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
). 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. 