The Colorado Court of Appeals decided a case in October 2011 addressing the issue of when an injured employee can receive workers’ compensation benefits after a physician has given the employee a maximum medical improvement declaration. The case demonstrates the role that medical improvement declarations play in Colorado’s workers’ compensation system.
Background of the Case
The claimant worked as a manager of a Kentucky Fried Chicken restaurant. In November 2008, the claimant had to work by herself running the entire restaurant after another employee walked off the job. The claimant injured herself and her employer sent her to see a physician, who diagnosed her with severe back strain. The doctor put work restrictions on the claimant and prescribed physical therapy and injections for the pain. In December 2008, the doctor said that the claimant was at maximum medical improvement (MMI) and that there was no permanent damage.
In March 2009 the claimant began to have back pain again, so she consulted her personal physician. An MRI revealed a bulging disc and a small annular tear. The doctor gave her an injection for the pain in June 2009, but the claimant’s pain worsened. In August 2009 the doctor told the claimant that she could no longer work and put her on a variety of medications.
The claimant told her employer about her condition and in October 2009 and filed a request for a hearing, claiming that she requested that her employer pay for her to go back to the original doctor for treatment but the employer refused. At the hearing, the administrative law judge (ALJ) ruled that the claimant had sustained a compensable injury in November 2008 and the later pain was a result of that injury. Since the employer had not provided medical care, physician selection fell to the employee and the employer needed to repay her for her medical bills. Additionally, the ALJ held that the employee should receive temporary total disability (TTD) benefits since her injury prevented her from working.
The employer appealed the decision and the Industrial Claims Appeals Office upheld the ALJ’s decision except for TTD benefits. The review panel noted that the claimant had not challenged the physicians claim that she had reached MMI, so she could not now receive TTD benefits. The claimant and the employer both appealed to the Court of Appeals.
The Court’s Decision
The appellate court upheld the ALJ’s finding that the claimant had met her burden of showing that she suffered a compensable injury. The court also found that since the employer had not offered treatment for the injury, the right to select a physician had passed to the employee and the employer needed to reimburse her for her care.
The appellate court reversed the review panel’s decision to set aside the claimant’s TTD benefits, due to the “unique circumstances” of the case. The court noted that although once a person reaches MMI, TTD benefits are often no longer available; the statute does not prevent the possibility of resuming benefits if a person’s condition worsens again after reaching MMI. The court noted that the claimant was not disputing that she reached MMI at the time the doctor declared it, just that her condition worsened again later. As such, the claimant was entitled to TTD benefits.
Medical Improvement Claims
This Court of Appeals case shows how MMI declarations operate in the Colorado Workers’ Compensation Act. When an employee sustains an injury at work, the employer often sends the employee to an authorized treating physician (ATP). The ATP treats the employee until the employee is either fully healed or no further treatment will improve the employee’s condition. At that point, the ATP declares that the employee has reached MMI. If the employee wishes to challenge the ATP’s declaration of MMI, the employee can request a division-sponsored independent medical examination (DIME). If an employee does not challenge the MMI declaration, then it becomes binding.
If the employee is not fully recovered when the ATP declares MMI, then the ATP will give the employee a permanent impairment rating, which if higher than 0 percent usually results in the insurer paying permanent disability benefits to the employee
When the ATP declares the employee has reached MMI, the insurer usually files a Final Admission of Liability (FAL). This form details the benefits the employer or insurer believes the employee is entitled to because of the injury. The FAL is also how the insurer closes a workers’ compensation case. If an employee wishes to challenge the benefits listed in the FAL or the closing of the case, it must be done within 30 days.
Obtaining workers’ compensation benefits can be challenging due to the complex nature of the laws and procedural rules. Navigating the system while trying to recover from an on-the-job-injury can be overwhelming. If you have been injured at work, contact an experienced attorney who can help you get the benefits you need.