P.R. Laws tit. 9, § 2054
(1) General.—
(a) Benefits.— The benefits provided herein include disability payments, medical hospital services, chiropractor services, dismemberment, death, and funeral expenses.
(b) Payable benefits and available services.— The payable benefits shall be as hereinbelow stipulated, after deducting therefrom any other benefits from other insurance programs to which the victim or his beneficiaries are eligible and which deduction is provided for hereunder.
(c) If the victim receives from the Administration services to which he is eligible under other insurance programs and for which deduction is herein provided, and said deduction is not made in the cases where it applies, the amount of the corresponding deduction shall be deducted from the benefits to which the victim is entitled in accordance with said programs and shall be paid by the agency in charge of the administration of said programs directly to the Administration, up to the limit of the coverage of the insurance programs.
(d) If a victim eligible to weekly compensation benefits for bodily injuries has received from the State Insurance Fund, by reason of the same automobile accident, benefit payments for transitory disability and the Manager of the Fund decides that the injury of the victim is one of non-occupational nature, said payments shall be deducted from the weekly compensation benefits to which he is entitled under this chapter. This deduction shall never be made for an amount exceeding the weekly compensation benefits to which the victim is entitled. The amount so deducted shall be reimbursed by the Administration to the State Insurance Fund, upon previous presentation by the Manager of the Fund of a certified voucher showing liquidation of the payments made to the victim.
(e) The claiming and obtaining of benefits by a claimant under the provisions of this chapter through false information or statements shall be a violation of Article 225 of the 1974 Penal Code or of any subsequent penal provision that typifies the crime of perjury.
(f) If the victim receives payments from other sources for medical-surgical and hospitalization services rendered as provided in this chapter, the Administration may recover from him or his beneficiaries up to a sum equal to the value of the services rendered.
(g) Deductible benefits.— All benefits or advantages that the victim or his beneficiaries may receive or may be entitled to receive from other sources on account of the injuries suffered shall be deducted from the benefits corresponding to him under this chapter, except when otherwise provided herein. Whenever the victim uses the services provided by this chapter, the payments that he or his beneficiaries may receive or may be entitled to receive from other insurance programs by reason of said services shall be paid to the Administration, up to a sum not to exceed the amount expended by the Administration to render said service.
(h) Nondeductible benefits.— The following benefits shall be considered nondeductible benefits and shall not diminish the amount to be collected or received from the Administration, nor shall they be payable to the Administration in case the services herein provided are used:
(i) Benefits by reason of the obligation of the family support;
(ii) inheritance estates;
(iii) life insurance;
(iv) gifts;
(v) social security benefits.
Payments made by the employer to his employees shall not be considered as gifts.
(i) The death benefit provided in subsection (4) of this section shall be paid provided the victim dies as a result of the injuries suffered within one (1) year after the date of the accident.
(j) If the injuries suffered in an accident caused the losses set forth in subsection (2) of this section within fifty-two (52) weeks after the date of the accident, the Administration shall pay the sum provided for such losses.
(k) The Board of Directors of the Administration, with the approval of the Commissioner of Insurance of Puerto Rico, shall increase the benefits provided by this chapter, including payments for disability, medical-hospital services, dismemberment, death and funeral expenses benefits. The Office of Commissioner of Insurance shall have sixty (60) days to determine the source or denial of the increase proposed by the Board of Directors of AACA. If said sixty (60) days elapse without any statement from the Office of Commissioner of Insurance, it shall be understood that there is no objection to the proposed benefits increase and they shall take effect immediately and/or on the date provided in the determination of increase made by the Board of Directors of AACA.
(2) Benefits for dismemberment.— The following benefits for dismemberment shall be paid by the Administration in the event the indicated disabilities occur: Loss of sight of both (2) eyes $ 10,000 Loss of both (2) feet at or above the ankle 10,000 Loss of both (2) arms at or above the wrist 10,000 Loss of one (1) arm and one (1) leg 10,000 Loss of one (1) arm at or above the wrist 7,500 Loss of one (1) leg at or above the ankle 7,500 Loss of one (1) hand or one (1) foot 5,000 Total loss of sight of one (1) eye 5,000 Loss of at least three (3) fingers or three (3) toes 2,500 In case a person suffers more than one (1) of the losses indicated above, the maximum amount for all the losses shall be ten thousand [dollars] ($10,000).
(3) Compensation for loss of income due to disability; reinstatement.—
(a) Compensation.—
(i) If within the twenty (20) days following the date of the accident the injuries received disable a victim other than a housewife, the Administration shall pay to him a benefit for loss of income by disability. Said benefit shall be equivalent to fifty percent (50%) of the weekly income not received by the victim, subject to a maximum of one hundred dollars ($100) weekly while he is disabled, during the first fifty-two (52) weeks reckoning from the date of the accident, and to fifty percent (50%) of the weekly income not received by the victim, subject to a maximum of one hundred dollars ($50) weekly while he is disabled, during the subsequent fifty-two (52) weeks.
(ii) To avail oneself of the benefit of weekly compensation it shall be required that at the time of the accident or during any six (6) of the twelve (12) months preceding same the victim was holding a remunerated job or performing an activity or engaged in a profession or in an income-yielding business of his own.
(iii) The regular disability benefit provided by this subsection shall not be paid during the first fifteen (15) days following the date the disability begins.
(iv) For the purposes of computing the compensation contemplated in this chapter, there shall be understood that the week consists of five (5) working days and the workday of eight (8) hours; except that from the facts investigated it is deduced that the victim worked regularly more than forty (40) hours a week.
(v) The loss of income shall be determined by taking as a basis the income earned by the victim at the time of the accident. If the victim had then no income, the loss of income shall be computed on the basis of the equivalent of the average weekly income earned by him during the last six (6) of the last twelve (12) months immediately preceding the accident, when he was holding a remunerated job or performed an activity or engaged in a profession or in an income-yielding business of his own.
(vi) The Administration shall by regulation ad hoc establish the criteria that may facilitate the determination of loss of income of the victims.
(vii) When the disabled victim is a housewife (man) the Administration shall pay the victim a benefit of twenty-five dollars ($25) a week subject to a maximum of sixteen (16) weeks.
(viii) The loss of income requirement to be entitled to collect weekly compensation for total and continuous disability shall be deemed as established even though the claimant continues to receive regular salary payments for accumulated vacation leave, it being understood that in such a case there is a real loss of income. However, there shall be no loss of income when one continues to receive regular salary for accumulated sick leave; in that case, the loss of income shall be established solely if the victim would have been entitled to liquidate his sick leave accumulated and not used, in cash, some time within the term of one (1) year from the date of the accident, in which case all the time that the victim is absent from work due to injuries suffered in the accident shall be counted as accumulated and then the loss of income shall be determined in accordance with what was actually earned or not earned.
(b) Reinstatement.— In the cases of disability covered by this chapter, when the injured person is employed, the employer shall reserve the job the worker was doing when the disability commenced and to reinstate the worker in it, subject to the following conditions:
(i) That the worker requires the employer to reinstate him in said job within the term of fifteen (15) days, counting from the date he is discharged from treatment, provided said requirement is not made after six (6) months have passed from the date of inception of the disability;
(ii) that the worker is mentally and physically able to fill said job when he asks the employer for reinstatement, and
(iii) that said job exists when the worker requests reinstatement. It shall be understood that the job exists when it is vacant or filled by another worker. It shall be presumed that the job was vacant when it was filled by another worker within thirty (30) days following the date the reinstatement was requested.
If the employer does not comply with the provisions of this clause, he shall be bound to pay the worker or beneficiaries the wages said worker would have earned if reinstated. He shall also be liable for any damages caused. The worker or his beneficiaries shall file and process the corresponding claim for reinstatement and/or damages in court by ordinary proceedings or by means of a wage claim procedure established in §§ 3118—3132 of Title 32.
(4) Death benefits.—
(a) A death benefit of one thousand dollars ($1,000) shall be paid for funeral expenses. This benefit may be paid, up to the sum of the expenses incurred, to any person who produces acceptable evidence to the Administration of having incurred the funeral expenses of the victim. Any remaining balance shall be paid to the beneficiaries of the victim.
(b) There shall also be paid the following death benefits following the classifications established in § 2053a of this title and subject to the conditions hereinbelow indicated:
(i) $ 10,000 to the primary dependent
(ii) $ 1,000 to each secondary dependent up to a maximum of $ 5,000.
(iii) The following benefits to the children of the victim:
$ 5,000 for each disabled child regardless of his age
$ 5,000 for each child four (4) years of age or under
$ 4,000 for each child over four (4) years, but under ten (10) years
$ 3,000 for each child ten (10) years or more but under fifteen (15) years
$ 2,000 for each child fifteen (15) years of age or over, but under eighteen (18) years; those children between the ages of eighteen (18) and twenty-one (21) years who depended on the victim and were students at the time of the accident shall also be entitled to this benefit.
If the benefit for the children, computed according to the preceding formula, exceeds ten thousand dollars ($10,000), each one’s benefit shall be adjusted by multiplying ten thousand dollars ($10,000) by the ratio there is between the benefit corresponding to each child according to the above scale and the sum total of the benefits corresponding to all the children, according to that scale.
If the children also qualify as primary dependents, the benefit corresponding to each one shall be determined by multiplying ten thousand dollars ($10,000) by the ratio there is between the benefit corresponding to each child as such, and the sum total of the benefits corresponding to all the children as such, according to the provisions of this section.
(c) For the purposes of the death benefit there shall be considered as:
(i) Primary dependent:
(I) The wife of the victim, or in lieu thereof
(II) the husband of the victim, or in lieu thereof
(III) the children of the victim, or in lieu thereof
(IV) the parents of the victim.
(ii) Secondary dependent:
(I) The parents of the victim when they do not qualify as primary dependent, or in lieu thereof
(II) other dependents.
(5) Medical hospital and chiropractor benefits.—
(a) The victim shall be entitled to receive medical and chiropractor services, and hospitalization and convalescence home services, and rehabilitation services and medicines that may be reasonably required by his/her condition during the two (2) -year term following the accident, which may be available within the jurisdiction of the Commonwealth of Puerto Rico. In the case of paraplegics and quadriplegics, and in cases of severe trauma and/or multiple fractures with complications of such a nature as to require prolonged medical treatment, said services may be given for a term longer than two (2) years as provided by the Board through regulations.
In connection with the above, “severe trauma” shall mean injuries whose treatment and rehabilitation require a term longer than two (2) years, in the judgment of a medical evaluation committee created by the Administration.
(b) The Administration shall provide said services under contract with physicians and facilities, or directly according to the limits, criteria, and methods of providing services which it establishes through regulations to such effects. If the victim receives emergency treatment in hospital or other types of facilities which do not have service contracts with the Administration, or if the latter authorizes the victim to use such facilities, they shall provide the services and the Administration shall pay them for the cost of the services rendered based on an average of the rates used by the Administration at present to pay for similar services to hospitals, physicians, laboratories and other entities which provide health services under contract in the area they are located. In the event the victim has paid for such services, he/she would be entitled to claim from the Administration the cost of such services on the basis of the above-stated average.
The invoices for claims for health services rendered shall be filed no later than one hundred twenty (120) days as of the date on which the services were rendered.
All claims with respect to the return of invoices or payments made by the Administration for health services invoices shall be filed within forty-five (45) days as of the date of the payment.
When the last day to file invoices for claims on time is Saturday, Sunday, or a non-working holiday for the Administration, said invoices shall be considered as filed on time, as long as they are filed on the next working day.
The Administration shall not pay invoices received after the deadline for their filing.
All terms and conditions established in this clause are of a jurisdictional nature and non-compliance therewith bars the Administration or the Court with authority from considering such matters.
History —June 26, 1968, No. 138, p. 335, § 4; Mar. 20, 1972, No. 7, p. 16; June 27, 1972, No. 28, p. 430; June 4, 1974, No. 53, Part 1, p. 217, § 1; July 23, 1974, No. 180, Part 2, p. 49, § 2; renumbered as § 5 and amended on Oct. 30, 1975, No. 12, p. 782, § 3; July 1, 1986, No. 54, p. 185, § 3; June 26, 1987, No. 45, p. 148, § 2; Jan. 8, 2004, No. 15, § 1; Sept. 21, 2004, No. 387, § 2; May 9, 2008, No. 57, § 1; Dec. 30, 2009, No. 222, § 1.