Usually, workers’ comp lasts until job injury victims reach maximum medical improvement (MMI).  Basically, MMI means further medical treatment won’t improve the victim’s condition. If Adam breaks his shoulder at work, he may permanently lose some range of motion in that joint, no matter how much treatment he receives. He may also be at risk for frozen shoulder and other more serious maladies, once again no matter how much treatment he received.

However, many states limit workers’ compensation benefits to under two years. When that period expires, many victims haven’t reached MMI and they don’t qualify for permanent disability payments. That’s a pretty bad place. Workers’ compensation length also depends on whether victims can choose their own doctors. Company doctors often quickly apply the MMI tag and cut off workers’ compensation benefits.

Types of Workplace Injuries

So far, we’ve focused on workplace trauma injuries, like falls. Most workers’ compensation claims are based on such injuries. Falls are also common at construction sites. Year after year, construction is at or near the top of those “most dangerous jobs” lists. Other trauma injuries, especially at construction sites, include caught between, electrocution, and struck-by injuries.

Incidentally, offshore workers, like fishers and energy exploration workers, are usually at or near the tops of those lists as well. Generally, these trauma injury victims have almost no immediate access to medical help.

Workers’ compensation benefits also apply to occupational diseases. These conditions develop over the course of more than one work shift.

Hearing loss is a good example. This condition is the most common occupational disease in the United States. If doctors intervene quickly enough, this condition is treatable. Any undue delay usually means the only option is risky and radical surgery to repair or replace the eardrum.

Such occupational diseases are also subject to the MMI rule, at least in most states. If Mary’s hearing is badly damaged, she may never hear things normally again, despite the best efforts of medical professionals.

Extending Workers’ Compensation Benefits

As mentioned, many doctors try to pull the plug too early. Attorneys intervene in these situations to keep the money flowing, so victims can keep getting therapy and keep improving.

The aforementioned disability determination may also come into play. If workers’ comp benefits end before victims reach MMI, insurance company lawyers typically argue that, based on their medical conditions, these victims aren’t entitled to permanent disability benefits. However, a “disability” is more than a medical term. This D-word also has educational, vocational, and other implications. Attorneys make such arguments in Administrative Law Judge appeal hearings.

In 2020, the total cost of job injury claims, mostly workers’ compensation benefits, exceeded $160 billion. These claims are so expensive that insurance companies will do almost anything to reduce these costs. Frequently, job injury victims unwittingly do some things, or don’t do some things, that help insurance companies reduce these costs. That means lower benefits for injured workers and their families.

Briefly, workers’ compensation is no-fault benefits that replace lost wages and pay medical bills connected to a job-related illness or injury. These victims don’t have to prove fault. However, they must prove the full extent of their losses. Any mistake during the claims process makes it almost impossible to meet this burden of proof.

Don’t Assume the Insurance Company Will Pay

First and foremost, never assume the insurance company will do the right thing and pay the claim. As mentioned, workers’ compensation claims are very costly. Insurance companies, like most other companies, are mostly interested in making money. They care little or nothing about the welfare of individual workers, especially since these workers don’t pay monthly premiums.

Don’t Do Normal Things

Overall, most lawyers suggest that recovering job injury victims do not do anything “normal.” If you normally pick up your children after school, make alternative arrangements. If you normally do the family grocery shopping, delegate that task to someone else. During initial reviews, Claims Examiners often ask about such items. If a victim is able to do everything except work, that omission looks suspicious. As far as many Claims Examiners are concerned, the mere suspicion of fraud is tantamount to fraud itself.

On a related note, when job injury victims appear at Claims Examiner hearings, we usually suggest they look injured. Act as if you’re having a bad day, even if you’re having a good day. To some extent, we all make judgments based on appearances. That’s a very bad habit, but that’s just the way it is. Something as simple as using or not using a cane could make a difference in a close case.

Don’t Disobey the Doctor

Also before the Claims Examiner hearing, follow a doctor’s instructions to the letter. This step is not as easy as it sounds, especially in some states. Many job injury victims must see company doctors, or doctors that have the company’s approval. Additionally, in some states, job injury victims are not entitled to second opinions.

Even in these states, a workers’ compensation attorney can usually set up an IME (independent medical examination), which is tantamount to a second opinion. Typically, IME doctors charge nothing upfront for their professional services.

If job injury victims disobey a doctor’s instructions, even if the instructions seem wrong, the victim might as well rubber-stamp the claim as “denied.”

Don’t Worry

We cannot stress this enough. An initial denial does not mean your claim is weak or meritless. So, do not figure that something is better than nothing and accept a low-ball settlement offer. Instead, turn your case over to your attorney and let your lawyer work for you.

In some cases, a workers’ compensation settlement is just around the corner. Most states have strong bad faith insurance laws. These companies act in bad faith when they refuse to pay valid claims. It’s also bad faith to delay an investigation or rubber-stamp a claim as “valid” or “invalid.” So, if the issues are clear, most workers’ compensation insurance companies must settle claims within a few weeks. However, as outlined below, the issues in a workers’ compensation case are seldom clear.

Therefore, most claims must go through all, or most of, the workers’ compensation process. This process begins with an injury report. Next, a Claims Examiner reviews the paperwork in the case, mostly the medical bills, and makes a decision. Most Claims Examiners deny most workers’ compensation claims, at least in part. When the case reaches the Administrative Law Judge appeal stage, an attorney has a better chance to clear up lingering issues and settle cases on favorable terms.

Medical Bill Issues

Most states require workers’ compensation insurance companies to pay all “reasonably necessary” medical bills. Unfortunately for victims, many insurance adjusters don’t use the facts of the case to decide what’s reasonably necessary.

The first workers’ compensation systems appeared around 1910. Since so much time has passed, more companies now evaluate medical bills like football coaches scout opponents. If a team has always run to the right on third and short, it’ll probably run to the right again. In the past, if X injury cost Y dollars in Z location, it’ll probably cost X dollars again.

The facts of the case could change any of these calculations. For example, if Mike sustains a serious trauma injury at work and all the trauma centers in Z location are full, Mike must go somewhere else.

Incidentally, workers’ comp settlements not only cover doctor bills. They also cover related expenses, such as emergency transportation, medical devices, and prescription drugs.

Lost Wage Replacement Issues in Workers’ Comp Settlements

Current lost wages are relatively easy to determine. However, some insurance company adjusters keep a thumb on the scale, so an attorney must be vigilant.

Future lost wages are different. Let’s go back to Mike. Assume he sustains a serious trauma injury, like a fall from a height, that causes significant loss of mobility. When it comes to future lost wages, a company doctor might approve nothing, reasoning that Mike can tough it out and work full speed. Another doctor might say that Mike must limit his work hours and activities for the rest of his life. That’s a very big difference.