In a separate article, I discuss the remedies potentially available to someone who has been cheated by a workers' compensation insurance company. In this article, I discuss the Top Ten Ways that workers' compensation insurance companies cheat injured workers.
1. Don't pay you.
This may sound obvious, but the motive for this tactic may not be so. You suffer a work-related injury, report the claim, and do everything that's necessary to get paid. The insurance company flatly refuses to do so, knowing that you will be forced to file a workers' compensation claim and await the outcome of your case, which could take quite a long time. Although it is expensive to fight a workers' compensation claim, the insurance company may calculate that starving you will force you to return to work or you accept a settlement far lower than your case deserves. The key to dealing with this tactic is to become an active partner to your attorney to speed up your case, which is described in greater detail in Chapter 8 of The Wounded Worker, "Let's Get This Done: Speeding Up Your Case."
2. Send you to doctors controlled by the insurance company.
Pennsylvania insurance companies develop cozy relationships with "panel doctors" who provide medical care to injured workers for 90 days following the date of first visit to the company doctor. I have written extensively on this topic, but the important point to know here is that these doctors will often treat you for 60 days and then suddenly find that you're fully recovered, ascribing any remaining difficulties you may have to a preexisting degenerative problem or some other non work-related condition. Under most circumstances, the insurance company cannot cut you off at that point. If they are paying you, however, pursuant to a Notice of Temporary Compensation Payable, they have the right to stop paying compensation benefits to you as long as they cease to do so within 90 days of the date that your disability began. You will then be forced to file a claim petition.
3. Limit the description of your work injury.
The obligation of the insurance company to pay medical expenses associated with your work injury is governed by the document called a Notice of Compensation Payable, which, among other things, will contain a description of your injury. Even if your injuries are severe, insurance companies try to minimize the description of injury. For example, if you suffered a herniated disc in your lumbar spine, a very serious condition, the insurance company may describe the injury as a "lumbar strain." If you tear cartilage in your knee, insurance companies will often describe the injury as a "knee contusion." Furthermore, though you may have suffered injuries to multiple body parts, the insurance company often will not accept legal responsibility for injuries other than your primary injury. They minimize the description of injury to give them a chance to "weasel out" of paying legitimate medical bills by claiming that the treatment is not related to the "accepted" work injury. You may have to file a Petition to Review the description of injury if the company refuses to pay for your treatment.
4. Calculate your benefits incorrectly.
Pennsylvania workers' comp insurance companies are usually pretty good in calculating your average weekly wage and benefits rate. To be certain that they're calculating it correctly, however, you need your pay stubs for the 52 weeks before the date your injury occurred. You can then plug this information into the Statement of Wages, which is described in greater detail in this article. Bonuses, incentive, and vacation pay are prorated over the year and added to the average weekly wage. Insurance companies often do not include those amounts. Money advanced or reimbursed to an employee for board and lodging is included in the average weekly wage. Profit sharing is sometimes included, as well as sickness and accident benefits. While fringe benefits are specifically excluded from the wage calculation, the most important thing to remember is that your average weekly wage is calculated based on all sources of employment. If you have a second job, you need to prepare a second Statement of Wages. If you have the slightest doubt about whether your average weekly wage has been calculated correctly, please contact us and we will provide you with a free review.
5. Send you to an “Anything But Independent” Medical Evaluation.
As I've discussed here, Pennsylvania workers' compensation insurance companies often have you undergo rigged Independent Medical Evaluations (IME). Using physicians who earn half a million dollars or more devoting half a day a week to medical/legal work, the insurance company will send you for a supposed "independent" evaluation that is anything but. You may have suffered an acute work injury that resulted in a set of symptoms that have persisted through the date of the Independent Medical Evaluation, but the doctor hired by the insurance company will suddenly proclaim that your work related injury has resolved and that any symptoms you currently have are related to a preexisting degenerative condition. Once that claim is made, the insurance company will file a petition to terminate your workers' compensation benefits. Fortunately, many of these physicians have terrible reputations before the Workers' Compensation Judges. To maximize the chance that you get through an Independent Medical Evaluation, read the advice that we provide here.
6. Stop payment of your weekly benefits.
Under normal circumstances, an insurance company will pay your wage replacement benefits automatically. There are insurance companies, however, who regularly refuse to pay your wage loss benefits in a timely manner. The usual excuse is that it was just some type of bureaucratic mistake. To counter this tactic, keep any paystubs that accompany your workers' compensation check and keep them in order. Take any envelopes you receive the checks in, and put the stubs back in the envelopes. If there is a clear pattern of abuse, you can recover penalties against the insurance company.
7. Harass your medical providers with multiple bill reviews.
As I have described in this article, the insurance company has the right to request that the reasonableness and necessity of your medical treatment be reviewed by a Utilization Review Organization (URO). While a utilization review is pending, the insurance company has no obligation to pay medical bills that are under review, so long as the utilization review has been filed within 30 days of the date they received bills from the particular provider. Once the insurance company has filed the utilization review, many providers will refuse to provide additional treatment. If your provider is subjected to a utilization review, direct them to follow the instructions that I have described here.
8. “Slow pay or low pay” your medical bills.
Under the Act, the insurance company has within 30 days of the date of receipt the obligation to pay medical bills for treatment provided to you for your work injury. Insurance companies often attempt to discourage medical providers from providing treatment by paying them slowly. If providers are not being paid in a timely fashion or are being underpaid, they have several remedies available to them, which are described in greater detail here. Medical providers must keep careful track of when they send their medical bills and when they receive payment. If there is a pattern of abuse by the insurance company, penalties can be assessed.
9. Delay payment of wage loss benefits to get you to seek other benefits.
The Pennsylvania Workers' Compensation Act gives the workers' compensation insurance company the right to take a credit for certain types of benefits, including unemployment compensation benefits. Though they have the obligation to begin payment of wage replacement benefits to you within 21 days of the date of onset of your disability, insurance companies will often delay making a decision on your claim, hoping that you will apply for unemployment compensation benefits. Because the insurance company is entitled to reduce your workers' compensation benefits by an amount equal to your net benefits, companies will often delay payment so that they can reduce the amount they must pay you.
10. Take credit for gross rather than net benefits.
In addition to unemployment compensation benefits, Pennsylvania workers' compensation insurance companies are entitled to take credit for certain other types of benefits you may receive while you're out in connection with a work injury, including sickness and accident and short term disability benefits, if the premiums for this coverage were paid by the employer. The insurance company is entitled to take credit for net (after tax) benefits and not gross (before tax) benefits. The most common situation will be when you receive unemployment compensation benefits. Make sure that the insurance company reduces your workers' comp benefits by an amount equal to the actual amount you receive after taxes are deducted. Otherwise, the insurance company will be cheating you.