DI 52120.215 Puerto Rico Workers’ Compensation (WC)
All WC in Puerto Rico is always paid by the State Insurance Fund (SIF). Since records are in Spanish, sections DI 52120.215A. and DI 52120.215B. below explain the most common Spanish terms related to the WC documentation.
A. Types of WC payment
CAUTION: This section explains the different types of WC in Puerto Rico and how the SIF pays those benefits. SSA does not always use the SIF WC payment amounts and dates in determining offset. It is important to use the special rules in part DI 52120.215C below to determine the amounts of WC and the effective dates for SSA offset purposes.
1. Temporary Total (TT) - (“Dietas”)
Dietas is paid while the worker is under medical treatment. The maximum period of payment is 312 weeks. The maximum weekly amounts are:
|Injury date||Max weekly amount|
07/01/1968 thru 06/30/1986
07/01/1986 thru 06/30/2004
Dietas continues until the alta definitiva (“alta”) or the condicion trabajar (CT), but may start and stop any number of times until the maximum has been paid or PT has been awarded. Periods of dietas on different claim numbers can overlap. Dietas can be paid while the worker is receiving PP payments. Dietas is not paid after PT is awarded, but retroactive PT can overlap the dietas.
2. Permanent Partial (PP) - (“Incapacidad Parcial Permanente” or IPP)
PP is expressed as a percentage of the total disability- Funciones Fisiologicas Generales (FFG).
While the PP is “awarded” as a lump sum (LS) amount, SIF usually makes payments as follows:
If the injury date is 07/01/1968 through 06/30/1987 and the PP award is large enough, the NH usually receives an initial check equaling $1000 plus payment for the applicable number of retroactive months at $100 per month. Then he receives monthly checks of $100 until the award is paid. The limitation for PP awards is $10000 for the injury date 07/01/1968 through 06/30/1987.
If the injury date is 07/01/1987 or later and the PP award is large enough, the NH usually receives an initial check of $1500 (or, in some transitional cases, $1000) plus payment for the applicable number of retroactive months at $150 per month. Then he receives monthly checks of $150 until the balance of the award is paid. For the injury date 7/1/87 or later, the limitation for PP awards is $12000.
Multiple PP awards based on the same injury represent an increase in the percentage of disability.
Before a PP award is completely paid, the worker may elect to receive some or all of the balance of his PP award as a LS payment. This LS is referred to as a “PP investment”. After the PP investment is paid, SIF would continue to make monthly payments until the balance of the award is paid.
3. Permanent Total (PT) - (Incapacitado Total Permanente or ITP)
This benefit is paid when the NH is determined to be 100 percent disabled.
a. Life Pension
These are monthly payments for life at a fixed rate. Any unpaid dietas or PP is cancelled when PT is awarded, but retroactive PT can overlap the dietas.
The maximum monthly amount of PT is:
|Injury Date||Maximum Monthly Amount|
07/01/1968 thru 06/30/1987
07/01/1987 thru 06/30/2004
(1) Although the TT rate increased 07/01/1986, both the PT and PP rates did not increase until one year later- 07/01/1987.
(2) If there was prior PP on the same injury, the PT monthly rate will be lower than the rate that would have been paid if there had been no prior PP.
A worker may petition SIF for a LS payment in lieu of ongoing monthly PT payments. This LS is referred to as a PT investment. Multiple investments can be paid. If a PT investment is awarded, the worker loses his life pension status. This is because there is a limit to the total amount of PP and PT that can be paid when a PT investment is awarded. See the chart below:
07/01/1968 - 06/30/87
07/01/2004 or later
After an investment is paid, SIF will pay monthly PT at a fixed rate until the maximum above is paid out.
alta definitive: maximum medical healing, so this should be the final date dietas payments stop unless there has been an earlier release to return to work; decision date for PP or PT.
alta para trabajar or condicion trabajar (CT): release to return to work, so dietas payments should stop.
alta: generally, any discharge from medical treatment.
en descanso (at rest): under medical treatment, so dietas payments may begin.
recidiva (relapse): allegation of need for medical treatment; dietas may resume if the individual is placed under medical treatment.
C. WC amounts to use for SSA offset
1. TT (Dietas)
Use the rate paid and the dates for which paid. Occasionally, a dietas payment is cancelled (not paid) and the computer printouts we receive may not reflect this. Therefore, when imposing or adjusting offset due to dietas, be sure to notify the worker of the dates of dietas used so that he can object in case some of the payments were cancelled.
2. PP (Incapacidad Parcial Permanente)
a. Proration of PP awards
Although SIF pays PP awards as a combination of a LS and periodic payments (see DI 52120.215A.2.), SSA prorates the entire PP “award” as a LS. The starting date is explained in DI 52120.215C.2.b. below.
The rate at which to prorate the LS is:
|Injury Date||Monthly amount||Weekly amount for ICF|
If the percentage of disability is increased, multiple PP awards can be made based on a single injury. In this case, add the PP award amounts together to lengthen the proration period and prorate using the chart above.
b. Starting Date
If TT (dietas) preceded the PP award, start prorating the LS from the day after the TT ended. If there are multiple periods of dietas, the LS should be prorated based on the alta corresponding to the end of the dietas period at the time the initial PP was granted.
EXAMPLE: Alta is 03/08/2008. Dietas is paid through 03/08/2008. PP is awarded on the 03/08/2008 alta. Later, dietas payment resumes as of 03/10/2008. The PP should be prorated from 03/09/2008 and would overlap the continuing dietas.
If TT (dietas) did not precede the PP award, we would prorate the PP from the award date, which is usually the alta.
c. PP Investments
As explained in DI 52120.215A.2, the NH can elect to replace some of his monthly PP payments with a LS (PP investment). The PP investment has no bearing on how the PP “award” is prorated. Do not confuse a PP investment with a PT investment. See DI 52120.215C.3.b below for PT investment.
3. PT (“Incapacitado Total Permanente” or ITP)
a. Life Pension
For offset purposes, use the dates and amounts actually paid.
Although SIF stops PP payments when PT is awarded, sometimes SSA will still be prorating the PP LS award amount when PT is awarded. In this case, we should continue to prorate the amount of PP actually paid by SIF; this could overlap the PT monthly payments for a period of time. However see note below if an investment is paid.
EXAMPLE: Suppose a PP award of $5000 is made in 2003. The initial payment is $1,800-- $1,500 + $300 (two months of retroactive entitlement) on 05/01/2003. Normally SIF would continue to pay $150 per month after that until a total of $5000 is paid. The NH is awarded PT on 03/01/2004, so SIF stops making payments. SSA starts prorating the PP award based on the date specified in DI 52120.215B.2.c. Assume this date is 03/01/2003.
SIF has paid a total of $3,150 ($1,800 initial payment + $150 per month from 06/2003 through 02/2004).
SSA has offset for $1800 ($150 per month from 03/2003 through 02/2004)
We must continue to offset for the remaining $1,350 paid by SIF (at $150 per month) for 03/2004 through 11/2004. This would be in addition to the PT monthly payments for those months.
Previously our instructions were to stop offsetting for PP when the PT was awarded so that there would not be an overlap. The revised instructions (to continue to charge off any PP paid by SIF even after PT is awarded) are considered a change-of-position (COP) effective 09/30/2008. Cases processed under the previous rule should not be re-opened prior to the 09/30/2008 COP effective date.
NOTE: If an investment is paid, the PP and PT will not overlap. Stop the PP proration when PT payments start and see DI 52120.215.C.3.b below for instructions on handling the investment.
b. PT Investment
Treat the PT investment as a LS. Start the proration (and stop offset based on the PT monthly payments) effective with the date the PT investment was granted. If there are multiple investments for one injury, add them together and treat them as one LS.
Prorate at the following rate:
|Injury Date||Monthly Amount||Weekly Amount for ICF|
c. PT Remainder
The PT Remainder is the balance of payments due on the record if an Investment is paid. It is equal to the maximum (see chart in DI 52120.215A.3.b) minus the total of:
The PT remainder is treated as its own LS. The proration starts as soon as the investment proration ends. The proration rate for the PT Remainder is:
|Injury Date||Monthly Amount||Weekly Amount for ICF|
D. SSA worksheets
The Workers' Comp Resource Page contains a guide and worksheets to use to compute offset in Puerto Rico WC cases. (On the Workers' Comp Resource Page select Developing WC and then select State-Specific Policy Guidance.) The guide provides detailed information about Puerto Rico WC payments, and explains how to interpret the computer printouts received as proof of the WC paid, and how to use the worksheets. The worksheets do not actually calculate amounts payable after offset but allow the user to compute the correct amounts and dates to use when entering information in WC/PDB ICF. They are especially helpful when a LS is involved.
There are three worksheets depending on the WC injury date (DOI):
Injury date from 07/01/1968 through 06/30/1987
Injury date from 07/01/1987 through 06/30/04
Injury date 07/01/04 or later
Users should familiarize themselves with these aids to ensure accurate processing of Puerto Rico WC cases.
Puerto Rico does not provide regular COLAs on its WC.
F. Attorney fees
There are no attorney fees or other excludable expenses for any award made after 06/18/1969.
G. Retirement insurance benefit (RIB) considerations
Puerto Rico SIF does not offset WC for SSA RIB.
H. Verifying WC payment amounts
Because many beneficiaries getting PR WC speak only Spanish, check the language indicator on the MBR before contacting a beneficiary by phone or mail. DIRCON (unless in Spanish) should not be used if the language indicator is S. In this case, contact the FO to obtain the SIF information (if on-line printouts do not provide the necessary information).