The workers’ compensation system is fraught with specialized jargon and unique requirements. Workers already dealing with the stress of an injury often find the claims process overwhelming. They may find many of the rules confusing.
The medical professional overseeing a claim and treating a worker is in a position of trust and authority. Their determinations can have a profound impact on what benefits the worker receives. If a doctor believes that the worker has achieved maximum medical improvement (MMI), that can have major implications for their eligibility for benefits in the future.
When does the worker achieve MMI?
The best outcome for a workers’ compensation claim is when an employee makes a full recovery. They break a bone, and the bone knits. They regain their lost strength and range of motion and can return to their employment as usual. Other times, workers have lingering symptoms. The physician providing their care recognizes that a full recovery is unlikely even with continued treatment.
They may determine that the worker has achieved MMI when additional treatment is unlikely to have any significant impact on their recovery or function. A patient may achieve MMI when they are no longer at risk of worsening their injury or have regained as much function as is likely.
How can MMI affect a claim?
A physician’s determination that a worker achieved MMI affects their benefits in two significant ways. The first is that the worker may no longer be eligible for ongoing treatment-related benefits. If they are unlikely to respond positively to traditional treatment, then workers’ compensation may not pay for additional treatment expenses. However, they may require ongoing medical benefits for symptom management and condition maintenance.
A determination that a worker achieved MMI can also affect their eligibility for disability benefits. When a physician believes a worker cannot fully recover, they may become eligible for permanent partial disability benefits. In more severe cases where they cannot work at all because of their functional limitations, they may be eligible for permanent total disability benefits.
It can be very difficult to navigate a claim in a scenario where a physician believes that additional treatment is unlikely to result in a positive outcome for the injured employee. Workers may need help optimizing the benefits they receive, negotiating a permanent partial disability benefit settlement or raising questions about the MMI designation.
Understanding the different rules that apply in complex workers’ compensation claims can help employees limit the losses they incur. Those with permanent symptoms often have a greater need for support throughout the claims process. Seeking legal guidance, therefore, is generally wise.
