When an insurance company accepts a work injury, they issue a document called a Notice of Compensation Payable (or a Notice of Temporary Compensation Payable). In this document, there is a section for the injury to be described. The description is extremely important to the injured worker because it will determine their right to medical treatment. The insurance company is only required to pay for medical treatment that is reasonable, necessary, and related to the accepted injury. The less severe the injury they accept – the less the medical treatment will cost that they agree to “cover”. If the injury is described as a minor contusion, sprain or strain – then medical treatment for a more severe injury (such as surgery or expensive diagnostic studies) might be refused by the insurance company. If the injury fails to list a particular body part that was injured, no treatment for that body part will be “covered”.
The Pennsylvania Workers Compensation Act enables a Judge to amend the description of injury upon being presented with sufficient, credible evidence. The burden to prove the injury is incorrect is on the party challenging the description. The type of evidence the injured worker must present depends upon the type of “correction” being sought.
- Was the injury you want to be included suffered at the time of the work incident; or did it happen at a later point in time?
- Was the additional injury something that progressively got worse over a period of time; or did some new incident/injury happen, that would not have happened ‘But For’ the work injury?
By way of several different examples: if the injured worker fell striking their knees, arms, hands and head on the ground, did the insurance company only list a knee and hand injury, leaving out the arms and head? Did the insurance company list the injuries as only sprains and strains, even though the Hospital diagnosed a rotator cuff tear, a displaced knee and a traumatic brain injury?
Six months later while getting physical therapy, the weights crash causing the claimant to suffer an entirely new back injury. Should the insurance company accept or deny these new injuries?
Two more months later, while driving to a new physical therapy location, the claimant is involved in a car accident, suffering a new neck injury. Must the insurance company accept these injuries?
We will accept each and every one of these kinds of claims, but each requires different types of evidence to prove (and convince) the Judge that your claim is legitimate.
Additionally, the type of Amendment may have time limitations on when the injured worker can pursue the change. Failure to challenge the injury description in a timely manner may jeopardize your rights to do so in the future. In some situations, a delay might only impact whether the Judge finds the evidence believable. A time delay between the incident and filing a Petition may cause the Judge to doubt the injury is related to the work incident. In other situations, a delay could entirely prohibit the petition from even being presented. See e.g. Cinram Manufacturing v. WCAB (Hill), 975 A.2d 577 (Pa. 2009); Weney v. WCAB (MAC SPRINKLER SYSTEMS), 960 A.2d 949 (Pa. Cmwlth. 2008); Berro v. WCAB (TERMINIX INTERN.) 645 A.2d 342 (Pa. Cmwlth. 1994)
Finally, the “value” of the case for settlement can be dramatically affected by an incorrect description of injury.