Work disability claim: from the degree of disability to the benefit
Injury allowance is paid for up to three months, after which a separate claim is needed to determine the degree of work disability. The threshold that decides between a one-time grant and a monthly pension falls between 19% and 20%, and the filing deadline is 12 months from the date of injury.
When the move from injury allowance to a disability claim happens
Compensation from the National Insurance Institute following a work injury is built in two stages.
At the first stage an injury allowance is paid - compensation for loss of income during the period in which the insured person is unable to work, for up to three months.
If disability remains at the end of that period, the second stage opens: a claim for determination of the degree of work disability and for payment of a work disability benefit. This is a separate claim, with its own form, and it is not filed automatically following the injury allowance.
In practice this means that the end of injury allowance payments is not the end of the process but its point of transition.
Source: National Insurance Institute, conditions of entitlement to injury allowance.
The deadline for filing
The National Insurance Institute publishes that the claim must be filed within 12 months of the date of the injury, and warns that late filing may impair the right to the benefit, in whole or in part.
This is one of the points where delay costs money. Even where the injured person medical position has not yet stabilised, it is better to open the process in time and update the medical material later than to wait for stabilisation and find that the deadline has passed.
Source: National Insurance Institute, work injury booklet.
The medical committee
The degree of disability is determined by a medical committee. According to the Institute, the committee is composed of one or two doctors, called medical adjudicators, who are experts in different fields of medicine. The adjudicators are not employees of the National Insurance Institute, and are appointed by the Minister of Labour.
The committee determines two things: the degree of disability caused by the work injury, and whether that degree is set for a temporary period or permanently.
The distinction matters. A temporary degree is re-examined at the end of the period, whereas a stable degree is the one that opens the financial question - a pension or a grant.
Source: National Insurance Institute, determination of the degree of disability.
Pension or grant: the threshold that decides
The type of payment follows directly from the stable degree of disability determined:
- 9% up to less than 20%, at a stable degree of disability - a one-time grant.
- 20% to 99% - a monthly pension.
The distance between 19% and 20% is therefore not a difference of one percentage point, but the difference between a single payment and a pension over time. This is the point at which precision in the medical documentation and in presenting the functional consequences changes the outcome more than at any other stage.
Source: National Insurance Institute, work injury booklet.
Regulation 15 and adjustment for occupation
The National Insurance Regulations on determining the degree of disability for work injury victims contain a mechanism allowing the committee not to stop at the percentage in the schedule.
Under regulation 15, the committee may determine a stable degree of disability greater by up to one half than that set in the schedule, having regard to the occupation and age of the injured person, provided that it does not exceed 100%.
The reasoning is plain: the same hand injury does not affect an office worker and a tradesperson doing physical work to the same extent. Invoking the regulation requires an orderly presentation of the actual occupation and of the gap between the capacity that existed and the capacity that remains.
Source: National Insurance Regulations (determination of degree of disability for work injury victims), regulation 15.
Appealing the committee decision
A first-level medical committee decision is not the final word. There is a right of appeal to a medical appeals committee.
The Institute publishes that the appeal, together with reasons, must be delivered in writing within 30 days of the day the notice was received.
Thirty days is a short period, particularly where documents or an expert opinion are needed to support the grounds. It is therefore worth reading the committee protocol as soon as it arrives rather than waiting.
Source: National Insurance Institute, appeal against a medical committee decision.
Aggravation of the condition
Even a degree determined as permanent is not necessarily final for life. The regulations allow re-examination where the condition has worsened or a new impairment has been discovered.
Two conditions accompany this: the passage of a period of time since the previous determination, and written certification by an approved physician of the aggravation.
In practice, an aggravation claim rests on medical documentation showing a real change in condition, not merely on a sense of deterioration. Gathering that documentation over the period is what makes it possible to prove the point later.
Source: National Insurance Regulations (determination of degree of disability for work injury victims), regulation 36.
In summary
Injury allowance is paid for up to three months, after which a separate claim is required for determination of the degree of work disability. The Institute publishes a deadline of 12 months from the date of injury for filing. The degree is determined by a medical committee of adjudicators who are not employees of the Institute, and may be temporary or permanent. A stable degree of 9% up to less than 20% gives a one-time grant, and a degree of 20% to 99% gives a monthly pension. Regulation 15 allows adjustment having regard to occupation and age, and an appeal is filed in writing within 30 days.
The three points that decide matters in practice are the deadline, the quality of the medical documentation, and the presentation of the functional effect on the actual occupation. All three can be improved, but only in time.
If you were injured at work and are approaching a medical committee, or have received a decision you disagree with, contact us with the protocol and the medical records and we will consider the next step.
The questions that come up most
From what degree of disability is a monthly pension paid rather than a grant?
How long is there to file the claim?
How long is there to appeal a medical committee decision?
What does regulation 15 allow?
Can a re-examination be requested if the condition has worsened?
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Send us the protocol and the medical records. We will review the degree of disability, regulation 15 and whether an appeal is worthwhile.