Medical Benefits

If you are injured in an on the job accident, or are diagnosed with a occupational illness, you may receive reasonable and necessary medical care, as prescribed by an authorized treating health care provider, for conditions related to the injury.

Emergency care: When an injury occurs, if immediate medical attention is needed, emergency care will be paid for, provided the claim is found to be compensable. Initial emergency care is not considered to be a selection of health care provider by either party.

Payment of care: Authorized medical care is paid completely by the employer/insurer. Injured workers should have no out of pocket costs. Health care providers should be directed to the adjuster to obtain prior approval of medical procedures, and all billing should be sent directly to the insurance company. Treatment received for a work-related injury should not be billed to a private health insurance company.

Health care services are covered when:

The service is for a work-related injury or occupational illness;
The service is with an authorized health care provider;
The service provided is reasonable and necessary;
The service has been pre-approved by the adjuster if it is not an emergency situation.

Health care services may not be covered if:

The service is with an unauthorized health care provider;
The service is for a condition not related to the work injury or occupational illness;
The service is determined not to be reasonable and necessary;
The claim for workers’ compensation benefits is denied.

Physicians: Throughout the course of your treatment you may be referred to many different doctors, with different areas of expertise. Below is a general listing of some of the types of physicians who treat workers’ compensation and how and what they do.

General practice or occupational physician: Usually a physician who is on the front line of treatment. Will likely treat your injuries in the beginning and prescribe the necessary medications, or when needed make referrals to specialists.

Orthopaedic physician: Generally diagnoses and treats disease and injuries to the bones or joints. Some specialize in backs, necks, knees, hands, shoulders and surgery to these areas. Extensively trained in surgery to these areas.

Neurosurgeon: Generally diagnoses and treats injuries to the brain, head, neck, back and neurological problems relating to these areas. Extensively trained in surgery in these areas.

Neurologist: Generally diagnoses and treats injuries to nerves and diseases affecting nerves. This doctor, highly trained in testing procedures, does not perform surgery.

Physiatrist: Soft tissue injury specialists. Generally treats injuries and problems which are not surgical in nature or people who have had surgery and need rehabilitation. This doctor does not perform surgery.

Physical Medicine and Rehabilitation: Generally treats injuries and pain and related problems with medicine and rehabilitative techniques.

Pain Management Specialist: Generally treats pain and related problems of a chronic nature with medicine and some invasive surgery.

Psychiatrist: Generally diagnoses and treats mental injuries and problems associated therewith. May refer to psychologist for testing or counseling. A psychiatrist is a medical doctor and can prescribe medication.

Psychologist: Generally diagnoses and treats mental and behavioral problems or depression or psychological or psychiatric problems from injuries. Highly trained in testing procedures and counseling.

General Surgeon: Generally diagnoses and treats injuries which need surgery and are not in the orthopedist or neurosurgeon’s expertise.

Ophthalmologist: Generally treats and diagnoses problems and injuries to the visual senses.

Chiropractor: Generally treats and diagnoses spinal and soft- tissue injuries of a non-surgical nature. Renders therapy to treat problems resulting from a lack of normal nerve functions. Employs manipulation and adjustments to body structure.

Physical therapist: Generally provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities. Work under the direction of a referring physician.

Independent Medical Examination:

In some cases a worker may be required to be examined by a doctor other than the authorized treating physician, for the purpose of providing an independent evaluation of the worker’s medical condition and treatment plan. This is called an Independent Medical Examination (IME).

Both the claims representative and the worker can request an IME under certain circumstances, such as a disagreement between doctors or a surgical evaluation. If the parties are unable to agree to an IME, either party may seek IME approval from a Workers’ Compensation Judge.

Temporary Total/Partial Disability

Temporary Total Disability (TTD) is a disability benefit paid when an injured worker is temporally totally disabled from his job duties. Benefits are generally paid every two weeks.

The authorized treating health care provider has the responsibility of determining whether or not the injured worker should be taken off work or returned to his job duties. It is not the decision of the employer, injured worker, attorney or adjuster.
If an injured worker is taken off of work by an authorized health care provider, for more than 7 calendar days, TTD may be owed. The first 7 days are a waiting period and are not paid unless the worker is kept off work for 28 calendar days of work.
TTD is calculated by obtaining the pre-injury average weekly wage (AWW) and multiplying it by sixty-six and two-thirds percent. However, the benefit level cannot be higher than yearly maximum benefit. This amount is determined each year by the state Department of Labor. In most instances is can not be less than $36.00 a week, the state minimum.
AWW is calculated by adding the total gross wages paid to the worker during the 26 weeks preceding the injury. If 26 weeks of wages are not available then the average weekly wage is based on the total amount of wages earned during the term of employment, and dividing by the total number of week employed.
EXAMPLE: Bob injures his back while lifting a box of supplies. His pre-injury AWW is determined to be $500.00. He is taken off work by Dr. Smith for at least 4 weeks. Bob’s weekly TTD rate is $333.35 ($500.00 x 66.67%)
If a judge approves, benefits may be suspended if you fail to comply with prescribed therapies or doctor’s orders, fail to keep medical appointments, or refuse to return to work at light duty.
TTD benefits cease when the employer makes a written job offer at pre-injury wages or maximum medical improvement (MMI) is reached.

MMI is reached when further recovery from or lasting improvement to an injury can no longer be reasonably anticipated based upon a reasonable medical probability as determined by the authorized healthcare provider.

Temporary Partial Disability (TPD) is paid when an injured worker has not yet reached MMI, but is able to return to work in a different capacity or on a part time basis at a reduced rate of pay.

TPD is calculated by subtracting the post injury wage from the pre-injury wage and multiplying by sixty-six and two-thirds (.667) percent.

EXAMPLE: Bob is released to return to work with no lifting over 25#. The employer is able to accommodate the restrictions, but only for 20 hours a week. Bob will be paid $250 a week working light duty. TPD will be paid at a weekly rate of $166.68 ($500 – $250 = $250 x 66.67% = $166.68).
To calculate TPD the claims adjuster must be provided with post injury wage information from the employer or a copy of the injured worker’s check stub. This can be provided either by the employer or the employee. Faxing or emailing the information will help the adjuster to process the TPD check the fastest.

Permanent Partial Disability

Permanent Partial Disability (PPD) is a disability benefit paid when an injured worker has reached Maximum Medical Improvement (MMI) and suffers a permanent physical impairment. In these cases the authorized health care provider will determine if there is a permanent physical impairment as defined by the American Medical Association Guides to the Evaluation of Permanent Impairment.

MMI is reached when further recovery from or lasting improvement to an injury can no longer be reasonably anticipated based upon a reasonable medical probability as determined by the authorized healthcare provider.
PPD is paid for a specific number of weeks, based on the body part injured. These benefits are not a wage replacement benefit, and will be paid as a percentage of the compensation rate.

The number of weeks of PPD benefits paid is completely dependent on the body part injured, and can range from 7 weeks for a injury to the 4th finger to 150 weeks for a injury to the knee, to 500 weeks or 700 weeks for a whole body injury.
EXAMPLE: Bob injured his knee while working. Surgery was required to repair a meniscus tear. After MMI a 3% impairment was assigned to the knee by the authorized treating physician. For the 3% impairment rating Bob will receive 3% of his compensation rate of $333.33, for 150 weeks or ($1,500.00 total).
A worker may also be entitled to compensation for loss of use for an injury to an extremity. This can be discussed with the adjuster.
In some cases when an injured worker has been unable to return to work making pre-injury wages, additional benefits are added based on the injured worker’s age, education, training, work history, vocational preparation and residual physical capacity.

Generally PPD benefits are paid bi-weekly. However, a lump sum payment may be allowed with the approval of a judge.

After the injured worker has reached MMI, a partial lump sum may be received for the sole purpose of paying debts that accumulated during the disability period (period TTD was paid). Reasonable and necessary medical care with the authorized doctor will remain open.
A worker may elect to receive a lump sum if they have return to work for at least 6 months making at least 80% of their pre-injury AWW. If this type of lump sum is received the worker is not entitled to any additional monetary benefits, even if their condition worsens at a later date. Additionally, the insured is allowed to take a present day discount in cases of a lump sum for return to work. Reasonable and necessary medical care with the authorized doctor will remain open.
If both sides agree, a lump sum payment can be made to close all benefits due the worker. This can include past, present and future disability benefits as well as future medical benefits.

Any lump sum payment requires the completion of paperwork and the approval of a Workers’ Compensation Judge.