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Maximum medical improvement is the point where an occupational injury will no longer improve. Temporary benefits are converted to permanent settlement, calculated using a disability percentage. Insurance companies may hire doctors to perform independent medical examinations. AMA Guides are used to determine maximum medical improvement.
Maximum medical improvement is a term found in the Workers Compensation Act. It is defined as the point at which the medical condition, created by an occupational injury, will no longer improve appreciably. This simply means that a treating or evaluator would not expect any additional improvement at this stage of recovery. This does not mean that the injured employee is exempt from the possibility that his condition may worsen or that he may be completely disabled.
When a worker is injured on the job, they may be entitled to workers’ compensation benefits due to temporary total disability. When the employee has recovered enough to achieve maximum medical improvement, his temporary benefit is converted into a permanent settlement. Permanent partial disability benefits are calculated using a rating number or a disability percentage. By this stage, when temporary total disability benefits are converted to permanent partial disability, most treatment options have been exhausted or at least changed from rehabilitative to palliative. At this point, the focus is less on treatment and more on a final resolution.
Consider the following example: An elevator operator in a warehouse is injured when a tall stack of boxes falls on her, resulting in a compound fracture on her ulna. This accident leaves her disabled for six months, during which time she receives interim full disability payments. She eventually returns to work part-time doing paperwork for the warehouse office. As a result, you start collecting temporary partial disability benefits.
Eventually, her attending physician determines that she has achieved maximum medical improvement. It establishes that you have a permanent partial disability of 20% as a result of your injury. After receiving its disability rating, the insurance company can then switch to a pre-specified schedule — published by the applicable state government — that dictates how much permanent partial disability benefit the insurer must pay over how many months.
Maximum medical improvement serves two basic purposes. Firstly, it represents a defense against the payment of any additional temporary total disability benefits; these payments simply cease. Secondly, it represents the point at which the degree of permanent partial disability of the injured worker can finally be established. These two important issues determine how much of the total workers compensation benefit is available to the employee. For these reasons, many insurance companies will hire their doctors to perform independent medical examinations to express their opinion regarding maximum medical improvement.
A physician must consider several factors provided by the American Medical Association (AMA) when ascertaining whether the injured employee has achieved maximum medical improvement. The primary source of this information is the AMA Guides to Assessing Permanent Damage. In the event of a dispute between the attending physician and the physician appointed by the insurance company to evaluate the injured worker, the matter is referred to the labor law administrative judge. This judge will consider a few factors, including the patient’s condition history, any pre-existing conditions, and current and proposed treatment plans.
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