3 Cases on Texas MMI

Key Cases

In Texas, "maximum medical improvement" means the earlier of the following:

(1) The earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.

(2) The expiration of 104 weeks from the date on which income benefits begin to accrue.

A settlement: 1) may not resolve an issue of impairment before the employee reaches maximum medical improvement (and settlement agreements even after that point must adopt an impairment rating using guidelines prescribed by the Act); 2) may not provide for payment of benefits in a lump sum except when an employee (a) has returned to work for at least three months earning at least 80% of the employee's average weekly wage and (b) elects to commute impairment income benefits; and 3) may not limit or terminate the employee's right to medical benefits.

Here are a few key cases in which MMI has played an important role in Texas.

Texas Mut. Ins. Co. v. Ruttiger, 381 SW 3d 430 (Tex. 2012). At the time the worker filed suit in this matter he had not reached maximum medical improvement, did not have an impairment rating from his doctors, and had not returned to work. Thus, as of the time he filed suit complaining of the employer's past delays, his workers' compensation claim could not yet have been settled.

Rodriguez v. Service Lloyds Ins. Co., 997 SW 2d 248 (Tex. 1999). Any dispute that challenges an impairment rating's finality necessarily implicates the date of maximum medical improvement and the amount paid as temporary income benefits. This dispute may also impact the employee's eligibility for, and the calculation of, impairment income benefits and supplemental income benefits. Disputes about an injured employee's impairment rating are, therefore, disputes about benefits. 

Ausaf v. Highlands Ins. Co., 2 SW 3d 363 (Tex. Ct. App. 1999). A certification by a treating doctor is invalid and will not be considered when the doctor's report contains a prospective MMI date. 

In re Xeller, 6 SW 3d 618 (Tex. Ct. App. 1999). If a dispute exists as to a claimant's impairment rating or as to whether a workers' compensation claimant has reached maximum medical improvement, the Commission must direct the claimant to be examined by a designated doctor chosen by mutual agreement of the parties. If the parties cannot agree on a designated doctor, the Commission must choose the doctor, who must make a written report to the Commission. If the designated doctor is chosen by the parties, then the Commission must adopt the impairment rating given by the doctor. If the designated doctor is chosen by the Commission, the doctor's determination of maximum medical improvement or impairment rating is given presumptive weight and the Commission must adopt that rating unless the great weight of other medical evidence is to the contrary.

Practice Point

MMI is a pivotal claim milestone that affects impairment ratings, benefit entitlement, and settlement options. Adjusters should ensure MMI certifications are valid, closely evaluate disputes involving impairment ratings, and recognize that MMI determinations often have significant implications for claim duration, exposure, and resolution.

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