How Long Can a Workers’ Comp Claim Stay Open?

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Each state manages its own workers’ compensation system and determines how long a Workers’ Comp Claim can stay open. So, the answer to this question varies by state. In general, workers’ compensation benefits usually last between one and three years. A few states are higher and a few states are lower. Claims in low-end states often have MMI (maximum medical improvement) issues.

Basically, MMI means physical therapy has plateaued and the victim won’t improve. So, if a state has less than a one-year cutoff, victims may be unable to complete physical therapy and reach MMI. In other words, these victims are still partially disabled but they aren’t entitled to partial disability benefits.

These same rules apply to both trauma injuries and occupational diseases. Trauma injuries, like falls, occur suddenly and without warning. Occupational diseases, like hearing loss, occur slowly over time.

Lost Wage Replacement

Most state workers’ compensation laws include a two-week waiting period for partial lost wage replacement benefits. After that, temporarily disabled victims are entitled to two-thirds of their average weekly wage (AWW) for the duration of those temporary disabilities.

A student’s grade point average changes over time. Hopefully, it goes up instead of down. Likewise, a worker’s AWW changes over time. It almost always goes up.

Assume an NFL player is hurt the week before training camp ends. During the offseason, many football players get nothing. During training camp, many players only get per diem allowances. Once games start, their incomes go through the roof.

Based on prior wages over the last six months, the NFL player’s AWW might be almost zero. His wage replacement benefits should reflect the time he will miss because of injury.

On a related note, the AWW includes more than regular cash compensation. It also includes per diem, expense reimbursement, and other irregular or non-cash compensation.

Insurance companies usually give permanently disabled victims lump-sum payments. The size of that payment depends on the nature and extent of the disability, as well as a few other factors. Insurance companies often make offers without considering the facts. For example, if Tim is an avid jogger and he has a knee disability, he’ll probably have to miss work in the future when his bad knee acts up.

Medical Bill Payment

Most likely, Tim will also incur future medical bills. He shouldn’t have to file a new workers’ comp claim every time the knee acts up. So, his initial disability settlement should include money for future medical bills well outside the initial one to three year coverage period.
Insurance company lawyers typically use generic charts to make future medical bill payment offers. Workers’ compensation lawyers typically partner with independent doctors who assess these cases and make recommendations. The second way is almost always the best way.
During the initial period, the medical bill payment benefit covers all reasonably necessary medical expenses, from the first moment of emergency care to the last day of physical therapy. Workers’ comp also covers medical devices, prescription drugs, and other ancillary medical costs.

How Long Can You Be on Workers’ Comp in California?

Typically, the Golden State is on the cutting edge of legal affairs. But in terms of workers’ compensation length, California is straight down the middle. Most states are between one and three years. Job injury victims in California can be on workers’ comp for up to two years. The Golden State does have an unusual wrinkle. The 104 weeks don’t have to be consecutive. This rule makes sense. As job injury victims recover, they often have good weeks and bad weeks.

During these two years, job injury victims receive important benefits, mostly lost wage replacement and medical bill payment. These benefits are no fault, which means a victim doesn’t have to prove negligence or anything else, except that the injury was work related. California has a strong exclusive remedy law, which means that most job injury victims must file for workers’ comp. A few victims can sue outside the system and obtain additional compensation.

During the 104 Weeks of Workers’ Comp in California

We mentioned lost wage replacement and medical bill payment above. Now, let’s break it down a little further.

Victims who can return to work within 104 weeks are temporary disability victims. In most cases, the workers’ compensation insurance company must pay two-thirds of the victim’s average weekly wage (AWW) for the duration of that temporary disability.

Most insurance companies only use prior cash wages to calculate the AWW. That’s a good start, but it’s not enough. The AWW also includes lost future compensation. For example, if Kim is hurt at her retail job in November, she’ll miss December overtime opportunities. Her lost wage replacement checks must reflect those losses.

Additionally, the AWW includes non-cash compensation. Housing allowances and school tuition payments are very common employee benefits.

California law requires workers’ comp insurance companies to pay reasonably necessary medical bills. To most insurance adjusters, this phrase means “lowest possible” medical bills. If Kim needs physical therapy, which she probably will, the insurance company sends her to a cut-rate provider that’s probably affiliated with the insurance company. If Kim has a lawyer, she’ll get the PT she needs, as opposed to the PT an adjuster pays for.

After the 104 Weeks of Workers’ Comp in California

If the injury recovery process lasts more than 104 weeks, victims may be entitled to permanent disability payments.

Future lost wage replacement payments depend on the nature and extent of the medical disability. These payments also depend on the victim’s future employability. If Lisa’s knee injury leads to permanent loss of motion, she probably can’t ever work retail again.

Total disability victims are also entitled to future medical bill payments. Usually, the insurance company offers a “buyout,” or an additional lump sum payment to cover these expenses. These buyouts are usually bad deals for victims. Because of inflation, today’s dollar is usually worth less than tomorrow’s dollar. Lawyers help ensure that victims get dollar-for-dollar future medical bill payment awards.

Curious to know what the average maximum worker’s comp pay out is per body part?  Check out our workers comp settlement chart.

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Bret Thurman

Bret is a former lawyer and full-time writer who knows how to simplify complex topics. He received his law degree from the University of Texas at Austin. For over twenty years, he handled a wide variety of cases, including criminal defense, personal injury, family law, and consumer bankruptcy.

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