by Karl Voigt
Navigating workers’ compensation claims can be complicated, particularly when the initial injury diagnosis is incomplete or inaccurately described. For workers injured in Pennsylvania, it’s essential to understand that insurance companies are legally required to acknowledge an injury through a document called the Notice of Compensation Payable (NCP) within 21 days of the injury. This initial acknowledgment sets the stage for what benefits will be paid and what type of medical treatment will be covered. However, at this early stage, the precise nature and extent of the injury may not yet be fully understood. As a result, the official description of the injury often requires subsequent revision as medical evaluations refine the diagnosis.
One common issue in workers’ compensation cases is that soft tissue injuries are often initially categorized as “sprains” or “strains.” According to Pennsylvania’s 2023 Workers’ Compensation Annual Report, sprain and strain injuries accounted for 57,973 cases, representing 35.6 percent of all reported injuries.
While such initial descriptions can be somewhat accurate, they may not fully encompass the complexity of the injury or its long-term impact on the worker. If the injury description remains unchanged, the scope of covered benefits could be limited to those associated with the initial, potentially inadequate diagnosis.
Why Prompt Revision of Injury Descriptions is Crucial
Since the NCP determines the specific benefits and medical treatments covered by the insurance carrier, an accurate and comprehensive injury description is vital. As the report highlights, the vast majority of initial descriptions involve general categories that do not capture the full spectrum of soft tissue injuries. When a worker’s injury is more severe or involves multiple body parts, simply categorizing it as a sprain or strain may leave them without full access to necessary medical treatments or wage loss benefits.
Moreover, insurance carriers are responsible only for the injury they have acknowledged. Thus, if an NCP describes an injury as a “back strain,” and further diagnostic testing later reveals a herniated disc, without an amended description, the insurer may deny payment for treatments related to the disc herniation. This could result in substantial out-of-pocket costs for the injured worker and potentially inadequate medical treatment, which can impede their recovery.
The Process of Amending the Injury Description
Recognize the Need for Revision: The first step is identifying when a revised description is needed. As additional diagnostic tests—like MRIs, CT scans, or even specialist evaluations—become available, they often provide a more detailed and specific diagnosis. For instance, a knee injury initially diagnosed as a sprain could later be found to involve ligament damage, meniscal tears, or even osteochondral defects.
Submit a Request for Review: The injured worker or their attorney should formally request that the insurance carrier amend the injury description in the NCP. This request should include any updated medical records, physician reports, and diagnostic findings that support the revised diagnosis.
File a Petition to Amend the NCP, if Necessary: If the insurance carrier refuses to amend the injury description voluntarily, the injured worker may need to file a petition to amend the NCP with the Workers’ Compensation Judge. This process involves presenting evidence and testimony to prove that the original description is inadequate and that an amendment is warranted.
Real-World Implications of an Inadequate Injury Description
The need for accurate descriptions is underscored by the high frequency of sprain and strain injuries recorded in Pennsylvania. Sprain and strain injuries made up a large portion of the state’s injury cases across various industries, with sectors like Trade & Transportation seeing 17,148 such cases and Education & Health Services reporting 14,843 cases.
These types of injuries are often more complex than they initially appear. For example, what is categorized as a back strain may actually involve underlying issues such as disc herniation, which may require prolonged medical treatment and time away from work.
Consider a case where a worker is initially diagnosed with a shoulder strain. This broad category may lead to a treatment plan limited to physical therapy and pain management. However, if the worker later undergoes an MRI and is found to have a rotator cuff tear, surgery and extensive rehabilitation might be necessary. Without amending the NCP to reflect the rotator cuff tear, the worker might not receive the appropriate wage loss benefits for their recovery period or may face difficulty obtaining coverage for the surgery.
Statistics Highlighting the Need for Accuracy
The 2023 Workers’ Compensation Annual Report in Pennsylvania further illustrates the importance of this issue. It reported that injuries affecting the upper extremities accounted for the majority of sprain/strain cases
Workers with initial diagnoses of strains or sprains to the shoulder, elbow, or wrist may experience lingering symptoms or develop chronic issues that necessitate more involved treatments. Inaccurate or vague injury descriptions can limit access to such treatments, impacting the worker’s ability to fully recover and return to their previous work capacity.
The Benefits of a Revised Injury Description
Full Access to Medical Care: An accurate description ensures that all necessary medical treatments are covered. This can include surgeries, specialist consultations, and advanced diagnostics that might be denied under a more general or less severe classification.
Appropriate Wage Loss Benefits: For workers who are temporarily or permanently unable to work due to an injury, wage loss benefits are crucial. If the injury is underrepresented in the NCP, workers might receive inadequate compensation, impacting their financial stability during the recovery period.
Improved Recovery Outcomes: When workers have access to the correct treatment, they are more likely to recover fully and regain their ability to work. A refined diagnosis and subsequent amendment to the injury description can lead to better-targeted treatments, helping workers return to work more quickly and reducing the likelihood of chronic issues.\
Protection Against Future Claims Denials: Revising the injury description also helps protect the worker in case of future disputes with the insurer. A well-documented case with an accurate injury description can make it easier to access ongoing treatments or handle claims if symptoms worsen over time.
Conclusion: Proactive Management of Your Workers’ Compensation Claim
For Pennsylvania workers navigating the complexities of workers’ compensation, requesting a revised injury description can be a critical step in ensuring full access to benefits. When an injury occurs, the initial diagnosis might be general or incomplete, often limited to descriptions like “strain” or “sprain.” As further diagnostics refine the injury, workers should seek to have the official description amended to reflect the true nature of their condition. By doing so, they can secure the medical treatments and wage loss benefits necessary for the best recovery.
With soft tissue injuries so prevalent, as highlighted in the 2023 Workers’ Compensation Annual Report, this issue remains relevant to thousands of workers across the state. If you or a loved one has experienced a workplace injury, consulting with a workers’ compensation attorney can provide guidance on ensuring that the injury is accurately documented and that you receive the full benefits to which you are entitled. Taking these steps can be instrumental in achieving a successful recovery and returning to work on your terms.
All statistics in this article where extracted from the 2023 Pennsylvania Workers’ Compensation and Workplace Safety Annual Report.
Prince Law Offices Blog 