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.
In a Pennsylvania Work Comp case, the employer/insurer usually issues a Notice of Compensation Payable when they accept the fact that a work injury took place. On this key, controlling document, there is a place in the upper left hand corner to list “body parts affected” and “type of injury”. In the vast majority of cases, the insurers will list the most benign diagnoses- such as a “lumbar strain/sprain” or “contusion”. There are several reasons for this. First, the NCP must be issued (although many times it comes later) within 21 days from when the injured worker gave notice of his/her work injury. In this early stage, the medical treatment hasn’t been very well developed. Also, the injured worker usually treats with the Employer’s Panel Doctors- who tend to minimize the nature of the injuries, naturally. In addition, since the insurer issues the NCP unilaterally, they are not going to put themselves on the hook for serious injuries- although in some cases, where the nature of the injury is clear- such as a fractured bone after a fall- they will. Because most people have some degree of arthritis, the insurers hope that a doctor will label the work injury a “contusion” or “sprain/strain” while pinning the causal connection of the injury after a few months to this underlying condition.
So, if you have been injured at work, what should you do if the insurer minimizes the nature of your injury? Talk with an experienced Pennsylvania Workmen’s Comp Lawyer. If your medical bills and wage loss benefits are being paid appropriately, I tend to let the description stand. However, if medical bills or wage loss isn’t being paid, I will file a Petition to Review to challenge the description of the work-related diagnoses. Or, if the insurer files a Petition to Terminate, Modify, or Suspend– efforts to reduce their liability-then I will counter with my Petition to Review at that time.
Why is the description of the work injury important? There are a host of reasons. First, you don’t need unpaid medical bills and credit problem which can result when the insurer refuses to pay medical bills for a work-related back surgery- with them claiming the injury was a mere strain or sprain. Secondly, the value of your case for settlement purposes may be affected by the description of the work injury. For example, if your chronic low back pain has caused a psychological condition such as anxiety or depression, you may want to file a Petition to Review to add these diagnoses, to enhance the value of the case for settlement purposes and/or to have medical coverage for ongoing treatment if no other source of insurance exists.
How do I win a Petition to Review? Talk to your PA Work Comp Lawyer. But generally, the lawyer will take the injured worker’s testimony in addition to testimony from the treating doctor. The insurer will almost always set up an Independent Medical Exam to see if the IME doctor agrees with the allegations. If the doctors disagree with each other- which is quite common- the litigation can take up to a year depending on many factors. (ie, what Judge gets assigned the case, coordinating schedules for doctors’ depositions, delays, etc).
In summary, the description of a PA Work Injury is a critical part of a PA Work Comp case. Don’t let your employer or insurance company dictate what injury is deemed work-related. Get a legal analysis from a Pennsylvania Work Comp Lawyer to determine if and when you should proceed with a challenge to the description of injury.
For more info about Pennsylvania Workers’ Compensation, call Attorney Michael Cardamone directly at (267) 651-7945 7 days a week or email Michael@cardamonelaw.com.
