Posted in Our Blog on October 16, 2022
Grappling with what to do following an accident can be challenging. Doctor appointments need to get scheduled, prescriptions filled, and bills paid. Concerns may be swirling in the minds of injury victims. The last concern they should have is being denied insurance benefits. But an insurance carrier contesting that an injury victim has reached maximum medical recovery is a reality of life.
Regarding accident victims who sustained severe injuries, maximum medical recovery could mean that they have recovered as much as possible after receiving the appropriate medical treatment. In this example, the person in question is not fully recovered and is highly likely to live with chronic problems due to their injuries.
Maximum medical recovery can also be referred to as maximum medical improvement. In some cases, the victim may recover fully from their accident injuries after receiving the necessary medical treatment.
The doctor treating the accident victim is the one to decide whether they have reached the point of maximum medical recovery. Of course, the victim has the right to speak with multiple physicians to see if they all arrive at the same determination or if there are any conflicting opinions. This is probably a good idea because having a medical consensus on something so crucial as maximum medical recovery can only benefit the victim.
Victims might ask themselves, “How does a doctor determine if I have reached the point of maximum medical recovery?” There is an impairment rating system that they use to arrive at this conclusion.
A physician might say the following to a patient: “You are at maximum medical recovery and have a 15 percent impairment rating.” If the patient is between 1-10 percent, that equals two weeks of lost wages for each percentage point. If they are between 11-15 percent, then it is three weeks of lost wages for each percentage point. Those between 16-20 percent are assigned four weeks of lost wages for each percentage point. And lastly, those who have an impairment rating of 21 percent or higher have six weeks of lost wages for each percentage point assigned to them.
Some injury victims may wonder if not undergoing elective procedures recommended by a doctor will work against them later. Will this mean they cannot be assigned a maximum medical recovery designation? The short answer is that it depends. In some situations, a doctor might say that by not undergoing elective surgery, the person has reached the level of maximum medical recovery. It is a case-by-case situation where all the variables need to be considered. There are no hard-and-fast rules that apply to all injury victims.
If the insurance company refuses to agree with the doctor’s designation for the victim, they may request an independent medical exam. If this were to happen, the insurance company would enlist their doctor’s services to look at the victims’ injuries and decide if they are truly permanently impaired or if they have recovered.
An independent medical examination, which an employer or insurer can request, is often biased. After all, the doctor conducting the exam is being paid for by the employer or insurer with the hope that their findings limit the claimant’s benefits. Some argue that those conducting these independent medical exams have a conflict of interest. Yet, they continue to provide results that predominantly benefit employers and insurers in the hopes of sending patients their way. They do this because it is in their financial interest to do so. Even though the ethical nature of independent medical exams has been called into question, they continue.
An insurance carrier contesting the maximum medical recovery designation or a doctor’s impairment rating means a victim’s benefits will be caught in limbo. Consulting with a skilled attorney is highly recommended because doing so can help expedite this process.
Whether an injury victim should wait until they have reached maximum medical recovery to send a demand letter might be debatable. However, in most cases, it makes sense to wait. In some situations, sending a demand letter sooner might make sense, but it all depends on the facts of the specific case.
Why would it make sense to wait? The biggest reason is that the actual cost of the claim might not yet be apparent. It might take some time for the injury victim, their physician, and their attorney to come to an accurate value for the claim, which directly influences the amount requested in the demand letter. The last thing the injury victim wants to do is ask for less than they truly need and deserve.
Maximum medical recovery is not an objective, easy-to-understand designation. There are many interpretations of whether it is warranted for a specific situation. This means that injury victims are fighting an uphill battle regarding getting the benefits owed to them by insurance companies.
From only getting one doctor’s opinion to misunderstanding how elective surgeries impact maximum medical recovery to not understanding the best timing for a demand letter, there are plenty of potential pitfalls between an injury victim and insurance benefits. An attorney well-versed in maximum medical recovery cases can help injury victims more easily navigate these issues and arrive at a satisfactory settlement.
Injuries can happen at any point in life, so knowing what maximum medical recovery is and how it is decided can be helpful. Understanding the maximum medical recovery ratings doctors use and why an insurer might request an independent medical exam, can also prove beneficial. It is also important to know when to send an insurance carrier a demand letter and the best time to do so because timing is everything.