages due to a work-related illness or injury. Compromise and Release Compromise and release is a type of workers’ compensation settlement in which the injured worker and the employer’s insurance company agree on a lump-sum payment. The agreement also releases the insurance company from any further liability or future payments related to the worker’s injury or illness. Contractor A person who conducts work or a service for someone else under the terms of a contract. Current Policy Term The period of time that an active workers’ compensation policy is in effect. 5  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Cumulative Trauma (CT) Cumulative trauma refers to an illness or injury that occurs due to repeated activity or exposure on the job, rather than one specific incident or accident. Such injuries might include respiratory issues from constant exposure to chemicals or carpal tunnel syndrome from repetitive typing over time. Date of Injury (DOI) In cases where the injury is the result of a specific event or accident, the date of injury is the date the accident occurred. In the case of cumulative trauma, the date of injury is the date the employee learns that their illness or injury is work-related. Declaration of Readiness A declaration of readiness is a form requesting a hearing of a workers’ compensation case before a judge. Delay Letter If something delays a workers’ comp claim, the claims administrator will send a delay letter explaining the reason for the delay as well as any additional information they may need to move the claims process forward. Denied Claim If a worker’s compensation claims administrator determines that a worker’s illness or injury is not job-related, and therefore not covered by workers’ compensation insurance, they will deny the claim. There are many reasons for a denied claim, but it is important to remember that no denial is final. An experienced workers’ comp attorney can often file a successful appeal. Dispute A dispute is a disagreement. In the case of workers’ compensation claims, an employer or an insurance company may dispute how the injury or illness occurred or the benefits an injured employee deserves. Duty Description An explanation of the job functions an employee performs. Exposures a measure of vulnerability to loss; the basis against which losses are compared; i.e., the payroll or other measure of risk, by class 6  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) General contractor A person hired to oversee or manage a building project. Hearing A proceeding before a judge who reviews the evidence and determines whether or not a worker will receive workman’s comp benefits. Impairment Rating In Pennsylvania, impairment ratings determine how disabled an injured employee is due to their workplace injury. If an evaluation determines a worker is disabled less than a certain percentage, it could limit the amount of their workers’ compensation benefits they receive. Independent Contractor An independent contractor does work for individuals or businesses for payment, but unlike an employee, they typically use their own equipment and determine where and during what hours they complete their contracted work. Under Pennsylvania law, independent contractors are not eligible for workers’ compensation coverage. Independent Medical Examination (IME) Medical examination performed on an injured worker by a company doctor usually for the purpose of showing that a work-related injury no longer exists or that it has decreased in severity In Force If a law or contract is in force, it means it is currently in effect and people must obey it. Lump sum settlements Compromise and Release Agreements are used to resolve future medical exposure, future indemnity exposure or both. If the parties agree, a structured settlement may be used to pay the claim. All settlements are subject to the requirements of Medicare 7  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Mail Audit Insurance companies perform audits to ensure that the premiums employers are paying for their workers’ compensation insurance accurately reflect the risk. They verify that employers correctly classify their employees and that payrolls are accurate. Mail audits are the simplest form of such audits and allow businesses to complete a form and submit it to the insurance company. Maximum Medical Improvement (MMI) Maximum medical improvement means a doctor has determined that an injured worker has improved as much as medically possible and is not likely to have any further significant improvement in the future. Modification Increase or reduction in the amount of workers compensation benefits payable because a disability either increases from partial to total or decreases from total to partial Modified Work/Mod Job If an injured worker is unable to return to normal duties, an employer may offer them modified, or light-duty work that accommodates their work restrictions. As long as the employer is acting in good faith, it is typically not wise for an employee to turn down modified work since it could jeopardize their workers’ compensation benefits. Notice of Injury Employers file one of these after they are notified of an injury by an injured worker. Notice of Temporary Compensation Payable (NTCP or TNCP) Temporary acceptance of liability for work-related injury filed by the employer or the employer's insurance carrier 8  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Notice of Workers Compensation Denial (NCD) Notice of denial of a work-related injury filed by the employer or the employer's insurance company. After a notice of workers compensation denial is filed, an injured employee has three years from the date of injury to file a claim petition. OSHA The Occupational Safety and Health Administration is a federal agency that sets and enforces workplace health and safety standards to reduce illnesses and injuries. Those can include everything from requiring employers to provide proper safety equipment to establishing exposure limits for toxic substances. OSHA also offers safety seminars and training, as well as onsite consultations to identify workplace hazards. Penalties for failing to comply with OSHA standards can include fines, legal action, and halting business operations. Penalty A judge may award penalties to an injured worker should an insurance company violate the Pennsylvania Workers Compensation Act. Such violations might include failing to investigate a claim, refusing to pay medical bills, or stopping weekly checks without reason. A judge may award an employee up to 50% of the compensation award, plus interest, for excessive and unreasonable delays. Permanent Disability Benefits Compensation paid to an employee who has suffered a work-related injury or illness that results in permanent disability. Permanent Modified or Alternate Position Rather than a temporary position for a worker who is still recovering from injury or illness, a permanent modified position is a long-term job that an employee can perform under medical restrictions when a doctor determines they have a permanent work-related disability that will make it impossible for them to return to their original job. 9  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Permanent Partial Disability Benefits In cases where a worker suffers a permanent partial disability and returns to work for fewer hours and less pay, PPD benefits pay two-thirds of the difference in lost wages. A worker can collect partial lost wage benefits for a maximum of 500 weeks. Permanent Total Disability Benefits In cases where a work-related injury or illness leaves a worker unable to return to employment of any kind, PTD benefits pay two-thirds of their average weekly salary at the time of injury up to a certain maximum, along with payment of injury-related medical bills, for as long as they live. If they also receive Social Security disability benefits, the total of both benefits can’t exceed 80% of their earnings. Policy Term The time period for which a workers’ comp insurance policy provides coverage. Reinstatement Resumption of payment of workers compensation benefits after suspension or termination of benefits due to a recurrence of the disability which results in a loss of earning power Specific Loss Benefits Benefits that are paid if a work-related injury results in loss of vision or hearing, or the loss of a specific body part. The injury does not have to be disabling, but the worker must prove he or she suffered at least 50% loss of use. State Workers’ Insurance Fund (SWIF) An issuer of workers’ compensation insurance created by the Workers’ Compensation Act; part of the Pennsylvania Department of Labor and Industry Supersedeas The temporary staying or stopping of an obligation, in workers’ compensation matters this typically is relates to the insurer’s obligation to continue pay benefits to the claimant during litigation 10  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Supplemental agreement An agreement between an injured worker and the employer or insurer entered into after a notice of compensation payable is issued or after an agreement for compensation has been signed which modifies, suspends, reinstates, or terminates the benefits then being received under the notice of compensation payable or under the original agreement between the parties Termination Cessation of the claimant’s entitlement to workers’ compensation benefits, typically based upon the claimant’s full recovery from the work injury. Total disability The total loss of earning power/wages as a result of the work injury TPD: Temporary partial disability Some employees can return to work, but are unable to perform their job as they could before the accident – and are therefore paid a lower wage. For example, a worker who did heavy lifting may be restricted to light duty work. TPD benefits pay 2/3 of the difference in average weekly wages (before and after the accident). TTD: Temporary total disability Employees who are unable to work while they are getting medical help have a temporary total disability and are entitled to 2/3 of their average weekly wage up until the time they can return to work or the time they reach maximum medical improvement. Utilization Review Organization (URO) An organization authorized for the purpose of determining the reasonableness or necessity of medical treatment administered to workers with work-related injuries 11  PENNSYLVANIA SPECIFIC TERMS (CONTINUED) Willful Misconduct In Pennsylvania, injured workers typically can’t file a lawsuit against their employer as long as the employer provides workers’ compensation insurance. However, there are some exceptions if the worker can show that the employer engaged in willful misconduct, such as fraud, misrepresentation, or misleading investigators. Workers Compensation Appeal Board (WCAB) An administrative board that exercises is powers and duties as an appeal board which reviews the legal decisions of workers compensation judges Workers compensation judge (WCJ) The hearing officer appointed to conduct hearings in an administrative proceeding for workers compensation cases 12 Addendum #2- Link to PA’s WC Administrator Department of Industry & Labor https://www.dli.pa.gov/Businesses/Compensation/WC/Pages/default.aspx 13  Addendum #3- Link to PA’s Worker’s Comp Administrator’s annual report https://www.dli.pa.gov/Individuals/Workers-Compensation/publications/Documents/2021%20WC%20Annual%20Report.pdf 14