What is a catastrophic workers’ compensation claim?
When an individual is injured in Georgia, they are entitled to 3 main benefits:
1. Indemnity benefits – also defined as defined as income benefits.
2. Medical benefits – treatment for their injured body part.
3. Permanent partial disability benefits – disability that is partial in character but permanent in quality, resulting from the on-the-job injury.
Under Georgia’s current workers’ compensation law, there is a time limit on the availability of these benefits—unless your injury falls in the category of a catastrophic workplace injury.
History of catastrophic work injury claims & Georgia law
Prior to 1992, there was no time limit for the receipt of indemnity benefits. An injured worker could receive indemnity benefits for the remainder of their life, regardless of whether or not the injury was deemed “catastrophic” or not. If an injured worker wasn’t able to return to his or her pre-injury employment, they would, in theory, be eligible for lifetime benefits.
In 1992, however, the state legislature of Georgia amended the workers’ compensation statute. As of July 1, 1992, an injured worker is only eligible for indemnity benefits for up to 400 weeks, unless they were legally deemed to have a catastrophic injury. The calculation of the 400 weeks begins with the date of the injury — not with the first date that an employee goes out of work.
Indemnity benefits are calculated by taking the average of the 13 weeks prior to the injury and multiplying it by two-thirds. Currently, the maximum amount of benefits an injured worker can receive is $675 per week.
Medical treatment on the injured body part was available to the injured worker for life up through 2013. At that point, the Georgia legislature changed the law and limited medical treatment on the injured body part to 400 weeks.
There are a few exceptions to this rule, one of which is if the case is determined to be catastrophic.
Furthermore, Georgia law (O.C.G.A. § 34-9-200) was again amended in 2019 to remove the 400-week cap in non-catastrophic claims on medical benefits for prosthetic devices, spinal cord stimulators or intrathecal pump devices and durable medical equipment, orthotics, eye glasses, or hearing aids, which were originally provided during the initial 400 weeks. This change was made retroactive by its terms and applies to injuries arising on or after July 1, 2013.
Below, we will explore how to a claim is determined to be catastrophic.
What is a catastrophic injury?
Georgia law (O.C.G.A. 34-9-200.1(g)) defines a catastrophic injury as one of the following injuries that occurs in the scope and course of employment:
- Spinal cord injury involving severe paralysis of an arm, a leg, or the trunk
- Amputation of an arm, a hand, a foot, or a leg involving the effective loss of use of that appendage
- Traumatic brain or closed head injury
- Second or third degree burns over 25 percent of the body as a whole, or third degree burns to 5 percent or more of the face or hands
- Total or industrial blindness
Any other injury of a nature and severity that prevents the employee from being able to perform his or her prior work—or any other work available in substantial numbers within the national economy for which the employee is otherwise qualified—may also be categorized as “catastrophic.”
That’s a whole lot to unpack, so let’s address each one of these categories individually.
Spinal cord injury and paralysis
The first category is fairly self-explanatory. If the injury sustained by the worker results in them becoming a paraplegic or quadriplegic, by definition, the case is deemed catastrophic. If the case is accepted and deemed compensable by the insurance carrier, then it is catastrophic and the injured worker is entitled to medical treatment and indemnity benefits for life.
Severe burns
For a work-related burn injury to be considered “catastrophic,” a worker must have suffered second or third degree burns over 25 percent of the body as a whole, or third degree burns to 5 percent or more of the face or hands. A statement from a treating physician is needed to determine the percentage and nature of the burns on the injured worker.
Amputation
The second example of a catastrophic injury includes the amputation of an arm, foot, hand or leg involving the loss of use of that body part. This means that even if an individual loses half a foot or hand but effectively loses the entire use of that appendage, then their case is deemed catastrophic. This means there shouldn’t be any litigation once it’s determined that the accident took place on the job.
It’s important to note that the loss of a finger or toe isn’t necessarily considered a catastrophic injury. While it’s true that an injured would be considered catastrophic if a finger is lost and renders the injured workers’ hand non-functional, this is typically a hard burden to reach. The same applies to injuries to toes and the foot.
Traumatic brain or head injury
A severe brain or closed head injury is defined by Georgia workers’ compensation statute (34-9-200.1) as involving at least one of the following health conditions:
- Severe sensory or motor disturbances
- Severe communication disturbances
- Severe complex integrated disturbances of cerebral function
- Severe disturbances of consciousness
- Severe episodic neurological disorders
To confirm any of the conditions listed above, you’ll need the diagnosis of a doctor or other medical provider. Due to their nature, brain and head injuries are difficult to prove, although advanced medical technology is helping doctors better assess the damage done after a workplace accident.
Blindness
The State Board of Georgia has taken the position that industrial blindness means vision of 20/200 or less, even with all corrective lenses and measures taken. As with burn injuries, a statement from a treating physician is needed to determine total or industrial blindness.
Miscellaneous catastrophic injuries
The final category was created to be a catch-all category. Any other injury of a nature and severity that prevents the employee from being able to perform his or her prior work, as well as any other work available in substantial numbers within the national economy for which such employee is otherwise qualified, may also be considered catastrophic.
The State Board of Workers’ Compensation has taken the position that the injury must render the injured worker unable to work not just in their prior job, but in any job available in substantial numbers within the national (not local) economy.
Unfortunately, this means that if any other jobs exist in the national economy that an injured worker could perform, even if they happen to live in a rural area where there is no such work available to them nearby, their injury will not be deemed catastrophic.
Experts are typically hired by both the insurance carrier and the counsel for the injured worker to litigate this matter. For example, let’s say an individual hurts their back and is therefore limited to sedentary work only. Even if no sedentary work is available with their former employer or in their town, the injury is not deemed catastrophic under Georgia statute.
However, keep in mind that there must be jobs available in significant numbers within the economy. There cannot be a random job in, say, Sioux City, Iowa that can comply with the injured workers’ restrictions.
What benefits are available for a catastrophic work injury?
Permanent partial disability ratings are not available in catastrophic cases. The reason for this is that the injured worker hasn’t reached maximum medical improvement (MMI) and continues to receive medical treatment.
If a case is deemed to be catastrophic, the injured worker is entitled to:
- Indemnity benefits without a time limit cap on those benefits
- Medical treatment on that body part for the rest of their life
- A rehabilitation supplier who shall furnish the injured worker with reasonable and necessary rehabilitation services.
Rehabilitations services include communicating with the injured employee and others to assess, plan, implement, coordinate, monitor and evaluate options and services to meet an injured employee’s rehabilitation needs to effect a cure, give relief or restore the employee to suitable employment. The catastrophic rehabilitation supplier shall meet with the injured employee within 30 days of the appointment, and complete an initial rehabilitation evaluation and an appropriate plan (WC-R2A) for medical and/or vocational services. Finally, the designated rehabilitation supplier may arrange for services outside of his/her scope of expertise and qualifications.
Example of how Georgia catastrophic injury law impacts workers
An example of how Georgia’s catastrophic injury statute affects injured workers recently happened to one of our clients. He was hurt in 2010 when a forklift struck him in the right knee. He continued to work for the employer for approximately 6 months while he received conservative medical treatment, which included pain medication and physical therapy. He subsequently was diagnosed with a torn ACL and surgery was performed.
The man’s employer couldn’t return him to work and he received indemnity benefits for only 370 weeks because his date of injury was 6 months before he was actually taken out of work.
Catastrophic work injuries and Social Security disability
We have many clients who are receiving Social Security Disability Income (SSDI) benefits as a result of their on-the-job injury. They are receiving these benefits because they are unable to work and the Social Security Administration has made a determination that they are disabled.
The state of Georgia, however, has determined that while being on SSDI benefits is admissible as evidence, it is not determinative in deciding if an individual is eligible for catastrophic designation.
Are catastrophic workers’ compensation benefits permanent?
Once a case is determined to be catastrophic, it doesn’t mean that it will always be catastrophic. An insurance company can litigate to try and prove that the injured worker has improved to the point that their claim no longer falls within one of the categories mentioned above—or that the individual is capable of performing work once again.
This can especially occur in the case of an amputation where the injured worker is able to return to work with the use of their injured appendage, or after a recovery from a serious brain injury. In such cases, the burden will be on the insurance company to prove that the injury no longer qualifies as catastrophic.
Statute of limitations for catastrophic work injury claims
Lastly, it should be noted that the statute of limitations still applies to requests to make a claim catastrophic if it’s not voluntarily accepted as such by the insurance company. Therefore, the injured worker has 2 years to file a request for catastrophic designation after the last receipt of indemnity benefits—or 1 year from the date they last received medical treatment.
If you have any questions about a catastrophic case or issues pertaining to a catastrophic case, don’t hesitate to contact the experienced Atlanta workers’ compensation attorneys at Gerber & Holder Workers’ Compensation Attorneys
