The five days to report to the Fund

It is Article 5 of Act 45-1935, which governs the injured worker’s examination and medical treatment: the five-business-day window to present, the consequences of missing it, the right to bring your own doctor, the recourse to the Industrial Commission when assistance is inadequate, and the effect of refusing or opposing treatment, whose definition sits in Article 36.

It applies to the worker injured or ill under the circumstances the Act covers, during the period of disablement. The duty to let oneself be treated and examined by a competent doctor designated by the Administrator, at appropriate times and places, runs through that period.

• Present to the doctor within the five business days following the accident for treatment.Verified against the official source
• Report at that appearance that you suffered a work accident: Article 36 requires it for the appearance to count.Verified against the official source
• Let yourself be treated and examined, at appropriate times and places, by the competent doctor designated by the Administrator during the period of disablement.Verified against the official source
• If you missed the window, satisfactorily explain the delay to the Administrator.Verified against the official source

• Evidence of the date of the accident and of the date you were attended: the window runs between those two.
• Whatever supports the explanation of the delay, if you missed it: the Act asks that it be satisfactorily explained and, once proven, obliges the Administrator to pay.

1. 1

   Step 1: Count five business days from the accident

   Article 5 puts it this way: if the worker does not present to the doctor "within the next five (5) business days after the occurrence of the accident for treatment, nor satisfactorily explain the delay to the Administrator, the latter may deprive them of the right to receive any compensation". Note the verb: "may". It is not automatic, and the same text opens the door of the explanation. But the clock starts the day of the accident, not the day the pain became serious.

2. 2

   Step 2: What counts as presenting — and the sentence you have to say

   Article 36 defines the requirement: it is met "when the worker attends for treatment at a State Insurance Fund dispensary, or before a doctor, hospital or clinic under contract with that Fund when at that appearance they report having suffered a work accident". The last clause is the one that most often fails: going to a contracted emergency room and not saying it was a work accident is not the same as saying it. Say it, and ask that it be written down.

3. 3

   Step 3: If you missed it, explain the delay

   The Act does not shut the door: it asks that the delay be satisfactorily explained to the Administrator. And it goes further, placing an obligation on the Fund: "when the worker has proven their delay to satisfaction, the Administrator shall be obliged to pay them the total compensation or the disability including the dietas for the time they were under medical treatment". That is, a proven explanation not only avoids the penalty: it restores payment for the period.

4. 4

   Step 4: Medical care cannot be denied to you

   This is the sentence worth memorising. Even when the Administrator exercises the power to deprive you of compensation, "the medical assistance the Administrator deems necessary to seek the worker’s full recovery may not be denied to them under any circumstance". Compensation and treatment are two different things in this Act, and only one of the two is at stake when the deadline is argued.

5. 5

   Step 5: You may bring your own doctor to the examination

   Article 5 gives the injured worker the right "to designate at their own expense a doctor or surgeon to be present at their examination or to give them treatment". The Act clarifies that this does not remove the Administrator-designated doctor’s right to visit you at the times they deem appropriate and under reasonable circumstances while you are unable to work. The two rights coexist: yours to have someone you trust present, and the Fund’s to examine you.

6. 6

   Step 6: If the assistance is inadequate, the Industrial Commission orders it

   The same article carries the remedy: "if the Administrator does not provide adequate assistance to the worker, the latter may go to the Industrial Commission, which, after investigation by a doctor designated for the purpose, shall order the assistance the case requires and the Administrator shall comply with the Commission’s order". This is not an informal complaint: it is an order the Administrator complies with, preceded by a medical investigation by the Commission itself.

7. 7

   Step 7: Refusing or opposing treatment is broader than it sounds

   Article 5 says that "the worker’s refusal or opposition without just cause to submit to the medical examination or treatment provided by the Administrator shall have the effect of depriving them of the right to receive compensation under this Act or to bring or continue proceedings" to obtain it. And Article 36 defines that refusal or opposition as "any voluntary act of the injured person that harms, hinders, prolongs or prevents the treatment provided to them, or that aggravates, or exposes to aggravation, their condition", expressly including disorderly or tumultuous conduct disturbing the hospital’s peace, acts of manifest immorality during hospitalisation making the patient’s stay undesirable, and manifest drunkenness during hospitalisation when it is a contraindication to the treatment, contributes to prolonging it, or comes with acts harming discipline or bothering other patients. Note the three words that protect you: "without just cause".

For treatment, at a State Insurance Fund Corporation dispensary or before a doctor, hospital or clinic under contract with the Fund, reporting right there that it was a work accident. If the assistance given is inadequate, the forum is the Industrial Commission, which investigates with its own doctor and orders.

• Counting the five days from when the pain worsened: the Act counts them from the occurrence of the accident.
• Going to a contracted clinic without reporting at that appearance that it was a work accident, which is what Article 36 requires for the visit to count.
• Believing that missing the deadline closes the case, when the Act admits a satisfactory explanation of the delay.
• Confusing losing compensation with losing treatment: necessary medical assistance cannot be denied under any circumstance.
• Putting up with inadequate assistance without going to the Industrial Commission, which investigates with its own doctor and orders.
• Not using the right to designate, at your own expense, a doctor to be present at the examination.

These are the government pages this guide is based on.

• Corporación del Fondo del Seguro del Estado (CFSE)

  Fondo del Seguro del Estado

  bvirtualogp.pr.gov