Impairment Ratings in Texas Workers’ Compensation Cases
Many times, following a work-related injury, although your medical condition may improve, you will still have some amount of residual impairment or loss of function. After you receive an Impairment Rating, your Temporary Income Benefits will stop and you will begin to receive Impairment Income Benefits to compensate you for your loss of function.
Upon reaching Maximum Medical Improvement (MMI), an Impairment Rating needs to be given so that your benefits can continue. Impairment Ratings are designed to assess your full or partial whole-person impairment following your treatment in a Texas Workers’ Compensation case. The Impairment Rating will serve as a basis to determine how much compensation you will receive for your remaining impairment.
How an Impairment Rating is determined?
Either an independent specialty examiner or the state-appointed Designated Doctor will assess your level of impairment. Upon reaching MMI, the certifying doctor will perform a special examination to determine whether you have remaining impairment as a result of your work-related injury. Certain aspects of your physical limitations will be measured such as your range of motion, your strength, loss of nerve conduction velocity, pain thresholds, visual acuity and or field of vision, etc.
The findings of the examination will be compared to the objective listings in a book called “Guides to the Evaluation of Permanent Impairment” 4th edition, published by the American Medical Association (AMA).
In the Texas Workers’ Compensation system, Maximum Medical Improvement can be reached several ways:
- If the employee fully recovers, then the employee has reached MMI.
- If the employee has not fully recovered, but no further improvement is expected, then the employee can be deemed to have reached his or her Maximum Medical Improvement.
- If 104 weeks have passed since the first day that the employee suffered Disability (lost wages) because of his or her injury, then the employee has reached MMI by operation of law. In short, the law states that if an employee hasn’t fully healed or naturally reached MMI within 2 years of losing time or wages from work, then the rules require that the employee be considered as having reached his or her maximum medical improvement.
Once an injured worker reaches MMI (whether by medical determination or by operation of law) the worker is no longer eligible to receive Temporary Income Benefits. At that time, a special evaluation will be performed to determine whether the worker has any degree of permanent or partial impairment because of the work-related injury or illness. Either the employee’s treating doctor or a state-appointed Designated Doctor will make the final determination as to the degree of permanent impairment sustained.
Impairment Rating Disputes
Either party (the injured worker or the insurance carrier) can dispute the Impairment Rating. The Impairment Rating must be disputed within 90 days of receiving notice of the rating amount, and failure to dispute the Impairment Rating within this time frame will (almost certainly) result in the rating becoming permanent.
What constitutes a case for Workers’ Compensation benefits?
Compensable Injuries in Texas Workers’ Comp Claims
If a Texas worker suffers an injury or illness on the job and all conditions are met for the injury to be covered by the employer’s workers’ compensation insurance plan, then the injury or illness is said to be “compensable”. Simply because an injury happens on the job or an illness occurs as the result of exposure to toxic or dangerous materials does not automatically qualify that injury as being covered under the Texas Workers’ Compensation program.
Elements of A Compensable Injury
For an injury to be considered a Compensable Injury, the injury or illness had to be suffered during the course and scope of employment. In short, this means that you suffered an injury or illness while performing duties and behaviors that would commonly be expected of an employee in your situation. Other elements of a compensable injury include:
- The injury or illness was not caused by or during “horseplay” (goofing off). In many work environments, occasional joking, shenanigans, games and even physical banter is tolerated by supervisors or managers. If your illness or injury occurred during moments of horseplay, the insurance company is under no obligation to cover your lost wages or medical bills.
- The injury or illness happened while you were “furthering the affairs of your employer”. In other words, for an injury to be compensable, it must have happened while you were “about business” in the normal duties of your employment. This also includes things that are normally expected during work hours, such as trips to the restroom, during lunch, taking a break, etc. Every situation is different and you should always consult a lawyer if there is any question about whether the injury occurred while furthering the affairs of the employer.
- The employee was either hired in Texas, or if the employee lived in another state at the time of the injury, was recruited from Texas by a Texas employer. This situation arises often for workers who were injured out-of-state such as truck drivers, oilfield workers, etc.
- The injury is not pre-existing. This means that the employee was not actively treating (or has not recently treated) for an injury that previously occurred. For example: if an employee had previous back surgery years ago and has not actively treated in a long time, then the employee re-injures his or her back during the normal course and scope of employment, chances are, the injury is compensable. However, if another employee with previous back problems has continued to receive treatment for the old injury from time to time, or if there is evidence that the “old injury” has never gone away and continues to cause problems, then there’s a chance any new workplace back injury may be deemed “pre-existing” and therefore, not compensable.