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Advisory 93-01

Statutory Maximum Medical Improvement at 104 Weeks

A claimant, by definition, reaches maximum medical improvement on the day after the expiration of 104 weeks from the date income benefits began to accrue. The claimant's eligibility for temporary income benefits ends at this point and eligibility for impairment income benefits begins. The first payment of impairment income benefits shall be made no later than five days after the expiration of the 104 weeks as required by Section 4.26(f) of the Act. The duration of the benefits shall be based on the impairment rating as assessed by the treating doctor, or, if disputed, based on the impairment rating as determined by the Commission.

In accordance with Rule 130.2, the Commission is currently sending a letter to the treating doctor of each claimant who has not been certified as having reached maximum medical improvement and is receiving temporary income benefits 98 weeks after benefits began to accrue. If the treating doctor fails to respond to the letter by providing an impairment rating, the Commission and the insurance carrier must make additional efforts to obtain a rating. Insurance carriers are encouraged to contact the treating doctor by phone if a TWCC-69 and an impairment rating are not received on or before the 104 th week after the accrual date. The doctor should be asked to give an assessment based on the findings at the time of the last evaluation or, if necessary, schedule an examination. If the treating doctor has not provided an impairment rating at the end of the 104 th week, the Commission shall require the employee to submit to a medical examination by a doctor selected by the Commission as provided in Article 8308-4.16(a) or, if requested, shall require the employee to submit to an examination by a doctor selected by the insurance carrier, for an assessment of impairment.

In claims where a rating is not obtained by the end of the 104 weeks, insurance carriers shall timely initiate impairment income benefits based on the carrier's reasonable assessment of the correct rating and promptly notify the Commission and the claimant of the assessment by filing a TWCC-21 indicating the transition to impairment income benefits. If a dispute arises as to the carrier's reasonable, the Commission shall schedule the claim for a benefit review conference to make a determination on entitlement to impairment income benefits pending final determination of the correct impairment rating.

Signed this 11 th day of January, 1993.

Todd K. Brown
Executive Director



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