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. Insurers also understand that 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 call us 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.
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 worn cartilage from the knee joint and replacing them with metal and plastic parts. Your doctor will shape these components to correct deformities and allow continued knee motion so you can resume daily living activities.
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.
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 doctors recommend 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.
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.
These last parts – knee pain and loss of function – are the primary criteria suggesting the need for knee replacement surgery. Positive imaging without symptoms and difficulty using the joint is not enough for arthroplasty.
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.
Below is an overview of what happens during total knee arthroplasty.
You will be under general anesthesia during total knee replacement surgery.
First, the surgeon makes an incision over the injured knee.
Second, the surgeon removes the patella (knee cap) and shapes the surfaces of the femur and tibia next to it so the prosthesis will attach better. This step involves removing damaged bone and cartilage from the knee joint.
Third, the surgeon positions the implant parts to recreate the joint. Simply put, one part attaches to the bottom of the femur, and another attaches to the top of the tibia.
Fourth, the surgeon reshapes the patella’s undersurface.
Fifth, the surgeon inserts a plastic part to recreate the cartilage removed during the knee arthroplasty.
Sixth, the surgeon puts the kneecap back in place.
Seventh, the surgeon closes the cut and dresses it.
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).
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:
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 factors, including the number of 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.
You will likely require the following medical treatment for a knee replacement surgery, even if it goes well:
Make sure your total knee replacement settlement includes money for these future medical expenses.
Like other joint replacement procedures, knee replacement surgery comes with several potential complications:
Workers’ comp must pay for these knee replacement complications 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.
You may miss time from work before and after the knee replacement while you heal.
Indeed, a significant percentage of injured employees we represent miss more than six months of work post-knee replacement.
In our experience, the typical return-to-work timeline for knee replacement patients is as follows:
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.
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. Lower extremity impairment ratings from 40% to 70% are typical for injured employees requiring total 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:
Any medical work restriction that prevents you from performing every pre-injury job task increases the value of your total knee replacement case.
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.
Indeed, we have seen many insurers deny MRI authorization due to fear that it will support the need for total knee replacement surgery to reconstruct the joint.
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 that 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. And it is unsurprising: osteoarthritis is the most common reason for partial or total knee replacement surgery.
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.
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.