The Pennsylvania Bureau of Workers’ Compensation has revised the Notification of Suspension or Modification Pursuant to 413 (c) & (d); form LIBC-751

This change is effective February 20, 2022.

What does this mean?  The form is simpler to use!

Here is a copy of the Bureau announcement -

On Dec. 22, 2021, Governor Tom Wolf signed Act 95 (House Bill 1837) into law. This act amended Section 413(c) & (d) of the PA Workers Compensation Act such that an affidavit is no longer required on the Notification of Suspension or Modification Pursuant to 413(c) & (d) - LIBC 751, effective February 20, 2022.

The Bureau of Workers Compensation has revised the Notification of Suspension or Modification, LIBC-751, to comply with Act 95. 

 

The notification now includes two verification boxes which must be checked before the document is signed. 

 

The notification must still be sent to the claimant and the bureau within seven days of the modification or suspension of benefits. 

 

Due to the substantive change to the form, the revised form must be used beginning February 20, 2022.

 After March 2, 2022, prior versions of the form will be marked incomplete.

Please upload completed forms into WCAIS. Filing in WCAIS is available 24/7 and reflects a "filed date" when uploaded. This practice offers cost savings,

timely filing to the bureau without the need for a valid US Post Mark and makes the document available for instant viewing by all parties to the claim. Uploading can be done within the Action Tab of a claim, using the "Document Type" Notification of Suspension or Modification (LIBC-751) in the tab's drop-down list. The form may also be mailed to the bureau for filing.

Here is a reproduction of the “new” sections – 

NOTIFICATION OF SUSPENSION OR MODIFICATION PURSUANT              TO §§ 413 (c) & (d)  LIBC-751 REV 12-21

INSTRUCTIONS

This form must be completed, mailed to the employee, and uploaded to WCAIS or mailed to the Bureau of Workers’ Compensation within seven days of the suspension or modification of benefits under the provisions of the Workers’ Compensation Act. You must submit an EDI transaction to match the LIBC-751 to update the status of the claim in WCAIS.

*** 

You are notified that because you returned to work on  month day year  your weekly disability benefits for this injury have been:

 __  Suspended effective month day year  because you have returned to work at earnings equal to or greater       

        than your time- of-injury earnings of $._____.

 OR

__  Modified to the rate of $ ____ per week, effective month day year  because you returned to work at earnings

       less than your time-of-injury earnings.

 *** 

 ___   I confirm I have served a copy of this form to the Bureau of Workers’ Compensation.

___    I confirm I have served a copy of this form to the employee.

***                                             

Claims representative’s signature                                                   

Claims representative’s name (typed/printed) 

phone number

This Insurer’s Verification language appears to the right of the Claim rep signature lines -

 INSURER’S VERIFICATION

I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsifications to authorities. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.

If you have any questions regarding the proper usage, preparation or filing of this revised form – please feel free to ask your workers compensation attorney at www.ChartwellLaw.com