Workers’ compensation cases rarely end with the last appointment on a calendar. An injury that seems stable today can evolve, and the cost of staying functional often extends far beyond a one-time surgery or a few months of therapy. When I evaluate a client’s claim, the most consequential number is usually not the wage loss already incurred, it is the value of care they will need next year, in five years, and sometimes for life. Getting that number right is the difference between a settlement that sustains recovery and one that collapses under real-world costs.
A seasoned workers’ compensation attorney looks at future care through clinical, legal, and practical lenses. The process blends medicine, insurance rules, statutory quirks, and lived experience of what injuries actually require over time. Below is how that assessment really works when you peel back the formalities and sit with the file.
The medical spine of the estimate
You cannot predict future care without credible medicine. I start with the treating physicians, then widen the circle until the projection feels complete.
The treating doctor’s plan is the anchor. For a lumbar disc herniation that required an L5-S1 microdiscectomy, a surgeon might anticipate additional epidural steroid injections, a course of physical therapy after flare-ups, a medication regimen including neuropathic pain agents, and perhaps, if symptoms recur, a revision surgery. That plan, written in plain clinic notes, carries weight with adjusters and judges because it derives from continuous treatment.
If the treating plan feels thin or hopeful, an independent medical examination can add structure. Independent examiners sometimes underestimate, but they speak the language insurers heed: specific frequencies, durations, and utilization patterns. I push for details. Not “therapy as needed,” but “12 visits after flare-ups, twice per year, tapering to 8 after year three if symptoms remain stable.” Not “possible injections,” but “up to 3 series of epidural injections annually for the first two years, dropping to 1 series every other year if symptom control holds.”
For chronic conditions, a life care planner may be essential. A life care plan is not magic, it is a standardized way of capturing the long tail of costs most people forget: replacement of a TENS unit every three to five years, annual durable medical equipment maintenance, realistic frequencies of diagnostic imaging, psychiatric or pain psychology sessions, and the mileage or transportation to get there. In complex orthopedic cases with hardware, the plan will include the risk of hardware failure and corresponding intervention rates.
The quality of these inputs matters. I have seen future medical awards crumble because a generalized “may need” was all that appeared in the record. A good workers’ comp lawyer translates medical possibilities into likelihoods and time horizons. The persuasive plan balances caution with realism.
The five drivers of future medical value
Every serious projection turns on a handful of drivers. If you understand these, you can predict the settlement posture before the first negotiation call.
1) Likelihood of revision or additional surgery. For many orthopedic injuries, the revision curve tells the story. Consider a total knee arthroplasty for a 48-year-old worker. Data suggests a meaningful revision risk over 15 to 20 years, and revisions cost more, take longer, and produce lower function than primaries. If the client is 60, the curve bends differently. The attorney must tie age, comorbidities, implant longevity, and occupational demands to a credible revision rate, not guesswork.
2) Chronic pain trajectory. Neuropathic pain after crush injuries or failed back surgery can shift a case from modest to substantial. The medicine supports long-term medications like gabapentin or duloxetine, occasional opioid use in carefully managed programs, interventional pain procedures, and psychology for coping. The plan needs to reflect ongoing monitoring and the real rate at which patients cycle through modalities when one stops working.
3) Maintenance therapies that add up. Physical therapy, work conditioning, aquatic therapy, chiropractic care, acupuncture, and home exercise programs are often prescribed in bursts. Over ten years, even modest utilization becomes significant. Ten sessions at 150 dollars each twice per year looks trivial in isolation, but over a decade, with utilization tapering from 20 visits to 8, the cost mounts.
4) Durable medical equipment and supplies. Knee braces wear out, orthotics compress, CPAP masks need replacement, TENS pads must be reordered, and even ergonomic chairs have lifespans. These are easy to overlook and easy to cut in a lean settlement. I audit the client’s actual usage and layer in typical replacement intervals.
5) Comorbidities and risk modifiers. Diabetes slows healing. Smoking increases nonunion risk. Obesity changes surgical planning and recovery windows. A workers’ compensation attorney has to account for these factors because they change both cost and probability. I never assume a best-case physiology. The projection should reflect the client I have, not an idealized one.
The evidence an adjuster or judge expects to see
Future medical value survives scrutiny only when the file reads like a peer-reviewed workup instead of advocacy. Here is what that looks like in practice.
I gather a timeline of care that shows symptom persistence or recurring exacerbations. Progress notes that document repeated flares after extended standing or lifting speak louder than any demand letter. Photographs of post-surgical swelling or gait changes can help, not for shock value, but to corroborate functional limits.
Diagnostic imaging matters in context. A new MRI that confirms recurrent disc herniation supports a projected injection series. Conversely, clean imaging does not negate pain, but it may change the mix of interventions. I want a physician’s note that explains why imaging may not capture pain generators, especially for nerve entrapment or complex regional pain syndrome.
Functional capacity evaluations can influence expected therapy needs, work restrictions, and ergonomic equipment. While not perfect, they help quantify limitations. If a client repeatedly fails to meet essential job demands despite good effort, it strengthens the case for ongoing care and perhaps job modification.
A pain management agreement, medication monitoring logs, and urine drug screens show that the client is compliant. Noncompliance gives carriers a reason to push for utilization review denials. I try to eliminate that excuse in advance.
When the record is thin, I ask the treating doctor targeted questions: What is the expected frequency of flare-ups? What is the plan if symptoms persist after injections? If surgery is needed again, what is the likely window? The written responses become the backbone of the projection.
State rules and how they change the math
The same injury can support very different future medical values depending on the jurisdiction. Workers’ comp is state-specific, and the details matter.
Some states allow open medical awards, meaning the carrier remains responsible for reasonable and necessary care related to the injury for life. In those states, the leverage for future medical is not always in a lump-sum valuation, but in ensuring authorization processes run smoothly and utilization review does not choke access. Settlement decisions turn on whether the client wants control over care or the security of an open file.
Other states push toward closure with a medical set-aside or a full and final settlement on medical benefits. When closure is on the table, the projection has to be granular: unit costs, frequencies, tapering schedules, and pricing for likely revisions. Carriers are comfortable with numbers tied to utilization review guidelines, fee schedules, and vendor https://gunnergxrm676.lucialpiazzale.com/workers-compensation-attorney-faqs-for-construction-workers contracts. A workers’ compensation attorney has to translate clinical needs into the state’s cost framework. That often means pricing injections at the state fee schedule, not chargemaster rates, and adjusting therapy visits to reflect preauthorization realities.
Statutes of limitations on reopening matter. If a state allows reopening for a change of condition within a fixed window, that reduces the need to load the present settlement with every contingency. If reopening is nearly impossible, you need to price contingencies now, with realistic probability weighting.
Finally, some states cap specific modalities or require panel physician systems that alter the richness of care. An attorney who ignores these constraints will over-promise in a demand and lose credibility.
Medicare’s shadow: when a set-aside is necessary
If the injured worker is a Medicare beneficiary or reasonably expected to become one within 30 months, Medicare’s interests must be protected. Medicare will not pay for care that should be covered by workers’ comp, so settlements often require a Workers’ Compensation Medicare Set-Aside arrangement, the MSA.
The MSA process forces discipline. It requires coding each projected service, applying state fee schedules, and justifying frequencies. The review contractor looks for evidence-backed prescriptions, not wish lists. A realistic MSA includes prescription drugs at current dosages and brands or generics, interventional procedures with appropriate intervals, and physician follow-ups consistent with the record.
Where clients get hurt is ignoring Medicare entirely or inflating numbers beyond the record. Both backfire. An MSA that aligns with treatment history usually clears faster and does not jeopardize future Medicare coverage. If the file reflects potential surgery, I try to get the surgeon to commit the likelihood and outline the pathway, so the MSA includes it with appropriate probability rather than omitting it or counting it twice.
The client must understand that MSA funds are restricted. If we settle medical rights, the MSA dictates how money for injury-related care is spent and tracked. For some clients, keeping the claim open for medical avoids the administrative burden and preserves flexibility. This is a judgment call where a workers' compensation lawyer adds real value.
Pricing future care without guesswork
A credible projection blends medical utilization with real prices. I do not rely on national averages when state fee schedules govern. Instead, I map each service to the fee schedule code, then apply inflation assumptions to both medical services and drugs. For medical cost trends, a 3 to 5 percent annual increase is common, but pharmacy inflation can diverge. Where possible, I incorporate generic substitution and step therapy patterns seen in the past years of the claim.
For medications, I look beyond current scripts. If the treating pain specialist has hinted at transitioning from short-acting opioids to buprenorphine, or from gabapentin to pregabalin due to side effects, that swap can change annual costs by hundreds or thousands of dollars. I also estimate adherence realistically, not at 100 percent forever.
Therapy tends to taper. Early years may carry 12 to 24 visits as the client rebuilds, then settle into 6 to 12 visits yearly during flare-ups. An evidence-backed taper brings credibility and can persuade a carrier to fund higher up-front care because it shows a plan to reduce costs over time.
Surgery probabilities get weighted. If a surgeon says there is a 30 percent chance of needing a revision within ten years, I multiply the fully priced event by 0.3, then discount to present value if the forum allows or expects discounting. Not every jurisdiction applies present value in comp settlements, so I adapt to local practice.
DME and supplies get scheduled by lifespan. A hinged knee brace might last two years with heavy use. Orthotics might require annual replacement. TENS units three to five years, with consumables monthly. I prefer to use the client’s past usage as a starting point instead of a theoretical list.
Vocational reality and how it reshapes medical needs
Work drives symptoms. A server with a cervical disc protrusion who returns to double shifts carrying trays will likely need more frequent therapy and medication than a clerk with the same imaging who works at a sit-stand desk. I interview clients about the grit of their days: how many hours on their feet, how often they lift more than 20 pounds, whether they can pace their tasks. That picture changes the medical forecast.
Accommodations matter. If an employer invests in a lift-assist device, upgraded flooring, or a rotating team to share heavy tasks, flare-ups may drop. Simple schedule shifts, like splitting shifts to allow rest, can cut therapy needs in half. I include the impact of these measures in the projection, and I flag them in negotiations. Carriers appreciate a plan that reduces medical exposure through practical changes rather than endless treatment.
When clients cannot return to their prior job, vocational retraining and job placement introduce transitional care needs. Anyone retraining on a computer after a shoulder labrum repair will require workstation ergonomics, possibly voice dictation software, and coaching on microbreaks. These small items, if budgeted, prevent bigger downstream problems.
Choosing between open medical and a full closure
The choice to settle medical benefits, keep them open, or partially close is personal and strategic. There are trade-offs.
Keeping medical open shifts the utilization fight to authorizations and utilization reviews. In friendly jurisdictions with responsive adjusters and reliable networks, that can work well. Clients who prefer predictable co-pays and provider networks may lean this way. The downside is a lack of control: switching doctors, getting non-formulary drugs, or scheduling procedures on your timeline can be slow.
Closing medical with a lump sum provides control and flexibility. A client can choose providers, seek second opinions, and time procedures without preauthorization. The risk is underestimating care, spending too quickly, or encountering unexpected complications. I counsel clients to pretend the money is not free cash. It is a medical budget with a job to do.
A middle path exists. Some settlements carve out future surgeries or specify that the insurer retains responsibility for big-ticket items while closing smaller categories. Others fund an annuity to spread medical money over years. A workers’ comp attorney should lay out options with numbers, not adjectives.
A practical example from the trenches
A 42-year-old warehouse picker tears a rotator cuff, undergoes arthroscopic repair, and returns to light duty. Six months later, he still has weakness with overhead reach and pain at night. The surgeon predicts ongoing therapy bursts, probable injections twice yearly for two years, then tapering, and a 15 to 25 percent chance of revision within 8 to 10 years due to the size of the tear and the client’s job demands.
We build the projection:
- Office visits: quarterly the first year, then twice yearly. Physical therapy: 16 visits year one after return, 12 visits in year two, 8 visits in years three through five, then as needed. Injections: 2 per year for two years, then 1 per year for two years. Medications: NSAIDs and intermittent neuropathic agents, with GI protection for long-term NSAID use. Imaging: MRI if worsening function after year two, probability-weighted at 40 percent based on surgeon’s notes. Surgery: revision probability at 20 percent, priced at state fee schedule, with associated therapy and recovery.
He is not a Medicare beneficiary, so no MSA yet, but at 42 he may be one in 30 years. We document every item with citations to clinic notes, include fee schedule references, and apply modest medical inflation.
In negotiation, the carrier challenges the injection frequency and the revision probability. We counter with literature the surgeon cites and adjust to one injection per year after year one. The revision probability remains 20 percent, with a narrower window. The result is a medical allocation that funds real needs and does not drown in hypotheticals. More importantly, the client chooses to keep medical open for two years to confirm stability, then revisit settlement once utilization patterns are clear. That staged approach saves him from locking in a guess.
Data gaps and how to handle uncertainty
No file is perfect. Doctors write sparse notes. Clients forget to mention over-the-counter purchases that signal pain levels. Utilization review rules shift. The way through is to name the uncertainty and design around it.
When frequency is unclear, I propose a baseline and a trigger. For instance, 8 therapy visits per year with the option to increase if strength testing drops below a documented threshold. When projecting medications, I carry both a conservative and an aggressive scenario, then negotiate to a middle number while clarifying that utilization is physician-directed.
Uncertainty cuts both ways. Carriers worry about over-utilization. I sometimes offer a structured settlement that pays more if certain clinical events occur, such as documented recurrence requiring surgery within a specified window. This aligns the budget with reality and lowers the chance of a lopsided outcome.
What a client can do to strengthen the projection
Clients influence the quality of their own future medical case. A few focused habits go a long way:
- Keep a simple treatment log. Dates, providers, what helped, and what did not. Patterns emerge that justify or limit future services. Follow through with home exercises. Document compliance. Providers will write stronger plans when they see engagement. Report flares promptly with functional examples. “Cannot lift milk,” “missed two shifts,” and “woke twice nightly” give doctors content for specific orders. Save receipts for supplies and co-pays. Real costs beat estimates. Talk candidly about side effects and obstacles. A plan that swaps a sedating medication for a tolerable alternative is more sustainable.
These behaviors turn guesswork into an evidence-based forecast that both sides can respect.
The art in the numbers
The hard part of assessing future medical needs is not math, it is judgment. Two clients with the same diagnosis can diverge because one has a supportive employer, a shorter commute, and a home suited for recovery, while the other faces stairs, long drives, and rigid schedules. A fair valuation has to see the person inside the diagnosis.
A workers' compensation attorney who does this well plays translator between the clinic, the statute, and the client’s life. The attorney understands the carrier’s actuarial view and the physician’s clinical caution, then builds a plan that honors both while protecting the worker. It is not about inflating numbers. It is about anticipating how human bodies heal and cope under real constraints.
When the case closes, I want the client to feel that the future care number is not a windfall or a cliff, but a tool. If they need an injection next spring, it is covered. If a brace cracks, there is a budget to replace it. If a revision surgery becomes necessary within the expected window, funds exist without panic. That is the goal: a settlement that breathes with the medical reality rather than fighting it.
How experience shapes the forecast
Experience supplies the soft data that does not appear in medical journals. After handling dozens of shoulder repairs, for instance, you know how often patients actually complete therapy, when they relapse after a return to heavy work, and which surgeons are conservative about revision calls. After enough lumbar cases, you recognize that a 52-year-old roofer with a multilevel fusion will not live on ibuprofen and occasional yoga, even if the record reads optimistically early on.
It also teaches humility. Bodies surprise you. A worker with a comparatively clean MRI can struggle with debilitating pain and insomnia for years. Another with a ghastly scan returns to full function with minimal support. You learn to build flexibility into the plan, avoid locking in rigid utilization where it is not warranted, and protect against both over and under funding.
The role of negotiation style
The best projections still need to be sold. Carriers respond to clarity and restraint. If a demand includes every imaginable treatment at maximum frequency indefinitely, expect a skeptical response and a long delay. If the demand connects each cost to a line in the chart and offers a reasoned taper, doors open. I often share the spreadsheet of services and frequencies, then invite the adjuster to flag disagreements line by line. It becomes a problem-solving exercise rather than a contest of wills.
Where the law allows, I sometimes propose a pilot period: authorize a year of the projected plan and then revisit. If utilization is lower, both sides learn, and the future number can adjust. If it is higher, we understand why, and the projection gains credibility. This approach suits cases where trust is low but the need for closure is high.
Why picking the right advocate matters
Any competent workers' compensation lawyer can recite statutory benefits. The difference shows when your case reaches the inflection point of future care. An experienced workers' compensation attorney knows which specialists write useful notes, how utilization review bodies think, and what actual vendors charge for braces, injectables, and therapy visits in your state. They also know when to keep medical open, when to press for a medical set-aside, and how to structure funds so care remains available when it is actually needed.
If you face a decision about settling medical rights or presenting a future care plan, look for a workers' comp lawyer who talks in specifics. Ask how they will quantify injections, therapy frequencies, and revision probabilities for your exact injury. Ask whether they price at the state fee schedule and how they account for inflation. The answers should be concrete, not generic assurances.
The goal is simple, though the work is not: build a projection sturdy enough to withstand scrutiny, flexible enough to fit your life, and funded well enough to keep you functional. When done right, that number becomes a safety net rather than a set of promises that unravel when you need them most.