A Santa Rosa workers’ compensation lawyer explains how reaching maximum medical improvement changes the benefits an injured worker receives

maximum medical improvementEveryone who is injured at work hopes to make a full recovery and to resume his or her employment. Unfortunately, some injuries never fully heal, leaving injured workers with a permanent impairment. An unstable knee that makes it impossible to climb a ladder, a back injury that limits the weight one can lift, or hearing loss that makes it difficult to hear a supervisor are examples of permanent impairments that can be caused by work injuries.

The difference between an injury that is healing and one that has stopped healing can be critical to the kind of workers’ compensation benefits an injured worker receives. That difference is whether or not the injured worker’s medical condition has reached “maximum medical improvement” (MMI).

Maximum Medical Improvement

A work injury will often leave an injured worker with a permanent functional impairment. A functional impairment is a reduction in the ability to perform the usual activities of daily living. For example, back pain might cause an impairment in the ability to lift objects or to stand for long periods of time.

A functional impairment caused by a work injury can prevent someone from working until the impairment heals. When that happens, the injured worker is entitled to receive temporary disability benefits until he is able to return to work, up to a maximum of two years. The injured worker’s treating physician determines when the injured worker can return to work, with or without limitations.

Sometimes an impairment stops improving, leaving the injured worker with a permanent functional impairment. Injured workers who suffer a permanent functional impairment are entitled to permanent disability benefits. Permanent disability benefits generally begin as soon as temporary disability benefits end.

In simple terms, maximum medical improvement (MMI) means that the injured worker’s medical condition is unlikely to improve any more. Specifically, the California regulations covering workers’ compensation define maximum medical improvement as the point when the medical condition “is well stabilized, and unlikely to change substantially in the next year with or without medical treatment.”

Challenges to MMI Decisions

When a treating physician determines that an injured worker’s medical condition has reached MMI status, the physician writes a report reflecting that fact. That report includes the physician’s assessment of the nature and extent of the impairment, including an impairment rating that is based on objective, standardized criteria. The impairment rating can then be used to determine a disability rating. Permanent disability benefits are based on an injured worker’s disability rating.

An injured worker, or the workers’ compensation insurance company, might dispute the opinion of the treating physician. When that happens, either party is entitled to obtain a second opinion from another physician called a qualified medical evaluator (QME). The Division of Workers’ Compensation maintains a list of QMEs and has a procedure that allows one to be chosen to examine an injured worker and provide a second opinion. The injured worker’s attorney and the insurance company claims administrator can also agree on a QME.

The QME will examine the injured worker and review relevant medical records before offering an opinion as to whether she has reached MMI, and whether or not she has a permanent functional impairment. Challenging that opinion at a hearing before a workers’ compensation judge sometimes occurs when one of the parties disputes the opinion of the QME. If the insurance company challenges the opinion of a QME report you may wish to consult with an attorney.

Getting Help with Workers Compensation

Injured workers who are uncertain whether their medical condition has achieved MMI status can benefit from legal advice. Experienced workers’ compensation lawyers can advise whether it is advisable to seek the opinion of a QME or not. To discuss your case with an experienced Santa Rosa workers’ compensation attorney, call Kneisler & Schondel at (707) 542-5132. You can also tell us about your case by submitting our online contact form.