In the evolving landscape of workers’ compensation, the term “legacy claim” has emerged as a critical area of focus for insurers, third-party administrators, and clinical case managers. These claims often carry significant financial, clinical, and operational burdens—yet many professionals struggle to define precisely what qualifies as a legacy claim. Understanding the characteristics, causes, and consequences of these claims is the first step toward developing effective management and resolution strategies.

What Is a Legacy Claim?

A legacy claim refers to a workers’ compensation case that remains open and active well beyond the expected duration of medical recovery and claim resolution. These claims often persist for years—sometimes decades—and may involve ongoing medical care, wage loss benefits, or legal disputes that prolong the closure process.

While no universally agreed-upon timeframe defines a legacy claim, many industry professionals consider a claim to be “legacy” when it has remained open for 5+ years without significant progress in treatment, recovery, or return-to-work outcomes.

Key Characteristics of Legacy Claims

Legacy claims often share a combination of the following features:

• Chronic medical conditions or complications
  • Unresolved pain, repetitive surgeries, or permanent impairments
• Psychosocial barriers
  • Depression, anxiety, fear of re-injury, or lack of support systems
• Comorbidities and aging
  • Diabetes, obesity, or cardiovascular disease that slows recovery
• Long-term medication use
  • Especially opioid dependence or polypharmacy concerns
• Lack of return-to-work options
  • Especially when claimants are near retirement age or in physically demanding jobs
• Ongoing litigation or settlement delays
  • Disputes over causation, extent of disability, or medical necessity

Why Do Legacy Claims Happen?

Legacy claims are not always the result of mismanagement—they are often the byproduct of real-world complexity. For instance, a worker may suffer a serious injury that triggers secondary health issues, or an injury might exacerbate a pre-existing condition, complicating recovery.

Other contributing factors include:

• Delayed or insufficient early intervention
• Fragmented care coordination
• Lack of functional benchmarks
• Limited access to specialty providers
• Insufficient focus on psychosocial and behavioral health drivers

The Financial and Operational Impact

Legacy claims are a major cost driver in workers’ compensation programs. While they may only represent a small percentage of open claims, they can consume a disproportionate amount of reserves. A 2022 industry analysis by WCRI found that long-duration claims—especially those with opioid prescriptions, mental health conditions, or surgical complications—can account for 10x the cost of standard claims over time.

From an operational standpoint, legacy claims:

• Tie up adjuster resources
• Impact carrier loss ratios
• Create administrative strain due to frequent file reviews and compliance checks

Rethinking the Approach to Legacy Claims

Understanding what defines a legacy claim is only part of the equation. Managing them effectively requires:

• Early flagging systems using predictive analytics
• Integrated clinical and behavioral care teams
• Realistic, functional goal setting rather than cure-based metrics
• Settlement options or structured plans for long-term maintenance cases

Ultimately, a legacy claim should not be seen as a failure—it should be treated as a signal that the traditional approach to claim management needs to shift toward individualized, multidisciplinary strategies focused on sustainable recovery and long-term outcomes.