For those who are new to Pennsylvania workers’ compensation, one of the most difficult concepts to understand is that benefits cannot be unilaterally ceased once compensation (as opposed to temporary compensation) is being paid. It seems absurd that benefits would continue under any of the following circumstances:
Claimant has returned to work without loss of earnings, but is subsequently fired for reasons completely unrelated to the work injury.
Claimant has been released by his treating physician to return to work with or without restrictions.
Claimant has reached MMI.
Claimant is in jail awaiting trial.
Claimant has stopped treating and has no ongoing documentation supporting ongoing disability.
Claimant returned to work without loss of earnings, but it is subsequently laid off due to economic factors.
Claimant no-shows for an IME.
All of the scenarios above, however, are circumstances which in which benefits CANNOT BE UNILATERALLY SUSPENDED in Pennsylvania. In fact, each of the scenarios above presents a situation in which if benefits are unilaterally suspended, not only will past due benefits likely be awarded, it is also very likely that a penalty will be awarded. In Pennsylvania, penalties can be quite costly, as they can be up to 50% of the award.
Basically, once a claimant is receiving ongoing compensation pursuant to an irrevocable document (anything other than a Notice of Temporary Compensation), there MUST BE a Bureau document allowing the suspension of benefits (Notification of Suspension, Supplemental Agreement or Final Receipt) or a judge’s order supporting that suspension. The only real notable exceptions are the death of the claimant or claimant’s incarceration following conviction.
Additionally, Pennsylvania remains a wage loss state. Even if a claimant has been released to return to work, the burden is on the Employer to prove that the claimant’s wage loss is unrelated to the work injury. While we understand that it seems to fly in the face of logic that ongoing benefits would be paid for “disability” when claimant has been released to full duty, this remains the state of Pennsylvania law. Thus, in situations where the pre-injury employer has no work available, we must still prove that work generally exists in the claimant’s geographic area.
The best way to understand Pennsylvania workers’ compensation is this: if you were to issue a Notice of Compensation Payable on a file and begin payment of total disability and stick the file in a drawer, benefits would continue for the rest of claimant’s life regardless of whether the claimant ever sought medical treatment again. Additionally, if a claimant returns to work and benefits are “cut off” without a proper Bureau form or a Judge’s order, claimant could come back years later and assert that he stopped working at any point for nearly any reason and seek reinstatement of benefits and a 50% penalty.
Key lessons to understanding Pennsylvania law are:
1. For every open Bureau document, there must be a Bureau document or Judge’s Order closing that file. Never close a file without a closing document.
2. Once an injury is recognized and total disability benefits are being paid, the burden shifts to the Employer to stop those benefits. Pennsylvania requires vigilant work by the claims professional, risk manager, and attorney to make sure that all is being done to move the case toward closure.