Understanding California Workers' Compensation C&R with Open Medical Benefits

Key Differences of C&R with Open Medical in California

In California, a Compromise and Release (C&R) settlement that includes open medical benefits obligates the employer or insurer to continue covering all medically necessary treatment for the injury, even after the lump‑sum payment is made. This contrasts with standard C&R settlements, which typically end medical obligations once the settlement is executed.

Eligibility for Open Medical Coverage

Open medical benefits are generally available when the injured worker's condition is expected to require ongoing care beyond the settlement date. Eligibility hinges on the nature of the injury, the prognosis, and whether the treating physician certifies that continued treatment is medically necessary.

Benefits Provided Under Open Medical

Open medical coverage includes:

• Doctor visits, specialist consultations, and hospital stays
• Physical therapy, occupational therapy, and rehabilitation services
• Prescription medications and medical devices
• Any future procedures deemed necessary by the treating physician

Employer and Insurer Responsibilities

When a C&R includes open medical, the employer or their insurer must:

• Maintain the same level of medical benefits as required by California law
• Process claims promptly and coordinate with the worker's chosen healthcare providers
• Provide periodic statements of benefits paid, as required by the Division of Workers' Compensation

Impact on Settlement Amounts

Because open medical benefits are an ongoing liability, the lump‑sum cash portion of a C&R settlement is usually lower than a settlement without medical coverage. Parties must negotiate a fair trade‑off between immediate cash compensation and future medical expense coverage.

Potential Disputes and Resolutions

Disagreements may arise over what constitutes "medically necessary" treatment. In such cases, a qualified medical evaluator (QME) or an independent medical review (IMR) can be requested to resolve the dispute. Both parties should document all communications and medical opinions to support their position.

Comparative Overview