Reaching Maximum Medical Improvement in Colorado Workers’ Comp Claims

During the initial phase of a Colorado workers’ compensation case, an injured worker is properly focused on doing whatever it takes to get better. At a certain point in the course of treatment, though, the treating doctor will determine that the injured person has reached maximum medical improvement (MMI). Essentially, MMI means that the person’s condition has improved as much as is realistically possible.

MMI is perhaps the most important stage in any Colorado workers’ compensation case. If you have any qualms at all about your doctors’ determination that you have reached MMI, you need to act soon to protect your rights.

Determination of Future Benefits

After a doctor determines an injured worker has reached MMI, the doctor will provide an impairment rating. The employer’s insurance company will then use the doctor’s determination to decide what, if any, future benefits the worker is entitled to. If the insurance carrier admits permanent disability it will be done through a document called a “final admission of liability.” At this point, any temporary disability benefits the worker has been receiving will stop.

In the vast majority of cases, the insurer’s decision will fall into one of four categories:

  • No future benefits: In these cases, the insurance company will decide that the worker is not disabled and does not require any further medical treatment related to the workers’ compensation injury.
  • Maintenance care benefits: In other cases, the insurer may determine that the worker needs to undergo future medical care to maintain his or her condition. Workers can be deemed to have reached MMI even if they need future care, so long as that future care is not expected to significantly improve the worker’s condition.
  • Permanent partial disability: Permanent partial disability is awarded when a worker experiences a permanent impairment or loss of function of a body part or body system, but is not so disabled that he or she can no longer work. Workers with permanent partial disability are entitled to a fixed benefit payment based on the doctor’s disability rating and formulas set by state law.
  • Permanent total disability: Permanent total disability is awarded to workers who are so disabled that they are no longer able to earn wages in any type of job. Permanent total disability benefits are paid for life. Usually, they are the same as the temporary total disability payments that were made before the injured worker reached MMI; however, there is a 50 percent offset for Social Security Disability benefits if the injured worker is receiving these.

Contesting an MMI Determination

An injured worker is allowed to contest the doctor’s determination that indicates MMI has been reached by asking for a Division Independent Medical Examination (DIME). Essentially, this is a request that another doctor issue a “second opinion” about the injured worker’s medical condition.

Alternately, the insurance company can also request a DIME. This is done when the carrier disagrees with the permanent disability rating given by the authorized treating physician.

Often, the insurance company will suggest a doctor to conduct the DIME. However, it is rarely a good idea to go along with this recommendation. Usually, an insurance company will recommend a doctor because they know that physician is particularly friendly to insurers’ viewpoints.

Instead, an injured worker can ask the Division of Workers’ Compensation to provide a list of three doctors. These doctors’ names will be drawn from a group of doctors who have agreed to perform DIMEs. Both the injured worker and the insurance company will be given an opportunity to strike one name from the list. The remaining doctor will perform the DIME.

The DIME doctor’s opinions are binding on both parties unless they are overturned at a later hearing. DIME findings regarding the date of maximum medical improvement and the disability rating will only be overturned based on “clear and convincing evidence.”

Contesting a Final Admission of Liability

An injured worker also has a right to contest the insurer’s determination of benefits pursuant to the final admission of liability by requesting an administrative hearing to review the insurance company’s decision.

An administrative hearing is a formal legal proceeding that is conducted by an administrative law judge. The hearing functions much like any other court case – all parties are given an opportunity to present evidence and question witnesses. However, there is no jury. Instead, the judge will determine what benefits, if any, the insurance company is required to pay.

Depending on the nature of the dispute, the injured worker may have to participate in a DIME before the administrative hearing.

Time is of the Essence

The worker must act soon if he or she disagrees with either the doctor’s determination that MMI has been reached or the insurance company’s final determination of benefits. The case could be permanently closed if too much time passes. From the date of the final admission of liability, the worker has 30 days to object to the final admission and request a DIME. In some circumstances, the worker may go directly to hearing, but, again, the request usually must be made within 30 days of the date the final admission is mailed.

Speaking With an Attorney

If you want to contest an MMI determination and have not already done so, contacting a Colorado workers’ compensation attorney is advised, even if you are only slightly unsure about what to do. Most workers’ compensation law firms do not charge a fee for an initial consultation.

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