Worker's Compensation Terms

Vocational expert (voc expert)

Either party may obtain the services of this person. They are often retained when an employee hasn't returned to work following a job injury or has returned at a lower wage. This person may opine about jobs that the injured employee is capable of performing within his medical restrictions. Often, they will prepare a report and provide a rating based on the injured employee's loss of earning capacity. The rating may be used as (1) a tool to determine PPD benefits owed to an injured employee, (2) a settlement negotiation tactic, or (3) persuasive evidence to a fact-finder.

Future Medicals (future meds)

Employers are typically responsible for payment of medical expenses associated with their employees' on-the-job injuries. Medical benefits are often lifetime benefits (I.e. employers are generally on the hook for future meds for the injured employee's lifetime as long as the medical expenses are related to the underlying job injury). In some states, the employee's right to future meds can be terminated when the employee and employer agree to the terms and a judge or appropriate administrative authority approves the agreement.

First report of injury (FROI)

Following an on-the-job injury, employers are usually required to file an FROI with the state administrative agency that oversees workers comp.

Maximum Medical Improvement (MMI)

Generally, to resolve a workers' comp claim, the claimant must reach this criteria. Typically, it is assigned by a treating physician when an injured employee's condition has stabilized to the point that no major change is expected in his medical condition, despite continuing medical treatment. After this is assigned, the payment of temporary workers' comp benefits may be suspended.

Vocational Benefits (voc beneftis)

In many states, this is available to injured employees. If an injured employee can't return to his regular job, he may be a candidate for vocational rehabilitation. IN many states, the employer may be on the hook for expenses associated with vocational retraining of an injured employee.

Third-party administrator (TPA)

In the workers' comp context, this is an organization that processes claims on an employer's behalf. A large company may be self- inusered for workers' comp claims but may outsource the administration of its claims to one of these.

Utilization review (UR)

Many states have procedures for this. It is the process used by employers or claims administrators to review whether treatment is medically necessary.

Case manager (CM) or nurse case manager (NCM)

People sometimes assigned by third-party administrators or workers' comp carriers to monitor and assist with the coordination of medical aspects of workers' comp claims. They are generally nurses or social workers. Some are employees of the third-party administrator or workers' comp carrier, while others are essentially independent contractors. On occasion, they attend medical appointments with workers' comp claimants, particularly in cases involving serious injury.

Claims Adjuster (CA)

Person who investigates and resolves insurance claims.

Benefit review conference (BRC)

Some states offer this to help resolve issues and disputes resulting from on-the-job injuries. These vary by state but typically involve an informal mediation conference administered by a neutral hearing officer or ombudsman. If a dispute is resolved at this, an agreement may be written and signed by the injured employee and a representative of the employer (or the employer's insurance carrier or third-party administrator).

Permanent Partial Disability (PPD)

When a worker has been assigned MMI and is capable fo returning to gainful employment but has some loss of function or residual problems as a result of an on-the-job injury, he is entitled to these benefits. In short, this describes a disability that is less than total. These benefits are calculated in different ways in different states, often in accordance with statutorily prescribed formulas. It may vary depending on the body part that is injured.

Retaliatory discharge (RD) or wrongful termination (WT)

When a worker is fired for filing a workers' comp claim. An employee who believes they were a victim of one of these crimes may file a claim against their employer.

Temporary total disability (TTD)

When an employee is injured on the job and can't return to work, he is temporarily totally disabled and entitled to receive these benefits during his convalescence. these benefits are generally paid weekly at the rate of two-thirds of the employee's AWW, subject to a maximum or minimum rate. For example, an employee who usually makes $600 per week would be entitled to receive $400 per week for the period that he is temporarily and totally disabled. These benefits may be discontinued after the claimant reaches MMI.

Temporary partial disablity (TPD)

When an employee returns to work following an on-the-job injury but hasn't achieved MMI and is earning less than his pre-injury AWW, he is entitled to these benefits. Typically, these benefits are payable at two-thirds of the difference between what the employee earned at the time of the injury and his current earnings. It is perhaps the least common type of workers' comp benefits.

Impairment rating (IR)

a medical assessment of a claimant's injury represented by a percentage value. A physician may assign an IR to the body as a whole or to a specific body part. The rating may then be used to calculate the workers' comp benefits owed to a claimant. Impairment ratings are particularly important in determining permanent partial disability benefits.

Carpal Tunnel Syndrome (CTS)

a nerve condition in the wrist and is frequently the subject of workers' comp claims.

Functional capacity evaluation (FCE)

a series of tests administered to a workers' comp claimant by a physical therapist or other health care professional. They can be beneficial in determining an injured worker's capabilities and restrictions. The evaluators can review job descriptions and make a determination regarding whether the injured employee is capable of performing certain jobs. After a claimant undergoes this, the evaluator typically provides a detailed report on the results, including the claimant's capabilities and restrictions.

Independent medical examination (IME)

an assessment of a person's physical condition (i.e., an evaluation) made by an independent physician. Many states authorize the use of of this in the context of workers' comp claims. This can be a valuable tool in your arsenal, particularly if you are suspicious about possible fraud or some other abuse of the workers' comp system.

Permanent Total Disability (PTD)

benefits payable to employees who are never able to return to gainful employment. An employee who is determined to be permanently and totally disabled because of an on-the-job injury is entitled to these benefits. In many states, these benefits are payable for the life of the injured employee. The rate is typically two-thirds of the employee's AWW.

Life Expectancy

sometimes a factor in determining the value of benefits owed to an injured employee, particularly in claims for permanent total disability.

Medicare set-aside agreement (MSA)

sometimes come into play when a workers' comp case is settled to include the closing of future meds and the claimant is a Medicare beneficiary or is expected to become one in the near future. As part of the settlement, money for projected medical expenses associated with the workers' comp injury is "set aside" into a bank account. The set-aside funds are used solely to pay for medical expenses related to the injury that would otherwise be paid by the employer. Designed to ensure that the federal government doesn't get saddled with medical expenses (via Medicare) that should be paid in accordance with state workers' comp laws.

Physical Therapy (PT)

the treatment of a physical injury by use of therapeutic exercise. It can be a valuable tool in getting an injured employee back to work.

Workers' compensation rate (WC rate)

typically two-thirds of the employees AWW and is often used to calculate an injured employee's temporary or permanent benefits.

Average weekly wage (AWW)

used to determine the employee's rate of temporary total or partial disability or permanent total disability. It is usually determined by dividing the employee's total wages for the previous year by 52.