If you have qualified for workers compensation benefits, you know how complicated the system can be. How to manage what you’ve earned is, in many ways, even more complex.
How long will your workers comp benefits last? How long can you be on workers comp? How long does workers comp pay?
The one-size-fits-all answer is probably the least helpful: It depends.
How workers comp works depends on the type, or types, of benefits for which you qualified. It depends on your prognosis, and it depends on how well you recover from your injury or illness. It depends on the type of work you were doing and what you’re able to do now.
Most of all, it depends on the state in which your work-related injury or illness occurred.
If this sounds like treacherous waters you should be navigating with an expert helmsman — that is, a proper legal representative — you’re already headed toward safe harbor.
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How Long Do Medical Benefits Last?
It’s not unusual that a sidelined worker will be capable of returning to work before the injury is fully rehabilitated. However, being back on the job does not necessarily mean the end of medical benefits paid by workers comp.
Theoretically, says Oakland, Calif.-based workers comp attorney Joseph Steve Franco, medical benefits can last a lifetime.
“You can enter an agreement whereby a workers’ compensation insurance carrier is responsible to administer medical bills corresponding to the body parts that you injured for the remainder of your life,” Franco said. “There are rules and procedures in terms of how medical treatment is authorized and requested, but in theory an individual can choose to have medical benefits covered for life.”
On this, there appears to be wide agreement in the legal field.
“Medical benefits coverage will typically cover all medical bills that derive from an occupational injury or illness irrespective of returning to work at full capacity,” says attorney David Reischer, CEO of LegalAdvice.com.
Good to know.
Under the federal enabling act, adds Sam Pond, managing partner of Pond Lehocky, a national workers comp and Social Security disability law firm, “the workers’ compensation insurance company is required to pay for all medical treatment that is reasonable, necessary and related to the work-related injury until the injured worker has made a full and complete recovery of the work-related injury.”
The insurer can file a petition to terminate, Pond says, but the burden of proof is on the company. Meanwhile, federal law provides for penalties against an insurer if it fails or refuses to pay for ongoing medical care.
Indeed, medical benefits most often are unlimited and include no deductible. The healthcare provider bills the workers comp carrier and is paid directly. As the injured/sickened employee, your sole responsibility is to attend your appointments and obey the doctor’s orders.
Generally, workers comp medical benefits continue until the doctor has released you from treatment. The decision might be made on your having completely healed from your injury or workplace illness. Or, in the doctor’s opinion, you have achieved “maximum medical improvement” — that is, your condition will not improve with additional treatment.
Again, the nuances of workers compensation law vary across the states. Pennsylvania and Delaware have no caps on how long your medical treatment is covered; in Pennsylvania, however, your employer can file a “utilization review” to challenge whether continued treatment is reasonable or necessary.
Keep this in mind, as well: “Even in a nonserious injury, an injured worker can reopen their case if they develop a new, additional or previously undiscovered condition down the road,” says Matt Fendon, Phoenix-based president of the Arizona Association of Lawyers for Injured Workers, “
Across the country, being sufficiently recovered to return to work — whether to your original job or some other area of the business — it’s the treating physician, not the company, that makes the call regarding the end of medical benefits.
If your condition requires rehabilitation services — medical, vocational, even psychological — everything depends on your state’s laws. In some states, you’re covered under medical benefits (unlimited); in others, there may be dollar or time limits.
If you are unable to return to work for your previous employer, your vocational rehabilitation benefits expand to cover a variety of next-job expenses, including aptitude and interest tests; job training; job search and interview skills; and job-placement services.
At the risk of being repetitive: You probably want someone with professional and licensed expertise to guide you and your case to the best possible leveraging of the benefits available in your situation.
How Long Does Temporary Disability Last?
For calculating lost wages, temporary disability can be total or partial.
Total temporary disability applies to employees who are expected to recover but are unable to work in any capacity while they recuperate. Partial temporary disability describes employees who can return to work in a modified — “light duty” — capacity while recovering.
Benefits vary depending on the severity of the disability. The generosity of the payout and how long it can last hinge on the state in which the work-related mishap occurred.
Temporary Total Disability Benefits: How Long It Lasts
Temporary total disability benefits generally fall in the neighborhood of two-thirds of your gross weekly income, up to the state maximum (which varies), and can range from 52 weeks (Idaho) to the duration of the disability (Michigan).
Here again, it’s vital to know the law in your state. It’s one thing to report that many state limits range from three to seven years. It’s quite another to get into the details and discover Florida and Pennsylvania allow up to 104 weeks at two-thirds gross pay; Georgia caps the benefit at $575 per week, but stretches the timetable to up to 400 weeks.
David Stern, a partner in Philadelphia-based workers compensation law firm Stern & Cohen, makes plain just how important it is to be guided by someone who knows the local ground rules.
In Pennsylvania, Stern notes, temporary total disability can last a lifetime, as long as the employee can demonstrate a loss of earning power. But watch out for an “Independent Medical Examination” that, in the Keystone State, can be ordered every six months.
Temporary Partial Disability Benefits: How Long It Lasts
Temporary partial disability is even more intricate, often involving a formula that pays two-thirds of the difference between pre-injury and post-injury wages. The number of weeks the benefit lasts varies wildly; California and Florida cut TPD at 104 weeks; Georgia goes up to 350, and Louisiana up to 520 weeks.
As mentioned above, the doctor treating you may declare that you have achieved maximum medial improvement: That is, your condition will not improve with more treatment. The doctor’s diagnosis may be subject to challenge — again, it’s good to be represented by someone who knows these ropes — but if it stands, it will mark the end of payments by the insurance company for that particular workplace injury or illness.
Maintaining your disability status means keeping regularly scheduled appointments with your doctor. Again, the frequency depends on state law. In Florida, for instance, retaining disability benefits requires at least one doctor’s visit every 12 months.
State Limits on Temporary Disability Benefits
State time limits mean it’s possible for an injured worker to get snared in a coverage gap — they run up against a deadline before achieving MMI and/or qualifying for permanent disability.
“Often,” writes attorney Bethany K. Laurence for Nolo.com, “this happens when insurance companies delay approvals for medical treatment, especially surgeries or other expensive procedures. If you hit your state’s limit on TTD benefits while you’re still waiting for surgery that your doctor has recommended, you could find yourself unable to work but without benefits to help replace your lost income.”
What to do? In some states, you might end up in court, battling for an extension. In others, you will be assumed to have achieved MMI and will be evaluated to determine whether your disability is permanent.
How Long Does Permanent Disability Last?
Medical disability is determined by independent professionals who evaluate sidelined workers using the Impairment Rating Evaluation, commonly known as a disability rating scale.
Based on a percentage ranging from 0 (no impairment) to 100 (complete disability), the scale assesses a worker’s degree of impairment. Everyone — the employee, employer, and workers compensation insurer — receives a copy of the evaluation.
Every state, as you might have guessed, applies its own impairment guide.
A rating above 50% means the employee has suffered a permanent disability — total or partial — and may qualify for permanent benefits.
First, some important distinctions. A permanent partial disability describes an injury or illness that prevents someone from working full-time for the rest of their life. Permanent total disability means the individual’s work life is over.
“Permanent total disability benefits, are available to people injured so badly that they cannot return to work anywhere,” Memphis, Tenn.-based personal injury attorney David Gordon said
“Again, the state legislatures have determined the number of weeks for which such a person should be paid. Usually it is 400 or 450 weeks and is usually paid in a lump sum.”
As attorney Gordon stipulates, compensation varies from state to state, even for exactly the same injury. Generally, states apply their version of the IRE to arrive at permanent partial disability benefits: The higher the degree of disability, the greater the payout.
However, other states base permanent partial disability on estimates of lost future earnings, or the loss of actual and ongoing wages.
And then there’s Pennsylvania, which has no “permanent disability” category at all.
“An injured worker is entitled to temporary total disability benefits for as long as they have no earning power due to their work injury, i.e., they are unable to work,” Stern said. “The burden is on the insurance company to demonstrate that an injured worker has an earning power. If they are unable to do so, temporary total disability benefits may last a lifetime.”
However, Stern adds, “Disability is never deemed “permanent.” Insurance companies can always make challenges to one’s disability status.”
How Permanent Disability Is Calculated
How long these payments continue, or how high they can go, varies across the country. Most states keep a statutory “schedule” of losses. The loss of a hand is worth a certain amount; the loss of a foot or leg is worth another amount. Within those schedules, the percentage loss of a body part also can be calculated.
In these cases, it’s not so much how long your permanent partial disability benefit will last — even if it’s based on a timetable, as many are — but how much.
Some common workplace injuries defy straightforward calculation. Back, spine, head, and internal organ injuries typically aren’t listed on schedules. Neither are certain occupational maladies, such as carpal tunnel syndrome.
These “unscheduled” losses trigger other methods of compensation, among them:
- Impairment-based compensation — weighs the degree of your disability to arrive at how many weeks of compensation you’ll receive; your benefit is based on your prior wages.
- The loss-of-earnings-capacity approach — requires a prediction about the injured/sickened employee’s future earnings ability.
- The wage-loss method — determines benefits ascertained by the actual lost or decreased wages as a result of the workplace mishap.
State Limits on Permanent Disability Benefits
With all of these situations, it is possible to have a permanent disability that does not result in permanent compensation payments. Where benefits are limited — either through weekly or lifetime maximums, or both — it’s because they are capped by individual state legislatures.
States that limit lifetime compensation include Arkansas, Indiana, Kansas, Mississippi, Oklahoma, and South Carolina. Several others discontinue or modify coverage based on benefits paid by Social Security Disability Insurance.
About that: If you have worked long enough and recently enough (and at jobs that paid into Social Security), you may qualify for Social Security Disability Insurance (SSDI) benefits until you are able to return to work, or until you reach full retirement age.
Wait, there’s more: You also may apply for Supplemental Security Income if you meet the criteria, including:
- You’re between the ages of 18 and 65;
- You’ve never been married;
- You aren’t blind;
- You are a citizen and meet residency requirements;
- You haven’t applied for or received SSI benefits in the past;
- You are applying for SSDI at the same time.
Caveats apply, says Oakland’s Franco, especially in a situation where the injured worker has reached a settlement with the insurance company involving a lump-sum payout.
“SSDI will be able to provide payments for an injured worker when their case has settled, only after an injured worker has demonstrated that they have used their settlement money to pay out their future medical costs,” Franco said. “After an injured worker has demonstrated that they have used their settlement funds to pay off future medical, he can then request for SSDI benefits.”
When applying for disability related Social Security benefits, be prepared for an uphill slog. Most first applications are rejected for one reason or another. The agency provides an appeals process, but if your initial try is turned down for something other than completeness, enlisting legal counsel is a savvy move.
About The Author
Tom Jackson won dozens of national awards as a columnist for newspapers in Washington, D.C., Sacramento and Tampa. His writing has spread from business to politics to sports with an emphasis on community issues. Tom splits his time between Tampa and Cashiers, N.C. with his wife of 40 years, a college-age son and a yappy Shetland sheepdog named Spencer. Tom can be reached at email@example.com.
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