What happens to my medical benefits when I reach Maximum Medical Improvement (MMI)?

Reaching MMI is a critical decision point in the life of a workers' compensation claim. If you need help with your workers compensation claim, we can help!

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Posted: 10/15/2020
 Workers Compensation    Medical Insurance  

If you have been involved in a work accident, you are likely focusing on recovery and trying to determine your next steps. It is overwhelming and this may be your first experience trying to recover compensation from your insurance carrier. We have detailed what to expect from your workers' compensation claim when you have reached Maximum Medical Improvement.

Medical Expenses Under Workers' Compensation

One of the most important benefits in a workers' compensation claim is the payment of medical expenses needed to heal from an injury. This need is immediate and should not be delayed by the insurer. To leave you in the best place possible to successfully move forward after a work-place injury, it's vital that you receive all the necessary and appropriate treatment to help you recover. Once a claim is accepted, according to Montana law, the insurer is required to pay for "reasonable primary medical services, including prescription drugs" for conditions that are a direct result of injury. Primary medical services are those that are necessary to help an injured worker get to "maximum medical improvement."

Maximum Medical Improvement

The term "Maximum medical improvement", or "MMI", is used under workers' compensation law to describe that point in an injured worker's healing process when they are not expected to further improve with generally accepted medical treatment. It's often described as the point when a person is "as good as they can get" with standard treatment. It is important to note that reaching MMI does not mean that the condition will not continue to improve with the passage of time, but that the injured person does not continue to experience pain caused by the injury. It simply means that the condition is not expected to continue to improve with further medical treatment.

Reaching MMI is a critical decision point in the life of a workers' compensation claim. It is important both from the perspective of available medical treatment and the determination of wage loss benefits that are ultimately available for a claim. The role MMI plays in wage loss benefit determination will be addressed in a later article. You can subscribe for email updates to receive alerts on new articles and other exclusive legal resources.

Workers' Compensation Glossary of Terms

Insurer's Requirements

Up until you reach MMI, the insurer is required to pay for the recommended medical treatment that the treating provider believes will improve your condition. After MMI, the insurer remains obligated to pay for medical treatment related to the injury, however, the treatment available is more limited. Post-MMI, the insurer is generally only responsible to pay for "secondary medical services." This is treatment that allows you to continue working or helps you to maintain MMI. Because the treatment available to you may be restricted once you reach MMI, it is important that your physician exhausts all possible treatment options to make you better.

Monitor Your Progress With Your Doctor

Don't hesitate to tell your doctor about ongoing symptoms, what treatment is or isn't helpful, how a particular therapy is working for you, and whether you think you have room for improvement. This is the time for you to be sure you are given the opportunity to heal as best you can. The insurer may try to hurry a finding of MMI to limit their liability for medical treatment. Your best protection from this is open, effective communication with your doctor.

After reaching MMI, you will be entitled to additional medical treatment that is related to the injury for a limited time, generally 5 years after the date you were injured. This treatment is geared towards maintaining MMI and helping you to continue working, as opposed to improving your condition. The type of treatment that can help you after reaching MMI varies from case to case and can be a source of dispute with the insurer. It is important to be your own best advocate to press the insurer to continue paying for treatment that helps you maintain your physical condition.

If You're Not Getting Results, We Can Help

If you have difficulties obtaining the medical treatment you need, before or after MMI, we are available to answer questions or provide assistance. We have extensive experience working with hard working Montanans who have been involved in work injuries and we are privileged to help our community.

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