The Fund’s dietas under the statute

The dietas are the weekly compensation the State Insurance Fund pays while a worker is temporarily disabled by a work injury or illness. This guide describes them not from the CFSE’s pages but from Article 3 of the Act that creates them, which is where the figures are.

Article 2 covers every worker or employee working for a covered employer who suffers injury, disability or death from an accident arising from an act inherent to their work and occurring in its course, or from occupational illness. It also covers the owner of a business, industry or individual employer who works full time in it and whose gross income does not exceed one million dollars. Expressly excepted is the worker whose labour is incidental or casual and not within the employer’s business. The state government and the municipalities count as employers, and the Act brings within the cover volunteer municipal firefighters, municipal assemblymembers, jurors summoned to the courts from leaving home until returning, and anyone serving as a volunteer to a municipality or agency. Article 4 excludes three cases: attempting to commit a crime or injure someone, deliberately causing the injury, being intoxicated where the intoxication was the cause of the accident, and where the worker’s reckless imprudence was the sole cause.

• That the injury or illness is one covered by Article 2 of the Act and falls under none of the three exclusions in Article 4.Verified against the official source
• Presenting yourself to the doctor for treatment: the Act says the worker is entitled to compensation “from the day they present themselves to the doctor to receive treatment”.Verified against the official source
• For a reopening after definitive closing: requesting it in writing within a term not exceeding three years from that closing, with clear and convincing medical evidence of the aggravation or relapse, and the originally compensated injury having been its sole cause.Verified against the official source

Information pending verification.

1. 1

   Step 1: The figure, and where it comes from

   Article 3(b) says it at once: if the disability is temporary or transitory, the worker is entitled “to a compensation equivalent to sixty-six and two thirds (66 2/3) per cent of the wage they earned on the day of the accident, or would have earned but for the accident, during the period of incapacity for work, payable weekly in arrears”. Two thirds of the wage, paid weekly in arrears. It is the starting point of the whole calculation.

2. 2

   Step 2: Three hundred and sixty-four weeks, two hundred and sixty dollars

   The same sentence continues with the three limits that decide what people actually receive. “The period of such payment shall in no case exceed three hundred and sixty-four (364) weeks; In no case shall more than two hundred (200) dollars nor less than sixty (60) dollars weekly be paid.” Three hundred and sixty-four weeks is the ceiling on time. Two hundred dollars is the weekly ceiling, and sixty is the floor: someone who earned little does not go below it, and someone who earned a lot does not go above it.

3. 3

   Step 3: The clock starts at the first medical visit

   It is a short line and it decides money: “The worker or employee shall be entitled to compensation from the day they present themselves to the doctor to receive treatment.” Not from the date of the accident, not from when the Fund decides the case, not from when the employer fills out the form. From the day you present yourself to the doctor.

4. 4

   Step 4: If you are sent for retraining: twenty-six weeks

   The Act sets a different limit for one specific case. “In those cases where an injured worker, in the Administrator’s judgement, requires referral to vocational training or retraining as part of the treatment, the injured worker shall receive the aforementioned compensation, but in no case shall more than twenty-six (26) weeks be paid.” That is: during retraining you receive the same amount, but the time ceiling drops from three hundred and sixty-four to twenty-six weeks.

5. 5

   Step 5: If you are a public employee there is one more cap

   Article 3(b) closes with a rule that applies only to the public sector: “No public employee or official may receive during the period of incapacity for work, except while enjoying regular vacation or sick leave, any amount in weekly compensation which, added to the salary they receive from the government agency they work for, exceeds the regular salary of their post.” Dieta plus salary may not exceed the post’s regular salary, except while on regular vacation or sick leave.

6. 6

   Step 6: While the Fund investigates, they must advance you money

   This is the part almost nobody knows, and it addresses the worst stretch of the process: the one between the accident and the Fund deciding whether the case is covered. Clause (1)(A) of Article 3(b) says that in those cases where the accident remains under Fund investigation “for a term to be fixed by regulation and which shall not exceed 60 days” to determine whether it is a covered accident, and which the Administrator deems meritorious, the Administrator “shall order that advances be made to the injured worker against the dietas they might be entitled to”. The verb is “shall order”. And if the investigation concludes the accident is covered, the Fund “shall continue paying the injured worker the transitory-disability dietas they are entitled to under the law”.

7. 7

   Step 7: Where that money comes from

   It is not an unbacked promise: clause (3) creates the fund that pays it. “There is hereby created a Special Fund within the State Insurance Fund which shall constitute and be called the Advance Fund for the Payment of Transitory Disabilities.” The Administrator is authorised to make periodic transfers from the CFSE’s General Fund to keep it solvent, administers it exclusively to pay advances to injured workers while the case is investigated, and that fund’s money “shall not be consolidated with other funds and shall be kept in a separate account on the State Insurance Fund’s books”. The advances may not exceed the total of the maximum dietas the worker would be entitled to under the law in force when the accident happened.

8. 8

   Step 8: And if the investigation goes against you

   Clause (2) says what happens then, and it is worth knowing beforehand. If the investigation’s result and the Administrator’s final determination is that the injury did not come from a work accident, “the State Insurance Fund shall have a claim and preferred lien over the insurance or any other plan, public or private, the injured worker is entitled to”. To collect it, the Administrator certifies an invoice with the settlement of what was paid, and those payments “shall be reimbursed immediately”. The Administrator may also obtain reimbursement by summary judicial claim, in the nature of an injunction, or by ordinary proceeding. The Administrator’s subrogation right applies to these cases in the same measure and with the same reach.

9. 9

   Step 9: The Act’s week is five days, not seven

   Subsection (d-2) defines the terms the arithmetic uses: “For the purposes of computing the compensations provided in this Act, it shall be understood that the week consists of five (5) working days, and the working day of eight (8) hours, unless the investigated facts show that the worker or employee regularly worked in excess of forty (40) hours a week.” If you regularly worked more than forty hours, that exception is yours and it is worth having it in the file.

10. 10

    Step 10: The medical care that comes with the dieta

    Subsection (a) of the same Article 3 covers the other half: the medical care and medicines prescribed, including hospital services where necessary. And it adds a way out: “where in the judgement of the State Insurance Fund Administrator such medical or hospital services should be discontinued, the worker may appeal to the Industrial Commission”. If they cut your treatment off, there is somewhere to go.

11. 11

    Step 11: Three years to closing, and nine exceptions

    Clause (a)(1) sets that “workers’ claims shall be closed for all legal purposes once three (3) years have run from the definitive closing of the case”, except in nine conditions where the effect may occur after a longer lapse: cytotoxics — as the text has it — asbestos exposure, mercury, lead, cadmium, radium, AIDS, hepatitis C and beryllium exposure. Those conditions are evaluated per the established medical protocols.

12. 12

    Step 12: Reopening the case: four conditions

    Clause (a)(2) says only reopening requests filed within a term not exceeding three years from the definitive closing will be processed, and subject to four conditions. (A) That clear and convincing medical evidence of the aggravation or relapse exists. (B) That the originally compensated injury was the sole cause of that aggravation or relapse, with no intervening factor or cause outside the original accident. (C) Where secondary conditions are alleged, that they were caused, precipitated or aggravated by the original condition, with no different agent intervening. (D) That the worker makes the reopening request in writing.

The dietas are paid by the State Insurance Fund within the case already open for the injury; there is no separate application to file. If the Administrator considers the medical or hospital care should be discontinued, the worker may appeal to the Industrial Commission. Reopening for aggravation or relapse is requested in writing. The Act publishes no addresses or phone numbers in Article 3 and we read none here, so we do not invent them: the matter is handled by the CFSE office holding the file.

• Believing the dietas start counting from the date of the accident: the Act counts them from the day you present yourself to the doctor for treatment.
• Waiting in silence while the Fund investigates: the Act says the Administrator “shall order” advances against the dietas in meritorious cases still under investigation.
• Not knowing the investigation has a ceiling: the term is fixed by regulation and may not exceed sixty days.
• Assuming the dieta is the full wage: it is two thirds, and with a weekly ceiling of two hundred dollars.
• Assuming someone who earned little collects proportionally little: there is a floor of sixty dollars a week.
• Counting the week as seven days: for computing the compensation, the Act defines the week as five working days of eight hours.
• Not putting on record that you regularly worked more than forty hours a week: it is the only exception to that definition of the week.
• Believing vocational retraining is paid for the same length of time: there the ceiling drops to twenty-six weeks.
• Letting the three years from definitive closing pass before requesting a reopening, or requesting it verbally rather than in writing.
• Accepting that your treatment is discontinued without appealing: subsection (a) gives the right to appeal that decision to the Industrial Commission.

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