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The duties of workers’ compensation insurance companies include investigating the claim and paying out benefits for eligible employees. Additionally, they have 21 days to accept or reject the benefits request after receiving notice of an injury. Other responsibilities of the workers’ compensation insurance company are to pay covered medical expenses and wage replacement benefits. The insurer may also request (and pay for) an independent medical examination and send notices before changing coverage. 

At Krasno, Krasno & Onwudinjo, we understand the obstacles faced by injured workers who are hurt on the job. Often, insurance companies can make the process of requesting benefits more complicated than it needs to be. Our team of Pennsylvania workers’ compensation lawyers have decades of experience fighting back against unfair practices by insurers and employers. 

How Does Workers’ Compensation Insurance Work?

Under Pennsylvania law, workers’ compensation is a specific type of insurance that covers expenses when an eligible employee suffers a job-related injury. The harm can be from a one-time event (e.g., a workplace slip and fall), exposure to harmful substances (e.g., cancer), or repetitive use (e.g., cancer or carpal tunnel syndrome). 

Employees may be eligible to receive benefits such as wage replacement payments, medical expenses, and specific losses. Surviving family members may also qualify for compensation if their loved one dies because of a workplace injury. To claim benefits, the employee needs to file a notice of injury with their employer within 21 days. The employee may have up to 120 days to bring a claim for a work-related accident or condition. 

Workers’ Compensation: Duties of the Insurer

The workers’ compensation insurance company plays an essential role in the claims process. Their responsibilities include investigating the claim, accepting or rejecting it within 21 days, and covering the workers’ medical expenses. The insurance company must also send out timely notices before they make a change in benefits (e.g., increase or decrease the length or amount). If the worker has a total disability, the insurer must also conduct an independent medical examination (in most cases) after 104 weeks. 

Investigate the Claim

After the worker reports the injury to their employer, the insurance company should receive notice of the incident. They will review the information given to them and investigate it. They may talk to the employer and the worker as part of this process. Additionally, the insurance adjusters might look at the employee’s medical records to determine what happened. They’ll use this information to determine whether the injury is covered. 

Accept or Deny Claim Within 21 Days

Insurers and employers have 21 days to investigate the claim and make a decision. Within these 21 days, they should notify the worker whether they accept or reject the claim. In some situations, the employer and insurer may pay temporary compensation during this time. Doing so helps give the worker the support they need (especially if they suffer serious injuries). But sending this temporary support doesn’t mean they accept the claim. In other words, it’s possible for the worker to receive temporary compensation and for the insurance company to deny the claim. 

If the insurer denies the claim, a Philadelphia workers’ compensation attorney can help the employee investigate the denial and file the necessary paperwork to appeal it. They can also prepare them for the workers’ compensation hearing. 

Cover All Reasonably Necessary Medical Treatment

Let’s say the employee’s injury qualifies them for workers’ compensation. In that case, the insurer and employer must pay for all reasonable and necessary medical expenses related to the injury. This is often true even if the employee didn’t miss work because of their condition. Likewise, the employee may receive medical costs for the duration of their injury. For example, if they need a replacement prosthesis down the road, the insurance company may have to pay for this. 

But there are rules about what doctor the employee can see. During the first 90 days after the injury, the employee may have to see a physician on a list given to them by their boss. The employer should have a list of at least six doctors posted on the worksite. If not, the employee may be able to see a doctor that isn’t on the list. The worker should notify their employer and the insurer about what physician they choose to see. 

Pay Benefits to Injured Workers

The insurance company must pay benefits to workers with valid job injury claims. The specific type of benefits they must send depends on the situation. Workers with a named loss outlined in the Pennsylvania workers’ compensation statute may receive a set amount. For example, someone who loses a hand may receive 66 and two-thirds of their wages. They should continue getting these benefits for a total of 335 weeks. 

For others, the wage replacement payments they receive depend on the severity of the injury. For example, someone with a partial disability may continue to get these payments for up to 500 weeks. Furthermore, if a worker dies because of their injuries, their surviving family members may be entitled to receive funeral costs and wage benefits. 

Send Notices of Changes in Coverage

The law requires the insurance company and employer to keep injured workers updated about their claim status and benefits. Anytime they change the amount of or how long the worker receives benefits, they should notify them. The time the insurer has to send out this notice depends on the circumstances. 

For example, if the insurer is paying temporary compensation while investigating the claim, they should send out the change notice within five days after making the final payment. If the insurer changes the tier of benefits (e.g., from total to partial disability), they may need to send the notice within 60 days. 

Conduct an Independent Medical Examination

When a worker has a total disability, they may have to participate in an independent medical examination. The insurance company should send notice of this within 60 days after the worker has received total disability benefits for about 104 weeks. During this evaluation, a physician examines the employee to gauge their level of functioning. If the injury reduces the worker’s function by 35 percent or more, they may continue to receive total disability payments for another 104 weeks. The insurance company may need to pay for this evaluation and any related transportation costs. 

What Can You Do if the Workers’ Compensation Insurance Company Denies Your Claim?

If the insurer denies the benefits request, the worker can challenge this decision. They may accomplish this by filing a claim petition. They may have three years to file this document. During this stage, the employee may submit legal arguments and medical evidence to support their position that they should receive benefits. 

The worker may also have to attend a hearing in front of a workers’ compensation judge. At this hearing, both sides present arguments and evidence about the claim. At the end of the hearing, the judge reviews the information given to them and makes a final decision. 

What Can You Do if the Work-Injury Insurer Is Acting Unfairly?

If the insurance company is acting unfairly, it may be a good idea to reach out to an attorney. Sometimes, insurance companies put up obstacles to employees who are just trying to get the support they need and are entitled to under the law. For example, they may wrongly deny a claim, fail to make timely payments, or refuse to pay interest on unpaid balances. 

When this happens, they are most likely breaking the law, and legal action is necessary. Employees can protect their rights by notifying the Pennsylvania Bureau of Workers’ Compensation and talking to an experienced job injury lawyer. 

Krasno, Krasno & Onwudinjo: Fighting for Injured Workers Since 1936 

When you’re hurt on the job, it threatens your ability to support your family while you heal. Workers’ compensation insurance exists to help injured employees get the financial help they need while they recover. Unfortunately, insurance companies often make it harder for workers to claim these benefits. Instead of going through this process alone, consider partnering with our firm. 

Krasno, Krasno & Onwudinjo has been fighting for Pennsylvanian workers for over 85 years. Our team includes Geoffrey Dlin, a former Workers’ Compensation Judge, who leverages his significant experience to serve as an effective advocate for those who suffer job injuries. His time on the bench gives him key insights into getting workers the benefits they deserve. 

If you experienced a job injury in Pennsylvania, contact us today by calling (844) 919-4016 to schedule a free consultation.