Challenging a Work Diagnosis in a PA Workers Comp Case
If you are an injured worker in Pennsylvania (or even if you live outside of PA, but were injured in PA and thus subject to the PA Work Comp Act), you will want to look at the Notice of Compensation Payable– this is a key document that is issued and filed by the work comp carrier or third party administrator, which admits that a work injury took place and delineates the nature of the injury, among other information. This document should be filed within 21 days of the date you gave notice of your work injury. As such, adjustors usually don’t have much in the way of medical records. They may have a report from a panel doctor claiming the injury is a “low back sprain or strain”. The Notice of Compensation Payable is a unilateral document, filed by an adjustor, not an injured worker or a doctor, and it is issued quickly after an injury is accepted as compensable- and therefore, it almost always lists a generic diagnosis such as “strain”, “sprain”, or “contusion” of whatever body part is at issue.
The Notice of Compensation Payable (NCP) is a controlling document in a Pennsylvania Work Comp case. This means that it tells the parties what the obligation is for the insurer until otherwise modified by Stipulation, Supplemental Agreement, or Court Order. If your Notice of Compensation Payable says that your injury is a low back strain, but your doctor’s records reflect a herniation at L5-S1, then the insurer will likely win an argument before a Work Comp Judge that it does not have to pay for the treatment because the Notice of Compensation says low back strain.
So, how do you fix this seemingly unfair situation? It depends. If the insurer is paying the medical bills, despite the mismatch between what the Notice of Compensation Payable says and what your doctor’s records reflect, then it is perfectly fine to let things remain that way. But if the insurer is denying payment, then call an experienced and Certified Pennsylvania Workers Comp Lawyer to pursue the proper diagnoses. This is accomplished by filing a Petition to Review which is heard by a Work Comp Judge over a series of hearings, with medical evidence and testimony from the injured worker presented. There are many complicated rules of evidence and procedural issues involved in litigating a PA Workers Comp case, so it is strongly recommended to seek counsel.
Every case is different. I cannot stress this enough. I’ve seen some cases where the accepted injury is a “low back contusion” on the NCP, but the treating doctor’s records reflect multiple disc herniations, radiculopathy, and chronic pain and the insurer pays everything with no dispute. But I’ve also seen cases where they deny treatment after treatment causing a Petition to Review to be litigated to set the record straight.
It is important to note that the mere filing of a Petition to Review doesn’t mean you win. The insurer will likely set up an Independent Medical Exam to see if they can challenge the work-relatedness of the diagnoses at issue, and the Work Comp Judge will ultimately have to decide which doctor’s opinions are more credible if the parties cannot come to an agreement on the work-related diagnoses. Make sure to confirm with your physician that they are board certified as credentials can become important when a Work Comp Judge is reviewing the matter.
For more information about Pennsylvania Workers Comp and how to get you true injuries recognized, call or email me 7 days a week at (267) 651-7945 (direct dial) or Michael@cardamonelaw.com
Nothing on this blog shall be considered as legal advice. It is general information about PA Workers Comp. For advice about your situation, please contact me.
