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change in condition in a workers comp caseWorkers’ compensation benefits are meant to support an injured employee until they have reached “maximum medical improvement,” or MMI, and can return to work. Many times, these cases are resolved in the form of a settlement. Depending on the way the case was settled, the employee may be able to reopen the case for additional benefits.

If Younce, Vtipil, Baznik & Banks, P.A., is your workers’ compensation attorney, we can fight for these additional benefits and seek to reopen your case if a change in your condition entitles you to medical care and/or time away from work. Contact us in Raleigh, NC, if you need help reopening a North Carolina workers’ compensation claim.

What Is a Change in Condition?

At some point after suffering a workplace injury, the patient will either fully recover or get as well as they can. The medical provider overseeing the case must then make a series of decisions to:

  • Declare the patient has reached maximum medical improvement (MMI)
  • Assign the patient a Permanent Partial Disability (PPD) rating
  • Order work restrictions as necessary
  • Release the patient from treatment, typically with instructions to seek follow-up care as needed.

At this point, the insurer may propose a settlement in the form of an N.C. Industrial Commission Form 26A or a clincher agreement.

  • Form 26A settlement. This is a signed agreement using the N.C. Industrial Commission’s Form 26A, which states the employee’s status and the PPD payments they are to receive and for how long. A Form 26A settlement preserves the right to reopen a claim within two years of the payment of the Form 26A settlement if there is a change of condition.
  • Clincher agreement. This is a final resolution and settlement of every issue in a workers’ compensation case. In return for a lump sum payment, the worker waives the right to further benefits under the Workers’ Compensation Act and releases their employer from any future liability arising from the case. You cannot petition to reopen the case for a change of condition if you settle with a clincher agreement.

Your claim cannot be settled without your written permission, and the Industrial Commission must approve all settlements.

After the Form 26A settlement, if the employee’s injury worsens and affects their ability to earn wages or their wage earning is affected without a change in their physical condition or there is a change in the degree of their disability, the employee has the right to petition to reopen their claim due to a change of condition. If they are successful, they will have a right to the payment of medical care costs and wage benefits based on two-thirds (66 2/3%) of their pre-injury wages.

North Carolina workers’ compensation law states that, upon a change in condition, the worker has two years to seek review of the claim and reinstate benefits. In other words, the injured worker may seek additional benefits if they suffer a change in condition within two years of their Form 26A settlement. However, the employer and their insurer may challenge the employee’s claim for change of condition.

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Understanding Maximum Medical Improvement and Permanent Partial Disability

When there’s nothing more that doctors can do for an employee who is receiving workers’ compensation, he or she is said to have reached “maximum medical improvement.” This may mean they have fully recovered. It may mean their current medical condition will not improve further. This latter status typically means the employee has some level of permanent impairment or disability.

When an employee at MMI has a disability, the authorized treating physician may assign a rating based on its severity. The rating determines the employee’s right to additional disability payments. For a permanent partial disability (PPD), the calculation is based on:

  • The employee’s compensation rate, multiplied by
  • The period of compensation (weeks) allowed by the state’s schedule of injuries, which is multiplied by
  • The employee’s percentage of impairment.

For example, among the 23 injuries and length of compensation for them on the state’s schedule are:

  • For loss of the index finger, 66 2/3% of the employee’s average weekly wages for 45 weeks.
  • For the loss of an arm, 66 2/3% of the employee’s average weekly wages for 240 weeks.
  • For the total loss of use of the back, 66 2/3% of the employee’s average weekly wages for 300 weeks.

For example, an employee with an average weekly wage of $1,000 would have a compensation rate of $666.67. If the employee was assigned a 20% disability rating to the arm, the employee would be entitled to $32,000.16 paid out at the rate of $666.67 a week for 48 weeks (20% x 240 weeks).

What If I Signed a Clincher Agreement?

In some cases, there may be valid reasons to accept a one-time, lump-sum payment to provide final and full satisfaction of your workers’ compensation claim and close it with a clincher agreement settlement.

We strongly advise having an experienced workers’ compensation attorney review a clincher agreement you were considering to determine whether the offer is fair and appropriate for your case.

How a Change in Condition Affects My Workers’ Comp Benefits

Suffering a change in condition after a Form 26A settlement and successfully petitioning to reopen your case entitles you to continued medical care and wage replacement benefits.

How Can a Claim Be Reopened Due to a Change in Condition?

If you settled your claim on a Form 26A and you have reason to claim further compensation, you must notify the Industrial Commission in writing within two years from the date you received your last compensation check by filing a Form 33 Request for a Hearing. To obtain benefits, you would have to document a change in your condition and the need for additional benefits at a hearing before the Industrial Commission.

It is likely that the insurer and/or your employer would challenge your attempt to reopen your claim by asserting that your current medical condition is not due to your injury and therefore should be denied. You need to be ready to prove your change of condition.

Your petition for a resumption of benefits would also place you back under the care of the doctor who presided over your original claim. He or she could ultimately support your claim, deny that your condition had substantially changed, or attribute your current condition to a source other than your occupational injury. You could obtain a second medical opinion and present it at your hearing, but the authorized treating physician’s opinion would also be considered.

If your petition to reopen your claim was approved, your weekly wage-replacement benefits would resume and your medical care bills would be paid. At some point, you would again reach MMI, and assuming you did not fully recover, your PPD rate and, thus, your further disability compensation would be recalculated and possibly changed.

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Get Help from Our Raleigh Workers’ Compensation Lawyers

North Carolina workers’ compensation laws are complex, but you should have someone on your side to protect your right to receive medical care and other benefits for occupational injuries. Have you experienced a change in your condition that necessitates reopening your workers’ compensation claim? If so, you should seek the guidance of an experienced workers’ compensation lawyer.

The Raleigh workers’ compensation attorneys of Younce, Vtipil, Baznik & Banks, P.A., can advise you and stand up for your rights as an injured worker if your employer or their insurance company objects to reopening your claim and resuming benefit payments. Our legal team includes Chip Younce and David E. Vtipil, who are both recognized by the N.C. State Bar as Board-Certified Specialists in Workers’ Compensation Law.

It won’t cost you a dime to discuss your change of condition with one of our experienced Raleigh workers’ compensation attorneys. We will not charge any legal fee unless we recover compensation for you. Call us now at (919) 661-9000 or contact us online for a free claim review and advice about your legal options after a change in your work injury-related medical condition.

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