Puerto Rico's State Insurance Fund: pay and your job

The first hours decide the case

If you are injured at work, the first thing is to report it to your employer and be referred to the State Insurance Fund. Act 45 of 1935 governs, and it carries a detail worth knowing from minute one: **compensation runs from the day you present yourself to the doctor** for treatment. Until you go, nothing runs.

The statute also requires the case report in order to receive medical and hospital services and the other benefits, **with the exception of emergency treatment**. That is: in an emergency they treat you first and the paperwork follows, but for everything else the report has to exist.

Do not let anyone route you to your private health plan «to keep it simple». If the injury is work-related, the Fund is the system that applies, and diverting it at the start complicates the claim later.

Who is covered, and yes, you too

The statute applies to **every employer with one or more workers or employees**. There is no small-business exception: a shop with a single employee is covered just like a pharmaceutical plant.

And there is a case that surprises people: the statute also covers the **owner of a business or individual employer who works full time** in it, so long as gross income does not exceed **one million dollars**. If you own and work in your own shop, you may be covered, with your own premium and your own sworn claim form.

What the statute expressly excepts is work of an **accidental or casual** character not falling within the employer's business, industry, profession or occupation.

What it pays: the real numbers

If the disability is temporary or transitory (the most common case) compensation is **66⅔ percent of the daily wage you were earning on the day of the accident**, or would have been earning but for the accident. It is paid weekly in arrears.

The caps are written into the statute and are not negotiable: **never more than $200 nor less than $60 per week**. And the payment period **does not exceed 364 weeks** in any case.

If as part of treatment you are referred to vocational training or retraining, you keep receiving that compensation, but there the cap drops to **26 weeks**.

There is a separate rule for public employees: during the disability they cannot receive weekly compensation that, added to their agency salary, exceeds the regular salary of their position. The exception is any period they are on regular vacation or sick leave.

Fund or SINOT: same injury, very different outcomes

This is the comparison almost nobody puts side by side, and it explains why it matters so much that the case enters through the right door. If the accident happened **at work**, it goes to the Fund. If it happened **outside work**, it goes to SINOT. Look at the difference:

• **How much it pays.** The Fund: 66⅔% of your daily wage, between $60 and $200 weekly. SINOT: a fixed table from $12 to **$113 a week**, no matter what you earn.
• **For how long.** The Fund: up to **364 weeks**. SINOT: **26 weeks** within any 52-week period.
• **From when.** The Fund: from the day you present yourself to the doctor. SINOT: **from the eighth day**, the first week is not paid.
• **Medical treatment.** The Fund covers medical care, medicines and hospital services when necessary. SINOT pays a cash benefit; treatment goes through your own plan.
• **Your job.** Here the two are very similar: both require the employer to hold your position, under nearly identical rules. The difference is when the 12 months start counting, and that the Fund adds damages if the employer fails to comply.

Your job must wait for you, and here are the clocks

Article 5-A is the one to know by heart if you are hurt at work: the employer **is obligated to hold the job** you held at the time of the accident and to reinstate you in it. But under three conditions, and all three must be met:

• **Ask within 15 days.** Counted from when you are medically discharged **or from when you are authorized to work with a continuing right to treatment**, watch that second door, because many cases continue in treatment while the worker is already cleared to work, and that is where the clock starts.
• **Not beyond 12 months from the date of the accident**, or **6 months** if the employer had **15 employees or fewer** on the date of the accident. Note: here the 12 months count **from the accident**, not from when the disability began.
• **Be mentally and physically able** to hold that job at the moment you request reinstatement.
• **That the job still exists.** The statute defines this in your favor: it exists when vacant **or occupied by another worker or employee**. And it is **presumed to have been vacant** if it was filled by someone else within **30 days following** your reinstatement request.

If they do not reinstate you: wages and then some

Here the Fund goes further than SINOT. If the employer does not comply with Article 5-A, it must pay you **the wages you would have earned** had you been reinstated, and it is **also liable for all damages** it caused you. That second item is not in the SINOT statute.

And the statute gives you two routes to claim it: an ordinary court action, or the **summary wage claim procedure of Act 2 of 1961**, which is far faster, the employer has 10 days to answer or judgment is entered against it.

The practical part, and the one thing you cannot neglect: **request reinstatement in writing and keep proof of the date**. Fifteen days from discharge fly by, and the deadline is proven with paper. An email, a text message, a letter with acknowledgment of receipt, any works, but it has to exist.

The rule that works for you when there is doubt

This sentence is in Article 2 and is worth quoting in full, because it is exactly what you need when the employer or the Fund questions whether the injury is work-related: «Being remedial in character, this Act shall be liberally construed, and **any reasonable doubt** arising in its application as to the existence of a causal relationship between the worker's or employee's job or occupation and the injury, disability or death, or as to the occupational character of a disease, **shall be resolved in favor of the worker or employee**, or their beneficiaries».

This is not an abstract principle: it is statutory text. If your case is in the gray zone (a condition that worsened over time, an occupational disease that took a while to appear) that clause is your argument.

It contrasts with what happened in general labor law: Act 4-2017 introduced an interpretation rule that pushes toward federal standards. Act 45 kept its own, and its own favors you.

The three cases that are not compensable

Article 4 is short and closed-ended. No right to compensation arises from accidents occurring in these three circumstances:

• When the worker is attempting to **commit a crime** or to injure the employer or any other person, or when the worker **intentionally causes the injury**.
• When the worker is **intoxicated**, and **only if the intoxication was the cause** of the accident. Both conditions must hold: having been drinking is not enough if it was not the cause.
• When the worker's **reckless imprudence** was the **sole cause** of the injury. Here too the key word is «sole»: if there were other causes, the exception does not apply.

If your employer is not insured

You are still covered. Article 13 provides that the Administrator determines the applicable compensation plus expenses and **bills the employer**, and that debt constitutes a **lien on all the employer's property**, preferred over nearly any other encumbrance.

But the most important part for you is the other one: when the employer failed to insure, you or your beneficiaries may file the compensation petition with the Industrial Commission **and also bring an action for damages against the employer, «just as if this Act did not apply»**.

That means the employer loses the immunity the Fund system normally provides. It is the harshest consequence in the statute, and it exists precisely so that insuring is not optional.

One procedural requirement not to forget: when starting the damages action you must **send a copy of the complaint by certified mail to the Administrator**, and the court will ask for evidence of that notice. If it was not done, the court **gives you fifteen (15) days** to do it; if you do not produce the evidence within that period, **the suit is dismissed**.

**The employer's three classic defenses are no use here.** Article 13 provides that in that proceeding it **shall not be a defense** that the worker was guilty of **contributory negligence**, that they **assumed the risk** of injury, or that the injury was caused by **the negligence of an independent contractor or subcontractor**, unless that contractor was itself insured under the Act. And it closes: **no contract between employer and worker purporting to permit the use of those defenses shall be valid**. What you signed does not give back the defense the statute took away.

There is also a powerful procedural tool: in that action you have the right, **without posting bond**, to **attach the employer's property** in the amount the court determines to secure payment, provided the court finds just cause of action after examining the complaint, **which must be sworn**. That attachment **includes attorney fees**, set by the court, and **is maintained until the case is decided and the judgment satisfied**.

One clarification so nobody expects to collect twice: if the damages action results in a judgment against the employer **in excess of the compensation set by this Act**, that compensation (if paid or secured by a guarantee approved by the court) **is deducted from the judgment**.

While all that runs, you are not left without care. When the employer failed to insure and the dispute is between worker and employer, the worker may go to the Industrial Commission, which **shall handle these cases with all urgency and preference**: upon the worker's statement of the pertinent facts, it **refers them to the Administrator to provide the proper medical assistance**, and once discharged the case is liquidated and billed to the employer. Watch the summonses: the Commission gives employer and worker the opportunity to be heard, and **if a summoned party does not appear, it is understood they waive that right and the Commission may decide by default**.

Closing the case is not always the end

Claims are closed for all legal purposes **three years after the case's final closing**. Within those three years a **reopening** can be requested in writing, and for it to proceed you need **clear and convincing** medical evidence of the aggravation or relapse, and the originally compensated injury must have been **the sole cause**, with no factor unrelated to the original accident intervening.

There is a group of conditions where closing can occur after a longer span, precisely because they take years to appear: exposure to **asbestos, mercury, lead, cadmium, radium and beryllium**, cytotoxics, **AIDS** and **hepatitis C**. They are evaluated under the established medical protocols.

If you worked exposed to any of those agents, that paragraph is the reason it is worth keeping your file even if the case closed years ago.