Wage Loss Off, Medical Still On? When Workers’ Comp Benefits End.
As workers’ compensation attorneys, we frequently consult with injured workers who, understandably, do not understand the system. In fairness, it can be confusing and illogical, and may not conform to common sense. One issue about which our clients are often confused is whether their medical benefits continue when their wage loss checks stop.
There are two main aspects to workers’ compensation benefits in Pennsylvania: wage loss (also known as “indemnity”) benefits, and medical benefits. It is very common for people to be hurt at work and require medical treatment but not to need work restrictions or to be accommodated with light duty restrictions by their employer. These are known as “medical only” claims, in which wage loss benefits are not paid because the injured worker is able to earn at above their preinjury wages. It is not unusual to have an open workers’ compensation claim where only medical benefits are being paid. In these situations, the workers’ compensation carrier is responsible to pay for treatment which is reasonable, necessary, and related to the accepted work injury.
In cases where injured workers are not able to earn at or above their preinjury wages, wage loss benefits, either total or partial disability, should be paid. If wage loss is being paid, by definition the workers’ compensation carrier will have accepted some kind of injury, and medical benefits will be open as well. What many people do not realize, however, is that wage loss benefits can then stop and the medical benefits can nevertheless remain open.
Wage loss benefits can stop in a number of ways. In the first 90 days after an injury, if the workers’ compensation carrier has only accepted the claim temporarily, the carrier can turn around and deny the claim, stopping both wage loss and medical benefits and forcing the injured worker to file a claim petition to prove his or her case to a judge. But once the claim is accepted, especially if wage loss benefits are being paid, it is not so easy for the insurance company to simply stop paying. One option is that the carrier can seek to prove that the claimant is fully recovered, which, if successful, would stop both wage loss and medical benefits.
Sometimes it is difficult for a workers’ compensation carrier to prove that a claimant is fully recovered. In those situations, they may try to limit their liability by at least trying to reduce or cut off the wage loss benefits. They can do that by asking the employer to offer the claimant work within his or her restrictions or they can try to prove that there are other jobs that exist in the labor market which would pay at least as much as the time of injury job. If the insurance company can prove that the claimant can return to work and earn more than their preinjury earnings, or if the claimant actually returns to work on their own (at the time of injury job or elsewhere) and earns more than their own preinjury wages, wage loss benefits would stop. This is known as a suspension of benefits.
A suspension of benefits only deals with wage loss checks. This is where people get confused. They think that because their wage laws checks stopped, their medical benefits stopped as well. However, the only way that the insurance company can stop paying for medical treatment on an accepted claim is if it can prove that the injured worker has fully recovered. Very often, people do not realize that they can continue to seek treatment for their injuries in these circumstances.
This is just one example of how confusing the workers’ compensation system can be. Injured workers need an experienced workers’ compensation attorney on their side, to help them navigate the twists and turns of their cases. Injured employees should always consult with their own counsel to help them understand their rights and options as their cases progress.