Why You Should Understand Maximum Medical Improvement Benefits

If you’ve been injured at work and are receiving workers compensation benefits, it is important to understand the perspective of those paying your benefits. Knowing your legal options will help you get the justice you deserve under Chapter 440 of the Florida workers compensation law.

A Goal of Your Employer and Insurance Carrier Is to Terminate Your Benefits

Employers and insurance companies (aka insurance carriers) have one goal in mind, which is motivated by money. They want to get you to the point of Maximum Medical Improvement (MMI) and shut off your benefits.

Learn more about your rights under the Florida workers’ compensation law.

Frequently Asked Questions About MMI

What Is Maximum Medical Improvement (MMI)?

It is the date upon which a treating medical doctor concludes that you are no longer in a stage of curative treatment. They determine that essentially you have reached a plateau in recovery from your injury. You are the best you will be, whether you are fully recovered or not. When a physician identifies your MMI, they communicate it to the claims adjuster at the insurance company which pays your worker’s compensation claims. A claims adjuster is the employee handling the communications and the claim for the employer and insurance carrier.

Often, a claims adjuster will suspend an employee’s benefits after receiving an opinion from a physician that the employee has reached MMI. If a surgeon determines there is no longer curative treatment to offer you, that surgeon then discharges you from their practice. From a treating surgeon’s perspective, there is nothing else to be done.

If Your Injury Prevents You from Working Ever Again

However, this determination is not the end of the employee’s rights under Chapter 440 of the Florida Workers’ Compensation Statutes. If your injury is serious enough that you can no longer work, you can received life-long benefits. Chapter 440 provides life-long benefits and medical treatment for injuries sustained in the course and scope of work. It must also be clear that the work accident remains the major contributing cause of the need for care and treatment.

What Are Impairment Ratings?

The severity of your injury will impact your ability to work in different ways. To determine how much an injury may impair your ability to work, a rating of your impairment must be provided by a medical professional. An evaluation to assign your impairment rating happens when you reach MMI.  When your treating physician’s evaluation of the this impairment rating is anything greater than 0%, it means the employee has sustained a permanent injury and is entitled to additional benefits.

What Are Impairment Benefits?

Impairment Benefits (IBs) are automatic compensation owed to an employee based upon the percentage of impairment assigned. For instance, if an employee receives an impairment rating of 6%, he or she is entitled to receive compensation 2 weeks for every impairment point, or 12 weeks based upon his temporary total disability (TTD) rate.

If the employee has an IR of greater than 10%, the employee is entitled to receive 3 weeks for each percentage point.

How Do Impairment Ratings and Impairment Benefits Affect My Rights Under Chapter 440?

As per Florida Statute 440.15, the following are the Impairment Benefits an employee is entitled to as matter of law:

  1. Two weeks of benefits are to be paid to the employee for each percentage point of impairment from 1 percent up to and including 10 percent.
  2. For each percentage point of impairment from 11 percent up to and including 15 percent, 3 weeks of benefits are to be paid.
  3. For each percentage point of impairment from 16 percent up to and including 20 percent, 4 weeks of benefits are to be paid.
  4. For each percentage point of impairment from 21 percent and higher, 6 weeks of benefits are to be paid.

If an insurance company does not pay these benefits within 7 days of receiving the IR from the treating physician, the employee may be entitled to penalties of 20% plus interest.

Further, an employee may only receive an IR for one area of his or her body injured, and may still have to receive an IR from a physician for the other body parts. Unless and until an employee is assigned MMI for all areas of his body injured in a compensable work accident, he or she is still entitled to receive temporary disability benefits (payments for wages while not working due to a disabling condition/injury).

Remember:

If the insurance company can save money by not paying Impairment Benefits, many such companies will intentionally withhold paying the IBs until the employee obtains an attorney and files a petition for benefits. The workers compensation attorneys at Feldman Williams get justice for workers. Call us for help in your case.

If I Reach MMI Can the Insurance Carrier Stop Providing Me Medical Treatment?

Generally, the answer is NO.

First, even assuming a treating physician has placed you at MMI with a 0% Impairment Rating, and released you to full duty, you may have the right to challenge this opinion with a request for a one time change in treating physician. Additionally, you can obtain an alternative opinion — an Independent Medical Evaluation or IME — from an independent treating physician of your own choosing to challenge the opinion.

Learn more about what can happen after you reach MMI.

How do the insurance carriers get physicians to place employees at MMI with a 0%?

Easy. They set up conferences, with or without their own attorneys, and use nurses to pressure the physicians to place the employees at MMI and to assign 0% IRs. The goal is to shut down the employee’s benefits.

The insurance carriers select treating physicians who they know will act in the best interests of the insurance carrier. They expect the physicians will discharge employees and assign them MMI very quickly to end the worker’s compensation benefits. These are the treating physicians the insurance carriers have on their approved lists. If the treating physicians do not cooperate with the insurance carriers and provide them with expeditious MMI and 0% IR’s, they will be removed from the lists and no longer assigned patients. So, these physicians know the requirements and expectations. In some cases, they will literally place a patient at MMI with a 0% IR, even without performing an MRI or performing diagnostic testing.

What Can I Do if the Insurance Company Has Closed My Case/Claim and Says I’m No Longer Entitled to Benefits?

Obtain the assistance of experienced workers’ compensation attorneys. They will serve as your advocate and challenge medical opinions and the actions of the insurance company. They will ensure the insurance company does not take away the compensation you’re entitled to. If you have permanent injuries, you have a right to free medical benefits for the rest of your life. A workers’ comp lawyer will also help you seek compensation for all periods of time you were disabled or expect to be in the future.

When an Insurance Carrier and Employer Take Away Benefits from an Injured Employee

Employees injured at work can suffer great harm when the insurance carrier and employer make a concerted effort to avoid paying claims. In some cases, a worker received workers’ compensation, but the benefits were stopped early. Cases like these are why workers need experienced attorneys to protect their rights. At Feldman Williams, PLLC, we get justice for workers.

EXAMPLE A – Knee Replacement Needed, But Benefits Shut Down

In one instance, the insurance company had direct communications with the treating physicians, who they selected for treating the employee (of course), and convinced or pressured the physician to place the claimant at MMI with a 0%. They also provided a written opinion that the work accident was no longer the major contributing cause of the need for care and treatment. Thereafter, the insurance company shut down benefits for an employee with a seriously injured knee who was in need of a total knee replacement surgery.

EXAMPLE B – False Allegations of Fabricated Work Accident

In another outrageous example, the insurance company obtained information from an employer alleging that the accident was fabricated. It sent letters to all the treating physicians that claimed the injured employee was a fraud. It alleged that witnesses had observed the accident and, based on their input, the accident — as reported by the employee — was fraudulent. Unbeknownst to the employee, each and every physician treating him discharged him with a 0% MMI and refused to treat him. They also would not explain the basis for the discharge.

EXAMPLE C – Insurance Company Refuses to Pay and Worker Driven to Homelessness

Here is another shocking example of insurance carrier conduct. In this case, the employee had serious neck and back injuries. The insurer refused to authorize any treatment or pay disability wages for many months and then convinced the employee that he should settle his case for a nominal or nuisance value. Yet, the law required the insurance company to seek approval from the Office of Judges of Compensation Claims (OJCC) since the employee was unrepresented and not at MMI. Left without benefits, the employee accepted the settlement, but the insurance company never paid the money and knew they could not obtain approval from the OJCC. Meanwhile, they continued to refuse to authorize any benefits. Their conduct and refusal to cover the injured employees medical costs , forcing the employee to treat on his own and become literally homeless.

What Can You Do as an Employee Under Florida’s Workers’ Compensation System?

Hire experienced counsel to be your advocate throughout the life of your injuries and disabling period, and do not delay. Don’t let the insurance company and the employer take away your benefits or not comply with the self-executing intentions of Chapter 440. They are required to provide you all the medical and disability wages you are entitled to as a matter of law. Fight back! Feldman Williams, PLLC brings decades of experience handling workers compensation claims to fight for the rights of the injured employees.