Workers’ compensation provides an injured worker several different and important benefits. If the worker suffers an injury resulting in permanent impairment to a part of their body, then they are entitled to permanent partial impairment benefits. This article will address when permanency benefits are due and how they are calculated. It will also provide other useful information concerning permanent partial impairment benefits.
Entitlement to permanent partial impairment benefits
Not all injured workers’ are entitled to permanent partial impairment benefits. An individual is entitled to such benefits if a medical provider determines that the work injury resulted in a permanent impairment to a body part.
When permanency is assessed
Permanency cannot be determined until an individual’s injury is at a Medical End Result. This means that the medical condition has plateaued such that significant further improvement is not expected. Often, in a work injury claim, the adjuster for the insurance company will ask the treating physician whether the injured worker is at Medical End Result. Alternatively, the injured worker may be asked to attend an Independent Medical Evaluation (IME) at which time the doctor may assess whether the injury is at Medical End Result and whether there is any permanent impairment.
Requesting permanent partial impairment benefits
If permanency has not been addressed by the insurance company and an injured worker wants to obtain permanency benefits, s/he needs to do two things:
- Ask the treating doctor whether s/he has a permanent impairment.
- Write to the Department and/or adjuster (writing to both is best) and request Permanent Partial Impairment benefits.
Note: An injured worker who fails to provide written notice of their request for permanent impairment benefits within 6 years of their work injury (or medical end result for their injury) may be forever barred from claiming permanency benefits due to the statute of limitations.
How permanency is determined
Vermont Law (21 V.S.A. § 648 (b)) requires that permanent partial impairment determinations be made in accordance with the most recent edition of the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. Typically, the treating doctor and/or the insurance company’s IME doctor provide written opinions providing a permanent impairment rating.
Whole person impairment
When a physician determines an impairment rating they may note the impairment rating for the “body part” and a different rating for the “whole person.” For example, a 10% impairment of one hand is equal to a 9% impairment of one upper extremity. In addition, a 9% impairment of one upper extremity equates to a 5% impairment of the whole person. The whole person impairment rating determines a claimant’s permanent partial impairment.
Independent Medical Examination
If the injured worker treats with a doctor of his/her own choice, the insurance company may require attendance at an Independent Medical Examination (IME) so that they may obtain their own opinion concerning permanent impairment. If a claimant fails to attend an IME and does not have a reasonable excuse for non-attendance, the insurance company may request suspension of the claimant’s benefits until such attendance.
One injury may yield different impairment ratings from different physicians. Although all medical providers are required to follow the 5th Edition of the AMA Guides, they may utilize different tables or consider different criteria or medical findings in evaluating an individual’s impairment.
1) If the doctors’ opinions (ratings) differ by 10% or less, Department Specialists review the medical information and the AMA Guides and determine which rating and opinion is more supported by the evidence. If the Department has not been provided complete information it may be necessary to provide additional medical records or for the doctor(s) to provide additional information concerning how s/he arrived at the impairment rating.
2) If the doctors’ opinions (ratings) differ by more than 10% the Department may select a different and independent doctor to examine you and render an opinion concerning your permanent impairment.
Computing Permanent Partial Disability Benefits
Permanent Impairment benefits are computed in one of several ways depending upon the body part(s) injured:
1) Spine -Take agreed upon permanent impairment rating percentage and multiply it by 550 weeks.
Example – 5% rating = 5% x 550 (weeks) = 27.5 weeks of compensation
2) Other body part – Take agreed upon permanent impairment rating percentage and multiply it by 405 weeks.
Example – 5% rating = 5% x 405 (weeks) = 20.25 weeks of compensation
3) Two injuries, one to the spine – For two injuries where one is to the spine and one is not, calculate each body part permanency separately then add the number of weeks together.
Example – if 5% to spine and 5% other, 27.5 weeks + 20.25 weeks = 47.75 wks total
The weekly benefit amount the injured worker is entitled to is based upon his/her compensation rate. The compensation rate is roughly 2/3’s of the injured worker’s usual wages before being injured. An injured worker with a permanent partial impairment receives their compensation rate for the number of weeks they are entitled to based upon their permanent impairment rating.
Lump sum request
An injured worker may request that all or part of their permanent partial impairment award be paid in a lump sum. The claimant must provide a written request for such an award and must state the reason(s) for such request. The insurance company (or employer) must have an opportunity to respond to such request. The Department will usually approve of the lump sum payment if both parties agree to it. The Department has the authority to order payment of permanency in a lump sum in a situation where the lump sum is intended to hasten the injured worker’s rehabilitation or recovery or is otherwise in the injured worker’s best interests. (For more information on lump sums see Rule 19.)
Department review of Permanent Partial Impairment Agreements
The insurance company submits all agreements for Permanent Partial Disability (PPD) compensation to the Department for review and approval. These agreements are detailed on a Form 22. (All Forms are available on the workers’ compensation website at http://www.state.vt.us/labind/wcomp/wcforms.htm)
Form 22 – Agreement for Permanent Partial Disability Benefits
The Form 22 contains important information concerning a claimant’s permanent impairment rating for a specific work injury. Form 22 information includes the claimant’s State File number; work injury employment; compensation rate; physician rating and the number of weeks of benefits the impairment rating covers. The Form 22 must be signed by the injured worker, by a representative of the insurance company (or employer) and it must be approved by the Department in order to be enforceable.
Permanent Partial Impairment - What it covers and what it does not cover
Permanency benefits are intended to compensate an injured worker for permanent impairment. According to the AMA Guides, impairment is defined as “a loss, loss of use, or derangement of any body part, organ system, or organ function.” An injured worker may suffer an injury that requires surgery or significant medical care, however, if after full recovery there is no loss of use or function, then there is no permanent impairment. Conversely, an injured worker may suffer a seemingly minor injury that results in significant loss of function and impairment.
Permanent partial impairment benefits are intended to compensate injured workers for the impairment they are expected to live with over their lifetime. This information is intended to provide an overview of information. For more information call the workers’ compensation division at (802) 828-2286 or visit our website at http://www.state.vt.us/labind/wcindex.htm.