Understanding Work Comp

I want to state right off: I am not soliciting for specific legal advice. I just want to understand the situation and my options to make an informed decision (one not colored by the interest of other parties.)

I injured my knee on the job. The insurance company fought the issue for some time, claiming they weren’t liable, but after several months finally gave in. After nine months I finally got the surgery.

According to the doctors/physical therapists I should achieve “maximum medical recovery” in 3 months or so. When this all started my attorney said that once MMR was achieved the insurance company would pay me a lump sum for my “Permanent Partial Disability” (for percentage of loss of use). It’s my understanding this is just to compensate me for the inconvenience of not having full use of my leg and any income it might cost me. It is also my understanding that the PPD money is NOT to compensate me for possible future medical costs. (Please confirm, if you know.)

My attorney also said at the start (9 months ago), that at this time I would have the option of “closing my medical.” I understand this to mean giving up all claims on future medical compensation from the insurance company. Why would I want to do this? In reading some related online forums, I see mention of insurance companies settling lump sums to cover future medical, but the money is NOT in “today’s dollars” and is “discounted” because of the possibility to earn interest on it. And the money MUST be set aside in a seperate account, and all money taken for medical must be rigorously documented and accounted for. Why would this be preferable to leaving the medical open?

The injury was a torn meniscus in the knee that had to be removed. I had a previous (partially healed) torn AC Ligament that gave me no issues for ten years, but one of the docs says that with the removed meniscus I may have stability issues due to the ligament. (I can go without one or the other but not both). Though the insurance company approved surgery for both the meniscus AND the ligament, the surgeon chose just to do the meniscus because he didn’t agree with the other doc’s assessment of the need for the ligament surgery. He thought repairing the ligament would cause me more issues than it fixed. But if it turns out that there ARE stability issues, and the surgery NEEDS to be done, does “closing my medical” prevent all future claims for issues directly attributed to my worker’s injury? Can it not be reopened?

In short what are the benifits of me “closing my medical”? I suspect that by doing so, my attorney will receive more money and be “done” with this case. But that’s not necessarily in my best interest. I just want to know what I’m walking into and not feel pressured or misinformed. I don’t want to decide something based on my attorney’s best interest or the Insurance company’s best interest rather than my own.

However I AM buying a home soon, and any lump sums would be benificial. But not if it means I have to pay for a needed future surgery myself!

This sounds like most of what you want is advice too specific to your situation to get from a message board. I do have a couple of general suggestions.

  1. You may want to hire a financial advisor or accountant (the kind you pay, not the kind that earns commission) in addition to your attorney. That is the type of person who would have the expertise to tell you if a specific discounted amount was a fair deal. Discounting is a legitimate concept, but is easy to manipulate if one party understands it better than the other party. Some attorneys might have this expertise, but some might not. A financial advisor could also help you factor in the value of the lump sum toward your house purchase.

  2. Would closing out your medical mean that you, personally, would need to pay for the future surgery, or that in the future it would be covered under regular health insurance, if you have that? Your attorney should be able to help with that question.

Good luck in any case.

My understanding is that, depending on your MMR, a lump sum is determined, and a time limit set on payment for ongoing medical care for that specific issue. I wish I could remember all the rules, but IIRC for an injury that does not leave you totally disabled, the time limit would be two years after the close.

Your workers comp adjuster can give you all that information. It’s pretty well set in stone for WC issues, so there should be no reluctance on their part to tell you.

I’m not asking for any advice at all. I just want to know why one would choose to “close medical”. It doesnt’ seem to be wise. Why give up possible medical coverage, should the injury worsen? There must be some benifit/advantage it anyone ever chooses to do this…

I just want to know if there are any benifits for me and not just the insurance company or my attorney. Give me the pros and cons. I’ll decide for myself, based on my own knowledge of the particulars. I just want to make an informed decision, and based on the forums I’ve reviewed, it’s not unheard of for an attorney to recommend settlement (or some other option), that gives him a better payout, and is not necessarily the wisest choice for the client.

From your post, it sounds like you give up the possible medical coverage in exchange for some amount of money. That is your answer right there as to why someone would do it. If it were a billion dollars, you’d take the money. If it were one dollar, you’d know it was a bad deal. You need someone who knows the finances and your specific situation to help you sort out what the offer to you is worth.

Stupid capybaras. :mad:

Former Workers’ Compensation attorney here.

What you are contemplating here may have some different terms than I use, because Missouri’s system may use different terminology from that used in California, where I practiced. But the basic ideas will be the same.

You are at a point where the law will normally provide you with two benefits: permanent partial disability (a compensation for the impact your disability will have on your earning power) and future medical care reasonably related to the injury you suffered. PPD is usually paid out over time as a weekly payment, at a legally specified percentage of your wages at the time of the injury, for a number of weeks that is determined by a series of tables and formulas so complex, you truly don’t want to understand it (it would mean you need a life :smiley: ). And, yes, that says something about me (I once filed a 48 page “brief” over the proper way to rate an admittedly complex hand injury :eek: ).

Future medical care is provided as needed by the insurance company. There is no time limit. As long as the care is reasonably related to the injury, you get it provided. Keep in mind, please, that Missouri’s rules on exactly what medical care is covered I am not familiar with, and the terms may, as I said, be slightly different. Your attorney can advise you on what medical care would likely be covered.

So much for the legalities. Now, for the practicalities.

Insurance companies hate future medical care. It forces them to guess about the cost of a case over time. This means that they assume the risk of the cost of the care, rather than being able to simply increase the “reserves” from the employer’s insurance account to cover expected costs. Insurance companies hate not having benefit payments established with certainty. So they find ways to overcome this flaw.

One way is to “compromise and release” all the claims you may have against the insurance company. In this situation, a “dispute” is alleged which, if litigated, would leave the parties uncertain of the outcome. So they choose to reache a compromise solution. In this type of settlement, the insurance company pays you one lump sum, and you agree never to darken their doorstep with your claim ever again. This, of course, prevents you from having them pay you for medical care in the future. (It also accomplishes the often desired result of turning your PPD payments into present value money). Now, in California, there was no limit usually put on the distribution of the lump sum settlement. If Missouri requires that some part of it be set aside to pay for medical, frankly, in my mind, that’s a good thing.

So, we know the insurance company wants this. The better question for you is, “What’s in it for me!!?”

Well, mosty peace of mind knowing you never have to litigate medical care ever again with the insurance company. See, here’s how it will play out in the future:

Assume you don’t settle the medical. In that case, when the time comes that everyone decides to do the ligament surgery, they will ask the insurance company for the authorization. But, they won’t get it. The insurance company will refuse to provide the care. They will assert any of a number of defenses. In your case, just cursorily from your statements, the adjuster would latch onto the fact that the ligament surgery was not done at the time of the meniscus repair, and the ligament injury is a pre-existing injury, so the current need for ligament surgery is the result of that injury, not your meniscus injury (they will claim). You, of course, will quite understandably assert that they were willing to pay for it before. But, they will say, that was because it was seen as needed when done at the same time as the meniscus repair. Now, the repair of the meniscus is done, and the ligament surgery is no longer their responsibility.

Now, without reading the medical records, the opinions of the doctors as expressed in their reports, and asking pertinent questions in deposition, I can’t say whether they would be right or wrong. But that’s not the point. The point is that getting the surgery authorized will require litigation, or, at the least, threatening actions by your attorney. Who, I might add, won’t be paid for this work. Why? Because he only gets paid (usually, say 99% of the time) out of disability benefits, not medical care benefits. Why? Because if he got paid out of the medical care benefits, either you or the doctor would be short money; if the doctor is short the money, he won’t operate and if you are short the money, you probably can’t afford the surgery. So guess how much injured workers’ attorneys like to litigate medical claims. :dubious:

They do it, but they don’t like it. AND, it rarely resolves quickly. Exams, reports, hearings, etc. are common.

So, a year later, your knee still hurts, you finally get the surgery covered by order of the judge, and you are thoroughly sick and tired of the whole mess.

Which starts over again four years later when your knee goes out on you will you are walking one day… :insert appropriate smiley of person pulling hair out in despair here:

THIS, is why YOU might want to compromise the case. In most cases, if you are working again, your medical care for the knee will be covered (mind you, not always: find out what your medical insurance does about things like pre-existing conditions, etc.), so compromising the right to have it provided by the insurance company for the work injury may not be that important. And not having to deal with the airhead adjuster may be a very valuable benefit to you.

BUT, before you do it, be certain to talk with you doctor about what he/she expects in the way of treatment needs in the next few years. After you close out the medical, you have no way to open it back up again at all.
As usual, this is a cursory examination of the law. It is not intended as specific legal advice regarding your case/claim. I am not an expert on the law in your jurisdiction. You have not engaged my services as your attorney, nor are you seeking specific advice from me on your situation. If you want such advice, see an attorney licensed to practice in the appropriate state.

Hope this helps you. :slight_smile:

Thank you DSYoungEsq.

That is exactly the information I needed. I feel more comfortable making these decisions now! Much, much appreciated.