Closing Out Your Workers’ Compensation Case
The Virginia workers’ compensation claims process is complex, with many stages. From filing a claim for benefits to presenting your case at a workers’ comp hearing to change in condition applications, it’s easy to get confused as to when the case ends.
This article explains when a workers’ compensation case closes – and ends temporarily. If you have questions about the process, or are looking for legal representation, contact workers’ comp attorney Corey Pollard for a free consultation. We’ve helped disabled workers and their families in Richmond, Chesterfield, Petersburg, Hanover, Fredericksburg, Hampton, Newport News, Williamsburg, Chesapeake, Norfolk, and Virginia obtain the workers’ comp benefits and resolutions they deserve.
Does a Workers’ Comp Case Ever End?
If you prove that you suffered an injury by accident arising out of and in the course of your employment, or that you contracted an occupational disease related to your work, then your employer is responsible for the payment of workers’ comp benefits. These benefits include all reasonable and necessary medical expenses related to your work injury, as well as temporary total disability, temporary partial disability, and permanent partial disability benefits. If you have permanent and total disability, then your employer may have to pay you additional wage loss benefits.
Many workers’ compensation cases never really “close.” This is because the employer and its insurance company are responsible for the payment of reasonable and related medical treatment for your entire life, even if you return to work with no restrictions or begin working with a different employer.
Though an award of medical benefits is for life, many workers’ comp cases come to a natural end. Below are some common situations where a workers compensation case ends for all practical purposes.
1. You reach maximum medical improvement and receive permanent partial disability benefits: When you reach maximum medical improvement (MMI), your attorney will speak with your doctor about permanent restrictions and permanent impairment. MMI occurs when you reach a point where your condition cannot be improved or when a treatment plateau has been reached during your recovery.
If your doctor believes you will have a permanent impairment due to your work injury, then your attorney will arrange for you to undergo an evaluation with a medical provider familiar with the AMA Guides to the Evaluation of Permanent Impairment. That provider will assign you a permanency rating, which is used to determine the amount of permanent partial disability benefits you’re entitled to.
Usually you cannot receive permanent partial disability benefits while you’re receiving temporary total disability benefits. The receipt of permanent partial disability benefits, therefore, means that you’re probably back to work or have been released to full duty work by your treating physician. When you’re back to work and have been told that no additional treatment will improve your condition (this is what MMI means), then it’s a good time to close your workers’ compensation case through settlement. At this point there is not much else to do. You’re entitled to ongoing medical care, but your doctor is not recommending any.
Once you receive permanent partial disability benefits from the employer and insurer, you have one year to request that the Workers’ Compensation Commission (WCC) re-open your case due to a worsening of your condition. If you wait too long then you are barred from reopening the claim and your case is closed.
2. The Commission issues an Order denying additional benefits or medical treatment: Let’s say you hurt your back at work and the insurer offered an agreement form stating that you suffered a compensable injury and providing for benefits. Everything is going smoothly, with the insurer paying you wage loss benefits and covering all your medical appointments.
Conservative treatment fails, however, and your orthopedic doctor recommends a lumbar fusion at multiple levels – an expensive surgery that will put you out of work for an extended period and may lead to permanent restrictions. Suddenly the insurer refuses to authorize additional medical treatment. You have to file a change in condition application seeking authorization and payment of the recommended surgery.
At hearing the insurer will defend your claim on the basis that your ongoing symptoms, disability, and need for surgery are related to pre-existing degenerative disc disease, not your work injury. The Commission will have to decide whether this is true or whether your compensable injury aggravated, accelerated, or caused the need for surgery.
If the Commission finds for the employer and insurer in full, and denies your claim, then your case is closed. Unless, of course, you appeal. Presuming you lose on appeal, you will continue to have a lifetime medical award, but there is no value to that award because the Commission has found that ongoing medical care is not the employer and insurer’s responsibility. It may even find that ongoing disability (work restrictions) is unrelated to the compensable injury, which prevents you from obtaining additional wage loss benefits at any time.
3. You have received 500 weeks of wage loss benefits and are not permanently and totally disabled under the Virginia Workers’ Compensation Act: The General Assembly has placed a limit on the amount of Indemnity benefits (wage loss and permanent partial disability) you can receive under Virginia workers’ compensation. The limit is 500 weeks, unless you meet the Commission’s definition of permanent and total disability, which is difficult to do.
If you’ve received 500 weeks of wage loss benefits but are not entitled to permanent and total disability, your case is technically open because you will continue to have an award for lifetime medical benefits that are reasonable, necessary, and related to your work injuries. But it is closed with regard to wage loss and permanent partial disability compensation.
4. You negotiate a full and final workers’ compensation settlement: In Virginia some workers’ comp cases close when the insurer offers, and the injured worker accepts, a full and final settlement of the claim. This means that the insurance company will pay you a lump sum of money in exchange for you giving up your right to additional medical and indemnity benefits for the work injury in question. Your workers’ comp case is closed permanetly when you settle, so make sure you consult with an attorney before making this big decision.
5. You die from causes that are unrelated to your work injury or occupational disease. If you pass away from reasons unrelated to your compensable injury, your case will close. Your dependents are not entitled to death benefits in this situation.
Situations Where Your Workers’ Comp Benefits are Suspended Temporarily
There are some situations where your workers’ compensation case is closed temporarily because the employer and its insurance company have filed an application for hearing to terminate, modify, or suspend benefits. This doesn’t mean that your workers’ compensation case is closed forever, but you’ll need to take action to get benefits reinstated or continued.
For example, your workers’ comp case will close temporarily if:
- You are incarcerated: Workers’ comp benefits are not available while you’re in prison or jail. And you have a statutory duty to report that you’re incarcerated.
- You refuse to attend an Independent Medical Examination (IME): The employer and its insurer have the right to send you to a limited number of IMEs. Though the IME doctor is likely to issue an opinion favorable to the employer/insurer and not to you, at least in our experience, you must still attend the appointment. If you fail to attend the IME the employer and insurer can suspend your benefits temporarily.
- You refuse to comply with your treating physician’s recommendations and proposed treatment, and your refusal is unjustified: For example, your doctor may recommend that you undergo surgery and that the operation is the only way you’ll recover. If you refuse to undergo surgery because you have a vacation scheduled or don’t feel like it, then your case may close temporarily. The insurer may argue that you are delaying your recovery and that it should not have to pay you benefits when you’re the one causing the delay. If, however, you have a justified reason for not undergoing surgery (the last surgery didn’t work, a friend or family member became paralyzed while undergoing surgery, the doctor is in the middle of disciplinary proceedings due to malpractice, etc.), then you may be able to avoid having your benefits suspended.
Your right to wage loss benefits, but not medical treatment, will stop temporarily if:
- Your treating physician releases you to full duty work: This doesn’t mean your case is closed forever though. We’ve represented many clients who were released to full duty work for trial periods before being taken back out of work to undergo surgery related to their work injuries.
- You sign a Termination of Wage Loss form: This form is filed with the Commission and indicates that you acknowledge you are no longer entitled to wage loss benefits. If something changes and your condition worsens, you may file a change in condition claim to reinstate wage loss benefits. Your workers’ comp case, therefore, is not closed permanently.
- You return to light duty work making equal to or more than your pre-injury average weekly wage: You are not entitled to wage loss benefits unless you have actual wage loss. We’ve represented many disabled workers who return to light duty work, only to be terminated weeks or months later when the employer realizes the injured employee will never be able to return to pre-injury work. If this happens to you, then you may receive additional wage loss benefits through a change in condition application.
Contact a Skilled Virginia Workers’ Comp Lawyer to Find Out If You Should Close Out Your Workers’ Comp Case and to Determine When Your Work Injury Claim Will End
We’ve lost track of the number of injured workers who have contacted us and said that the insurance company claims adjuster had cut off benefits and told them their workers’ comp case was closed, even though it wasn’t. Telling injured workers that their case is closed when the person may still receive benefits is a common insurance company tactic.
Closing out your workers’ compensation case is an important decision. When you contact top-rated attorney Corey Pollard, you’ll receive high quality advice and recommendations on making the best decision for you and your family.
Call, text, or email us today for a free strategy session about closing your workers’ comp case and how to avoid losing benefits. We’re here for you.