THIS ARTICLE IS INTENDED TO SUPPORT THE READER’S AWARENESS AND UNDERSTANDING. IT IS NOT LEGAL ADVICE. IF THE READER SEEKS LEGAL ADVICE CONCERNING HIS OR HER PARTICULAR SITUATION, HE OR SHE SHOULD SEEK OUT AN ATTORNEY IN A LAWYER CLIENT RELATIONSHIP.
If A Self Insuring Employer And/Or Its Third Party Administrator Excessively Delays And Unreasonably Disregards Workers’ Compensation Act Rules Of Procedure Under Sections 406.1, 413, and 422 Upon An Employee’s Notice Of Injury Reinstatement , That Employer Shall Be In Default Of Workers’ Compensation Payments Under Section 428, With The Entire Balance Of Compensation Payable To That Employee Along With Accrued Interest And Penalty , As Provided In Sections 406.1 and 435. Such A Self Insuring Employer And Third Party Administrator Would Also Be Subject To Revocation Or Suspension Of The Respective Privileges Granted To Each Of Them By The Pennsylvania Department Of Labor And Industry, As Provided Under Section 441 of The Act.
A. Once A Self Insuring Employer Is Notified Of An Employee’s Reinstatement Of His Workers’ Compensation Injury Based On His Increased Disability, It Has A Legal Duty To Promptly Investigate That Injury And Proceed To Promptly Pay Compensation Due To That Employee , At Least Pursuant To A Notice Of Temporary Compensation, On Forms Prescribed By The Pennsylvania Department Of Labor And Industry And Furnished By That Employer Insurer, Not Later Than The 21st Day After The Employee’s Notice To The Employer Of His Reinstated Injury Claim, With Interest Accruing On All Due and Unpaid Compensation Thereafter At The Rate Of Ten Per Centum Per Annum.
If Such Employer Wishes To Controvert The Employee’s Reinstatement Of Injury Notice, It Has A Legal Duty To Promptly Notify The Employee Of That Fact Not Later Than The 21st After It Has That Notice, On A Form Prescribed By The Department , Stating The Grounds Upon Which The Employee’s Right To Compensation Is Controverted And Furnishing A Copy Or Copies To The Department.
See § 406.1.(a) of the Workers Compensation Act : The employer and insurer shall promptly investigate each injury reported or known to the employer and shall proceed promptly to commence the payment of compensation due either pursuant to an agreement upon the compensation payable or a notice of compensation payable as provided in section 407 or pursuant to a notice of temporary compensation payable as set forth in subsection (d), on forms prescribed by the department and furnished by the insurer. The first installment of compensation shall be paid not later than the twenty-first day after the employer has notice or knowledge of the employe’s disability. Interest shall accrue on all due and unpaid compensation at the rate of ten per centum per annum.
See § 406.1 (c) If the insurer controverts the right to compensation it shall promptly notify the employe(e) …, on a form prescribed by the department, stating the grounds upon which the right to compensation is controverted and shall forthwith furnish a copy or copies to the department.
See § 406.1 (d) (1) In any instance where an employer is uncertain whether a claim is compensable under this act or is uncertain of the extent of its liability under this act, the employer may initiate compensation payments without prejudice and without admitting liability pursuant to a notice of temporary compensation payable as prescribed by the department.
See § 406.1(d) (3) Payments of temporary compensation shall commence and the notice of temporary compensation payable shall be sent within the time set forth in clause (a).
See § 406.1 (d)(4) Payments of temporary compensation may continue until such time as the employer decides to controvert the claim
B. Any Self Insuring Employer and/or Third Party Administrator Decision To Controvert, Suspend, Decrease or Terminate Payments Related To An Employee’s Notice Of Injury Reinstatement Must Be A Reasonable , Rational , Timely And Procedurally Proper Decision , On Forms Prescribed By The Department, Containing Findings Of Fact And Conclusions Of Law , Based Upon The Evidence As A Whole, Which Clearly And Concisely States And Explains The Rationale For The Decision , Adequately Explaining The Reasons For Rejecting Or Discrediting Competent Evidence. Uncontroverted Evidence May Not Be Rejected For No Reason Or For An Irrational Reason.
See § 422. (a) …. All parties to an adjudicatory proceeding are entitled to a reasoned decision containing findings of fact and conclusions of law based upon the evidence as a whole which clearly and concisely states and explains the rationale for the decisions so that ….When faced with conflicting evidence, the …judge must adequately explain the reasons for rejecting or discrediting competent evidence. Uncontroverted evidence may not be rejected for no reason or for an irrational reason;
See § 109. In addition to the definitions set forth in this article, the following words and phrases when used in this act shall have the meanings given to them in this section unless the context clearly indicates otherwise:
See 2 Pa.C.S. § 101 “Adjudication.” Any …, decision, determination … by an agency affecting personal or property rights, privileges, immunities, duties, liabilities or obligations of any or all of the parties to the proceeding in which the adjudication is made.
See § 406.1 (c) If the insurer controverts the right to compensation it shall promptly notify the employe …, on a form prescribed by the department, stating the grounds upon which the right to compensation is controverted and shall forthwith furnish a copy or copies to the department.
See § 413(b) Any insurer who suspends, decreases or terminates payments of compensation without submitting an agreement or supplemental agreement therefor as provided in section 408, or a final receipt as provided in section 434, or without filing a petition and either alleging that the employe has returned to work at his prior or increased earnings or where the petition alleges that the employe has fully recovered and is accompanied by an affidavit of a physician on a form prescribed by the department to that effect which is based upon an examination made within twenty-one days of the filing of the petition or having requested and been granted a supersedeas as provided in this section, shall be subject to penalty as provided in section 435 .
C. If The Self Insuring Employer and/or Third Party Administrator Does Not Initiate Timely Temporary Compensation Payments To The Employee, Along With Providing Him Or Her With A Notice Of Temporary Compensation Payable With A Copy To The Pennsylvania Department Of Labor And Industry, The Department Will Not Have The Opportunity To Send That Employee Important Notices Indicating That : A. The Payment Of Temporary Compensation And The Acceptance Of That Compensation Does Not Mean That The Employer Is Accepting Responsibility For Such Employee’s Increased Disability Injury Or That A Compensation Claim Has Been Filed Or Commenced; B. That Such Payment Of Temporary Compensation Entitles The Employee To A Maximum Of Ninety (90) Days Of Compensation; And C. That The Employee May Need To File A Claim Petition In A Timely Fashion Under Section 315, Enter Into An Agreement With The Employer Or Receive A Notice Of Compensation Payable From The Employer To Ensure Continuation Of Compensation Payments.
See Section 406.1(d)(2)(i)(ii)(iii)
(2) The notice of temporary compensation payable shall be sent to the claimant and a copy filed with the department and shall notify the claimant that the payment of temporary compensation is not an admission of liability of the employer with respect to the injury which is the subject of the notice of temporary compensation payable. The department shall, upon receipt of a notice of temporary compensation payable, send a notice to the claimant informing the claimant that:
(i) the payment of temporary compensation and the claimant’s acceptance of that compensation does not mean the claimant’s employer is accepting responsibility for the injury or that a compensation claim has been filed or commenced;
(ii) the payment of temporary compensation entitles the claimant to a maximum of ninety (90) days of compensation; and
(iii) the claimant may need to file a claim petition in a timely fashion under section 315, enter into an agreement with his employer or receive a notice of compensation payable from his employer to ensure continuation of compensation payments.
D. When An Employer Has Been In Default In Compensation Payments Due To The Employee For Thirty Days Or More Beyond The Due Date Of Temporary Compensation Payable To Him Regarding His Notice Of Injury Reinstatement Based On Increased Disability, That Employee Is Entitled To An Order Of The Department Of Labor And Industry Approving The Entire Balance Payable Under The Agreement , And The Prothonotary Of The Court Of Common Pleas Of Any County Shall Enter The Entire Balance Payable Under That Departmental Order To Be Payable As A Judgment Against That Employer , With Such Judgment Being A Lien Against Property Of The Employer And Execution May Issue Thereon Forthwith.
See § 428. Whenever the employer, who has accepted and complied with the provisions of section three hundred five, shall be in default in compensation payments for thirty days or more, the employe or dependents entitled to compensation thereunder may file a certified copy of the agreement and the order of the department approving the same or of the award or order with the prothonotary of the court of common pleas of any county, and the prothonotary shall enter the entire balance payable under the agreement, award or order to be payable to the employe or his dependents, as a judgment against the employer or insurer liable under such agreement or award. Where the compensation so payable is for a total and permanent disability, the judgment shall be in the amount of thirty thousand dollars less such amount as the employer shall have actually paid pursuant to such agreement or award. Such judgment shall be a lien against property of the employer or insurer liable under such agreement or award and execution may issue thereon forthwith.
E. Based On The Employer’s Unreasonable And Excessive Delays and Suspension Of Workers’ Compensation Payments, The Self Insuring Employer Will Be Subject To Being Penalized An Additional Sum Of Fifty Per Centum Of The Amount Awarded To The Employee With Interest Accrued And Payable, With Such Penalty Payable To The Employee Under Section 435(i) .
See § 413(b) Any insurer who suspends, decreases or terminates payments of compensation without submitting an agreement or supplemental agreement therefor as provided in section 408, or a final receipt as provided in section 434, or without filing a petition and either alleging that the employe has returned to work at his prior or increased earnings or where the petition alleges that the employe has fully recovered and is accompanied by an affidavit of a physician on a form prescribed by the department to that effect which is based upon an examination made within twenty-one days of the filing of the petition or having requested and been granted a supersedeas as provided in this section, shall be subject to penalty as provided in section 435 .
See § 435 (a) The department shall establish and promulgate rules and regulations consistent with this act, which are reasonably calculated to:
(i) expedite the reporting and processing of injury cases,
(ii) insure full payment of compensation when due,
(iii) expedite the hearing and determination of claims for compensation and petitions filed with the department underthis act,
(iv) provide the disabled employe or his dependents with timely notice and information of his or their rights under this act,
(v) explain and enforce the provisions of this act.
(b) If it appears that there has not been compliance with this act or rules and regulations promulgated thereunder the department may, on its own motion give notice to any persons involved in such apparent noncompliance and schedule a hearing for the purpose of determining whether there has been compliance. The notice of hearing shall contain a statement of the matter to be considered.
(d) The department, the board, or any court which may hear any proceedings brought under this act shall have the power to impose penalties as provided herein for violations of the provisions of this act or such rules and regulations or rules of procedure:
(i) Employers and insurers may be penalized a sum not exceeding ten per centum of the amount awarded and interest accrued and payable: Provided, however, That such penalty may be increased to fifty per centum in cases of unreasonable or excessive delays. Such penalty shall be payable to the same persons to whom the compensation is payable.
(ii) Any penalty or interest provided for anywhere in this act shall not be considered as compensation for the purposes of any limitation on the total amount of compensation payable which is set forth in this act.
F. Self Insuring Employers and Their Third Party Administrators Are Subject To Having Each Of The Respective Privileges Granted To Them By The Pennsylvania Department Of Labor And Industry Revoked Or Suspended For Repeatedly and Unreasonably Failing To Promptly Pay Workers’ Compensation For Which Those Employers Are Liable And/Or For Failing Or Refusing To Submit Any Required Departmental Report.
See § 441.
(b) If any employer who is subject to this act as an approved self-insurer repeatedly or unreasonably fails to pay promptly compensation for which it is liable or fails or refuses to submit any report…under this act, the secretary may revoke or suspend the privilege granted to the employer to carry its own risk and require it to insure its liability. The secretary shall not take such action against any employer until the employer has been notified in writing of the charges made against it and has been given an opportunity to be heard before the secretary in answer to the charges.
(c) Any person, not an insurer or self-insurer, engaged in the business of adjusting or servicing injury cases for the payment of compensation under this act shall register with the Department of Labor and Industry as a condition of conducting such business and shall furnish such reports of its activities as may be required by rules and regulations of the department. If any person engaged in such business repeatedly or unreasonably fails to provide such services promptly with the result that compensation is not paid promptly, the secretary may revoke or suspend the privilege of conducting such business. The secretary shall not take such action against such person until such person has been notified in writing of the charges made against it by the secretary and has been given an opportunity to be heard before the secretary in answer to the charges. Proceedings for revocation of the privilege of conducting such service or adjustment business shall not relieve any insurer or self-insurer who has engaged in the services of such person from its responsibility under this act or from its liability to revocation under this section. ….
G. The Pennsylvania Department Of Labor And Industry And Any Department Referee , Including An Unemployment Compensation Appeals Referee , Has The Power To Conduct Any Investigation Which May Be Deemed Necessary In Any Matter Properly Before Him Or Her, Either Personally Or By Any Officer Or Employee Of The Department, Or By Any Inspector Of The Department, Or By Any Person Or Persons Authorized By Law . Every Inspector And Employee Of The Department Is Empowered And Directed To Conduct Any Investigation Authorized By The Workers’ Compensation Act , At The Request Of The Board, Department Or Any Referee, With The Consent Of The Secretary.
See § 437. The board, department and any referee shall have the power to conduct any investigation which may be deemed necessary in any matter properly before them. Such investigations may be made by the board or referee personally, or by any officer or employe of the department, or by any inspector of the department, or by any person or persons authorized by law. Every inspector and employe of the department is hereby empowered and directed to conduct any investigation authorized by this act, at the request of the board, department or any referee, with the consent of the secretary