A Guide to Workers’ Comp Settlements for Total Knee Replacement
Use These Tips to Negotiate a Reasonable Workers’ Compensation Settlement for Knee Arthroplasty
A work-related knee injury can cause posttraumatic arthritis or worsen preexisting osteoarthritis, resulting in the need for total knee replacement surgery.
Workers’ comp covers knee replacement; however, insurers often fight these claims because the surgery is expensive and may require a revision procedure, and you will likely have permanent restrictions after doctors replace the knee joint.
This article explains factors to consider when determining a reasonable workers’ compensation settlement for total knee replacement. In addition, we give tips to build your case. You can use these details no matter your occupation – we have helped construction workers, nurses, truck drivers, and warehouse employees for major employers (Amazon, Walmart, Home Depot, Target, Lowe’s, American Airlines) win workers’ comp claims for knee injuries or joint replacement surgeries.
Continue reading for more information.
And give us a call if you have questions about workers’ compensation in Virginia. See why our colleagues and clients regularly vote for us among Virginia’s best work injury attorneys.
What is Knee Replacement?
Knee replacement surgery, also called knee arthroplasty, is a medical procedure to replace parts of damaged or injured knees.
The procedure involves removing or resurfacing damaged bone and cartilage from the knee joint and replacing it with metal and plastic parts. Your doctor will shape these components to allow continued motion of the knee.
How Common is Total Knee Replacement Surgery?
Surgeons perform more than 785,000 total knee replacements annually in the U.S., making this procedure one of the most common operations requiring a hospital stay.
This surgery volume continues to grow. Indeed, one study projects more than 3 million U.S. adults will undergo total knee arthroplasty by 2030.
Many knee replacements involve injured workers.
Partial vs. Total Knee Replacement
The knee has three compartments: the medial (inside), lateral (outside), and front (anterior) compartments.
Your doctor may recommend a partial knee replacement (a unicompartmental knee arthroplasty) if the bone or cartilage in one compartment is damaged while the other sections remain normal.
These surgeries comprise a small percentage of knee replacements in the United States – less than ten percent. But they have some advantages for those whose doctor recommends them.
For example, partial knee replacement benefits (compared to a total knee arthroplasty) include a smaller incision and scar, shorter hospital stay, increased range of motion, and faster recovery times.
When is Knee Replacement Recommended?
Your orthopedic surgeon may recommend knee replacement (total or partial) when medical imaging confirms you have advanced osteoarthritis in one or more knee compartments, significant bone trauma, or a valgus or varus deformity that has failed conservative treatment and causes severe pain and stiffness affecting your ability to work or perform daily living activities.
The surgeon may, however, delay performing the knee arthroplasty if you are morbidly obese, lack a support system to help after surgery, or have an active infection or other medical condition that increases the risk of complication. Indeed, I have represented many injured workers whose doctors required weight loss before performing a total knee replacement.
Does Workers’ Compensation Cover Knee Replacement Surgery?
Yes.
Your employer (or its insurer, such as Travelers, Liberty Mutual, Hartford, Builders Mutual, etc.) must pay for all reasonable and necessary medical treatment related to the work accident if you have a Workers’ Compensation Award Letter.
Surgery, even joint replacement, is no different.
The insurer’s responsibility remains even if you do not need a total knee replacement until years after the occupational injury.
Workers’ comp provides lifetime medical benefits. Therefore, if you can prove that the medical care is reasonable, necessary, and causally related, the insurer must pay for it, no matter when the doctor prescribes it.
For example, I have represented many hurt employees who underwent surgery for a torn meniscus or an ACL injury within a year of the work incident but required a partial or total knee arthroplasty several years later. Ultimately, workers comp covered the arthroplasty.
In addition to paying for knee replacement surgery and related treatment (MRI, physical therapy, doctor visits), workers comp also pays wage loss benefits when you miss time from work due to the arthroplasty or ongoing restrictions.
These workers compensation benefits include temporary total disability (paid at two-thirds of your pre-injury wages), temporary partial disability (paid at two-thirds of the difference between your pre-injury and post-injury earnings in light duty), mileage reimbursement, and compensation for permanent partial disability (PPD).
What is the Average Workers’ Comp Settlement for Total Knee Replacement?
In our experience, a reasonable workers compensation settlement range for total knee replacement is $115,000.00 to $325,000.00 (or more).
We recommend considering these factors when sending a workers’ comp settlement demand in a total knee arthroplasty case:
Average Costs for a Total Knee Replacement
A total knee arthroplasty may cost more than $100,000.
Indeed, we have seen total knee replacement charges from $45,000 to $102,000 for injured employees.
The final bill for a total knee replacement procedure depends on several items, including how many days you stay in the hospital, the surgical technique, and the implant type (the medical device may cost $1,500 to $30,000 or more).
However, the insurance company may pay much less after adjustments. For example, the workers’ comp insurer may be able to reduce the charges under the state’s medical fee schedule. At the same time, private health insurance companies may have contracts governing reimbursement rates for the procedure. In addition, Medicare and Medicaid have their reimbursement schedules.
Post-Replacement Medical Care
You will likely require the following medical treatment for a knee replacement surgery, even if it goes well:
- Assistive devices (canes, crutches, wheelchairs, braces, etc.)
- Office visits (with the surgeon or their physician’s assistant)
- Diagnostic imaging (X-rays, MRIs)
- Cryotherapy (cold therapy) to reduce knee swelling
Make sure your total knee replacement settlement includes money for these future medical expenses.
Risks and Complications of Knee Arthroplasty (Including a Possible Revision Replacement Surgery)
Like other joint replacement procedures, knee replacement surgery comes with several potential complications:
- Infection: I have represented injured workers whose knee replacement became infected, requiring additional surgeries and disability from work
- Deep vein thrombosis (DVT): The American Academy of Orthopedic Surgeons (AAOS) says this condition is “the most common complication of knee replacement surgery …” A DVT is a blood clot that develops in a leg vein and is life-threatening if left untreated.
- Loosening of the prosthesis
- Falls due to instability (balance problems)
- Need for revision total knee arthroplasty, which may be more expensive than the initial knee replacement surgery
- Injury or damage to the “healthy” lower extremity (knee, ankle, foot, or hip) due to overuse: These conditions are considered compensable consequence injuries under workers comp.
- Injury or damage to the upper extremity (for example, the rotator cuff in the shoulder) if you must use a cane or crutch for an extended period or if you fall
- Back pain due to changes in how you walk (altered gait), which worsens a herniated disc and results in sciatica and nerve damage
Workers’ comp must pay for these complications of knee replacement in most cases. The general rule is that the insurer and employer remain liable for all natural consequences of the compensable injury and treatment. Therefore, consider the possibility that things may go wrong during your recovery when calculating a settlement amount for total knee replacement.
Disability from Work (Timeline for Knee Replacement Recovery)
You may miss time from work before and after the knee replacement while you heal.
For example, in our experience, the typical return-to-work timeline for knee replacement patients is as follows:
- Total disability: Your doctor will likely put you on “no duty” for two to eight weeks after the arthroplasty.
- Sedentary work: Your doctor will probably restrict you to a seated position for two to 26 weeks post-replacement.
- Light work (lifting/carrying up to 20 pounds, standing/walking up to six hours in an eight-hour workday): Some knee replacement patients receive permanent restrictions at the sedentary level; however, other injured workers receive releases to jobs that require occasional standing and walking within six to 12 months of the arthroplasty.
Some of you work in positions classified as medium, heavy, or very heavy.
And your physician may never release you to return to full duty.
Therefore, your knee arthroplasty demand should include amounts to compensate you for these periods of wage loss and the possibility you can never return to your pre-injury job.
Permanent Impairment from Knee Replacement Surgery
Your doctor may assess a permanent impairment rating for the lower extremity due to the need for a knee arthroplasty. This rating, typically based on the American Medical Association’s (AMA’s) Guide to the Evaluation of Permanent Impairment and performed when you reach maximum medical improvement (MMI), determines the value of your permanent partial disability benefits.
Some states (including Virginia) allow injured workers to seek PPD benefits based on a pre-joint replacement impairment rating.
For example, the Court of Appeals of Virginia said in a total joint replacement case, “[a]warding compensation based on a pre-surgery loss-of-use rating recognizes that a work-related injury has permanently deprived the claimant of natural functionality. Although the procedure to implant a prosthetic … joint is commonly called a total … ‘replacement,’ the natural joint’s function and ability to heal is irreplaceable.”
We recommend estimating (or obtaining) the partial disability rating for your leg and including that in your settlement calculation regardless of whether your jurisdiction uses pre- or post-joint replacement ratings.
Permanent Restrictions After Knee Replacement
Many of the employees we represent who require knee arthroplasty receive permanent restrictions from their orthopedic or pain management doctor. Indeed, dysfunction of this weight-bearing joint is a leading cause for applying for disability with the Social Security Administration.
For example, you may receive permanent restrictions after total knee replacement surgery addressing your ability to do the following:
- Climb stairs and ladders
- Walk a block at a reasonable pace on an uneven surface
- Stand or walk without using a rail, crutch, cane, or wheelchair
- Use the leg to drive an automobile
- Work at heights or in environments that require balance
- Stand or walk for prolonged periods
- Bend, stoop, twist, crouch, squat, or crawl
- Lift, carry, push, or pull significant weight
- Use the lower extremity in a full range of motion
Any medical work restriction that prevents you from performing every pre-injury job task increases the value of your total knee replacement case.
What if the Insurance Company Denies the Knee Replacement?
The workers’ comp insurer or claims administrator (Sedgwick CMS, Helsman, Gallagher Bassett, ESIS, etc.) may deny the knee arthroplasty, even when the authorized treating physician you chose from the insurer’s workers’ compensation panel recommends it.
These medical treatment denials are common in occupational injury claims. But you can overcome them.
We recommend using workers’ compensation discovery (interrogatories, requests for production of documents, requests for admissions, depositions of claims adjusters) to determine the basis for the insurer’s denial.
Often the insurance carrier argues the work injury did not cause the need for knee replacement surgery. Instead, the insurer claims that you had wear and tear, yielding a preexisting condition (degenerative joint disease, degenerative tearing of the meniscus, past injury) responsible for the doctor’s surgical recommendation. This defense is prevalent in claims involving injured employees who played sports (running, football, basketball, bicycling) when they were younger (or more recently), are obese, or have physically demanding jobs.
Do not give in to this defense.
You have several ways to defeat it and meet your burden of proving the total knee replacement surgery is related to your covered work accident.
First, you do not have to prove that the workplace incident caused the end-stage arthritis or deformity leading to the knee replacement recommendation.
Instead, workers’ compensation law only requires you to show that the work-related knee injury contributed to the need for the arthroplasty or sped up its scheduling. You can win your claim if the medical evidence shows your workplace injury aggravated, exacerbated, flared up, worsened, or accelerated arthritis, resulting in the need for partial or total knee replacement now.
Second, you can defeat the insurer’s denial of the arthroplasty by asking your orthopedic surgeon to complete a disability letter (or narrative report) addressing causation and attacking the defense medical examiner’s (also called an independent medical examiner, or IME) report, if applicable. Generally the Workers Compensation Commission gives more weight to your treating physician’s opinion than the defense examiner’s report.
Top-Rated Workers’ Comp Attorneys for Knee Replacement Claims
Insurance companies challenge workers’ comp claims for knee replacement surgery because these procedures cost a lot of money and often result in permanent restrictions. Indeed, many insurers will offer a worker’s comp settlement before approving surgery, hoping you take a lowball offer and do not litigate the dispute.
Instead of giving up, call us to build your case and scare the insurance adjuster into increasing claim reserves and offering a fair arthroplasty settlement: 804-251-1620 or 757-810-5614.
In addition, our disability lawyers will review your medical records and work status to determine if you have a viable claim for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). Those over 50 with knee joint dysfunction have a strong chance of qualifying if unable to return to employment after replacement surgery or a total knee revision.
- Will the Dollar Tree Store Closures Affect My Workers’ Compensation? - March 14, 2024
- Workplace Injuries in 2022: BLS Releases Statistics - December 15, 2023
- SSA Proposes a Rule Change to Work History Evaluation - November 1, 2023
