Workers’ Compensation Terminology
There are many acronyms and terminologies that are unique to the workers’ compensation system. Here are a few that will make understanding workers’ compensation a little easier:
Permanent and stationary (P&S) – This is a level where the injured worker’s condition has reached a stable plateau and further medical treatment is unlikely to improve or worsen the injury, also called maximal medical improvement (MMI). The doctor will assign a level of permanent disability to the injured body part or body system. Temporary disability benefits will terminate on this date, if those benefits have not already terminated. The doctor will also assign permanent work restrictions for the injured worker.
Agreed medical examiner (AME) – This is a neutral doctor agreed on by all parties whose opinion is binding with regards to treatment, permanent and stationary date and status, future medical care and qualification for vocational rehabilitation benefits. This option is only available for injured workers who have hired a workers’ compensation attorney.
Panel qualified medical examiner (PQME) – This is a neutral doctor who provides an overview of treatment and injured worker’s condition. If there is a dispute as to injury, the extent of the injury, work restrictions, inability to return to work, or really any other dispute in the case, a party may request a panel of three doctors from the Department of Industrial Relations (DIR). This doctor is similar to an AME, but the opinions of the PQME are not binding and any party may put the opinions of the PQME on trial. The doctor is selected from the panel of three using a strikeout method. An unrepresented employee may choose any of the three doctors they want on the list.
Temporary disability (TD) – These are bi-weekly payments made from the insurance company to the injured worker while the injured worker is still under a doctor’s care and unable to work. Payments are equal to two-thirds (2/3) of the injured worker’s average weekly wages for the 52 weeks prior to the injury. The maximum weekly rate that an injured worker can receive is set every year by the Department of Industrial Relations. Also, in most cases, this benefit is payable for a maximum of 104 weeks in a five year period.
Modified duty – An alternative work from the employer that accommodates the injured worker’s restrictions from the doctor, either while the worker is in treatment or on a permanent basis once treatment has ended.
Permanent disability advances (PDAs) – These are bi-weekly payments made from the insurance company to the injured worker after the treating doctor has declared the injured worker permanent and stationary. These payments are advances on the estimated value of the ultimate settlement and will be deducted from the final settlement amount.
Permanent disability rating – A percentage of permanent disability assigned to the injured worker’s body by the doctor. Each percentage is adjusted for the injured worker’s age and occupation and corresponds with a dollar amount set by the state of California.
Stipulation (Stip) – Settlement for the amount of permanent disability set by the state with open future medical care provided by worker’s compensation insurance carrier. Medical care is subject to prior approval and may be denied if the permanent and stationary report does not allow for a procedure. Allows injured worker to keep their job if the employer has modified work available on a permanent basis. Payments are made in bi-weekly installments until total amount is paid. Case may be reopened for new and further disability based on doctor’s findings within five years of the date of injury. .
Compromise and release (C&R) – A final settlement, which includes the permanent disability payment and an additional payment for a buy out of future medical benefits, based on the doctor’s recommendations. Payment is made in one lump sum check to the injured worker and case is closed permanently. Allows injured worker to treat with their family doctor and receive treatment without prior approval of the worker’s compensation insurance carrier. Available to injured workers who are unable to return to their previous jobs based on their work restrictions.
Qualified injured worker (QIW) – An injured worker who is unable to return to their previous line of work due to the extent and nature of their injuries.
Vocational rehabilitation – A system for qualified injured workers to enter into job retraining to reenter the job market.
Findings and award – The final award issued by a worker’s compensation judge after a trial. Awards a percentage of disability and the corresponding dollar amount based on the doctor’s reports submitted and testimony given. May also award future medical care as outlined by the doctor’s report, if any future treatment is recommended.
Medicare set aside (MSA) – If the parties decide to do a C&R, a set aside to protect the interests of Medicare may need to be completed in certain circumstances, such as if a person is currently a Medicare recipient or may become Medicare eligible in the very near future. If this is the case, then an analysis needs to be complete of the anticipated future medical costs and that analysis needs to be submitted to, and approved by, Medicare before the parties can finalize a C&R.
Utilization review (UR) -The process used by insurance companies to decide whether to authorize medical treatment requested by doctors.
Independent medical review (IMR) – A process where an anonymous doctors at the state reviews medical treatment disputes between the PTP and UR for medical treatment for the injured worker. The injured worker is never examined by the IMR doctor and the IMR doctor’s decision is binding and not appealable. Denials that are upheld by IMR are valid for one year, unless the PTP can show that there has been a change in circumstance necessitating another review by UR.
Deposition – A question and answer session that is recorded by a court reporter, conducted at the attorney’s office with the insurance company’s attorney. Because the injured worker is the best source of information about how the injury happened and their medical history, this process helps us understand the case better.
Medical provider network (MPN) -A list of doctors pre-approved by an insurance company to treat worker’s compensation patients. Insurance companies with a MPN will not allow the injured worker to treat outside of the network and will not pay for medical treatment by doctors that are not on the list.
It is recommended that you hire an experienced workers’ compensation attorney to assist you though this complicated and time consuming process.
** Nothing on website is designed to provide legal advise and nothing on this site creates an attorney-client relationship. Please contact Eric M. Overholt, Esq., Attorney at Law or another experienced workers’ compensation lawyer if you would like more information about retaining an attorney to represent you for your work related injury in San Diego or throughout California. Mr. Overholt is one of the best lawyers in San Diego and in Imperial County and will fight for your rights in court.