PART 1- COVERAGE OF LOSS

Chart 1 – Type of Law & Insurance Requirement (pg.no. -12)

Type of Law – Compulsory
Insurance – Required
Self-Insurance – Permitted (May have to setup reserve fund to pay compensation or benefits)
Penalties on failure to Insure -

 Third Degree Misdemeanour

 Fine up to $2500 &/or 1-year prison for each day of Non coverage
 If intentional then considered as 3rd Degree Felony with fine up to $15000 and 7 years
in prison per day of non-coverage.
 Complaint against uninsured party can be filed by any party with county district
attorney office.

Chart 2 – Employment Covered (pg.no. -21)

Private –

 Compulsory to all employment.

 Elective to executive officers.
Public –

 Compulsory to all employment.

 Elective to executive officers.
Special Coverage Provision –
Employer maybe exempted from covering employees whose religious sect prohibits benefits
provided they make provision for them.

Chart 3 – Coverage of Minors (pg.no.28)

 Covered – Yes
 Illegal Employment – 50 % additional compensation
Note – Additional amount of compensation may not be insured.
Chart 4 – Coverage of Occupational Diseases (pg.no.35)
Nature of Coverage – All diseases
Medical Boards – IME (Insurance Medical Exam) may be ordered
Onset Disability or Death – Within 300 weeks of last exposure (except death following
disability that occurs within 300 weeks of last exposure).
Time Limit on Claim Filing -

 Within one year from date first discovered or in exercise of reasonable care
should have discovered the occupational disease.
 One year from date of Disability or being informed by physician.
Medical Care – Unlimited
Compensation – Same as for accidents.

Chart 5 – Occupational Hearing Loss (pg.no.43)

Separation from Noise before Filing – No Requirement
Minimum Exposure in Last Employment – No Requirement
Liability for Prior Loss – No
Benefits for Total Loss – 260 Weeks
Benefits of One Ear Loss – 60 Weeks
Deduction for Presbycusis – Possible
Failure to use Protective Device – No impact
Compensable Loss of Hearing(dB) – AMA, 4TH Edition
Loss of Hearing Considered Total(dB) – 75% presumed
Cycles at which loss is measured (Hz) – 500-1000-2000-3000
Note – Compensation is paid in amount of 66.67% of wages calculated under AMA for
partial loss. Whereas compensation for total loss will depend on cause of loss. (pg.no.46)
 PART 2 – BENEFITS PROVIDED
Chart 6 – Income Benefits for Total Disability (pg.no.55)
For computing weekly benefits payments formula expressed as percentages of wages is used.
Percentage of Wages – 66.67%
Max Weekly Amt – $978
Max Rate (%) – 100%
Min. Weekly Amt – $543.2
Min. Rate – 90% of AWW if AWW is $517.77 or less
Time Limit – TT Disability PT Disability up to 500 Weeks
Offsets – Unemployment Compensation, old age social security & pension payments
Notations – Injuries after 6/24/96 who receive TT for 104 weeks may have to undergo
impairment rating evaluation to determine degree of impairment. If disability rating is less
than 50% then compensation will reduce from total to partial status.

Chart 7 – Income Benefits for Scheduled Injuries. (pg.no 64)

Percentage of hearing loss under AMA impairment Rating Guides multiplied by 60 weeks.

Chart 8 – Income benefits for spouses and Children (pg.no.69)

Percent of Wages –

 Spouse + Children – 60 to 66.67%

 Spouse only – 51%
 One child only – 32%
Max Per Week –

 Spouse + Children - $978

 Spouse only – 978
Min. Per Week –

 Spouse only – Max is 100% of SAWW & Min is 50% of SAWW.

Time Limit – In case of dependent child dependent due to disability up to 23 while a full-time
student.
Max Burial Allowance - $3000
Chart 9 – Waiting period for Income/Medical Benefits (pg.no.82)
Waiting Period – 7 Days
Retroactive Period – 2 weeks
Medical Fees Unlimited – Yes
Choice of Physician –

 Employer – May have preferred list

 Employee – From Employer List
If provider is chosen by employee, then they must treat with that provider for 90 days after
the initial visit. After 90 days if employer does not accept the claim or if list is improper then
employee can treat with any provider they choose.
Artificial Appliances Furnished – Yes (D)
Medical Benefits Special Provision – There is no waiting period for Medical Benefits under the
ACT.
NOTE – Employers and Insurers are only liable for amounts set forth in medical fee schedule.
(pg.no.86)

Chart 10 – Rehabilitation of Disabled Workers (pg.no 90) (D)

Sources of Funds – Federal and State sources
Maintenance Allowance –

 State Office of Vocational Rehabilitation or Private Rehabilitation may provide cash

payment for living expense.
Special Provision –

 They also provide physical restoration, training, support and job placement services.
 Part 3 – Administration of Laws
Chart 11 – Administration: Notice to Employer & Claims (pg.no.106)
Administration – Bureau of Workers Administration
Notice to Employer –

 Not given within 21 days no compensation due until given.

 If not given within 120 days compensation disallowed.
Claim Filling – Within 3 years after injury, death or last payment.
How Claims are settled –

 By agreement after seven days from injury, subject to department approval.

 Disputed cases heard by Workers Compensation Judge.
 Appeals from WCJ decision may be taken within 20 days to the Workers Compensation
Appeal Board.
 Appeals from WCAB decision maybe taken within 30 days to Commonwealth Court.
 Finally appeal maybe filled with Supreme Court within 30 days of Commonwealth
Court Decision.
Award Effect – Payment within 30 days unless order is appealed and supersedes is granted
Review by Agency – By workers Compensation Appeal Board, within 20 days of Workers
Compensation Judge Decision.
Modification – By dept. on Application within statutory limits.
Attorney Fees –

 Fees are limited to 20% of the award to the injured employee.

 Generally paid out of the employee award.
 However, in some cases fees maybe ordered to be paid in addition to award to the
employee.
Note – Late discovery of Occupational Disease may extend the time for filing claim.
(pg.no.113)
Chart 12 – Employers Report of Accident (pg.no.115)
Keeping of Accident Record by Employer – Required
Injury Reporting – Death Cases, Disability of one day or more.
Time Limit –

 Within 48 hrs. in death cases.

 After 7 days but not later than 10 days in case of disability.
Max Fine (Penalties for failure to report)–
10% of Compensation in case of late filing + Interest accrued and payable
50% of Compensation in case of excessive delay

Chart 13 – Second Injury Funds (pg.no.123)

Injuries Covered – Second injury loss or Loss involving hand, arm, foot, eye that involve total
disability.
Payable by Employer – Scheduled benefits as a result of second injury
Payable by Fund – Remaining compensation due for total disability
Sources of Funds – Assessment against carriers and self-insurers proportional to
compensation payments. (D)
Special Provision – Payment made directly by department. (D)

Chart 14 – Administration Expenses (pg.no.130)

System Provided for – Competitive Fund
Fund for Appropriation – Administrative Fund
Assessment Provision Against whom – Employers via assessment on insurers and self-insured
employers
Assessment Provision Amount –

 Insurers – prorated by premiums earned

 Self-insurers – assessed based upon compensation paid
Other Income – Fines, Fees, Penalties,3rd party recoveries and criminal restitution
Chart 15 – Appeal Provision (pg.no.135)
Administration – Bureau of workers compensation
Time for Appeal – 20 days in Workers Compensation Appeal Board,30 days in Commonwealth
Court,30 days in Supreme Court.
Question reviewed law only – Yes
Process and Procedure – WCAB-Appeal, Commonwealth Court – Petition for Review ,
Supreme Court – Petition for allowance of appeal.
Question Reviewed Law only – Yes
Question Reviewed Law and Fact – yes
Basis for Review – Certified Record
Jury Trail - No