TTD / Temporary Disability – payments issued as wage replacement, calculated at 2/3rds of the applicant’s average weekly wage (AWW). Temporary disability benefits end after 104 weeks (two years) (with few exceptions). Temporary disability is paid by the worker’s compensation carrier when a worker misses more than three days of work due to a work injury.
AWW – Average Weekly Wage – Earnings of the injured worker, taking the average hourly rate and for the average work schedule for a full week of employment, used to calculate TTD rate
PD/ Permanent Disability – Permanent disability is intended to compensate an injured worker for residual physical disability sustained as a result of a work injury; Permanent disability payments start once an injured worker has reached MMI / Maximum Medical Improvement, also called permanent and stationary status or “P & S.” This is the point at which your condition has stabilized and is unlikely to change significantly, either with or without treatment. At this point, TTD will stop.
QME – Qualified medical examiner – a doctor, certified by the State of California, trained to write medical legal evaluations and reports on an injured worker’s level of permanent disability (PD)
PQME – Panel Qualified Medical Examiner – a doctor chosen off a list issued by the State of California of QMEs, designated as the med-legal evaluator for an injured worker
MMI – Maximum Medical Improvement, also called “P&S” or Permanent and Stationary. It is at this point that the injury is unlikely to change significantly and the level of disability can be assessed.
AME – Agreed Medical Evaluator – this is an agreed upon doctor used in place of a Panel Qualified Medical Examiner. Typically only injured workers with attorneys use an Agreed Medical Examiner, an injured worker without representation will have to use the PQME /Panel QME system to obtain a medical-legal evaluation.
Medical-Legal Evaluation – this is a medical evaluation used to assess the effects of a work injury. The appointment can last between 45 minutes to 4 hours, depending on the complexity of the evaluation. For example, a psychiatric evaluation involves many tests and takes hours longer than an examination limited to physical issues only. A medical-legal evaluation is done by a Qualified Medical Examiner, and preparation of a detailed report follows. This report will give the history of the injury, the medical treatment history, background on the injured worker, and the doctor’s assessment of the injured worker’s residual disability from the injury.
AMA Guides – Refers to the American Medical Association Guides for evaluation of disability (fifth edition). This is a book which provides a framework to objectively assess physical limitations and disability. This framework is basically an algorithm where measurements (loss of range of motion, limitations, etc) can be measured. Each body part has a value, and this value is calculated through these measurements. The measurements add up to “whole person impairment” (WPI), which is then used in connection with your age and occupation to calculate the level of disability from the work injury.
WPI -Whole Person Impairment – The base number used to calculate a Permanent Disability rating.
The WPI is the raw number, before adjusting for age and occupation to get a final permanent disability rating. If you are older, your rating will increase to a higher percentage because older people are more disproportionately affected by injuries. Similarly, if you are younger, your age will affect your rating and cause it to go down to a lower percentage because younger people are presumed to be able to recover from injuries more than older people. High risk or very physically demanding jobs, such as construction work, or working in Law Enforcement, are rated higher than say, an accountant or office worker, because of the physically demanding nature of the job. If you twist your ankle, you can still sit and type. If you twist your ankle as a police officer, you cannot do a lot of your regular duties.
Rating – Also called a “permanent disability rating” or simply “a rating.” This means the number string that makes up your permanent disability value. Briefly explained, it is a percentage of your disability. This percentage has a specific cash value. That is your permanent disability “award” – it is an estimate of the residuals of your injury.
(body part code) – ( WPI ) – (age) – (occupation) = permanent disability rating %
% = $
Stipulations and Award – Stipulations is the ‘default’ settlement in worker’s compensation. The parties stipulate to a specific percentage of disability (see rating, above). The permanent disability amount is then paid out at $290 per week. When the funds are exhausted, no more payments will issue. Applicant’s attorneys are paid directly by the insurance carrier, out of the award of permanent disability. Fees are capped at 15% of the total permanent disability cash value.
Compromise and Release – C&R – This is a lump sum settlement of all issues in a worker’s compensation claim. Parties have to agree to settle everything (including future medical treatment). A judge cannot order either party to settle by a C&R /lump sum settlement.
Utilization Review – “UR” – The process of reviewing requests for medical treatment for reasonableness. A doctor you have never met is paid by the insurance company to review the medical treatment your treating doctors are requesting for you. UR went into effect as of January 1, 2013, and applies to ALL DATES OF INJURY, PAST AND PRESENT. If you settle your case by stipulations, the award of future medical care is subject to the laws in place at the time of treatment, including Utilization Review. Approximately 65% of all medical treatment requests, including prescriptions, are denied. Of this number, about 40% are appealed through the IMR (Independent Medical Review) process. Of those appeals, 81.3 percent of the denials are upheld. The treatment denials remain in effect for one year – that means if UR denies surgery, your doctor has to wait one year before they can request it again. The level of medical treatment in worker’s compensation is comparable to having to rely on the DMV for open heart surgery.