Category: LNI Claim Appeal (Page 5 of 8)

Closing L&I Claim: Do I Need an Attorney?

I get calls from work injury claimants often. The #1 reason they call is because their L&I claim is closing. Also, the same goes for self-insured employer claims in Washington State. L&I claim closure can be very stressful. To help, I put together this checklist below. You can use it to check for any red flags. If there are some, I strongly recommend you consult with a workers’ compensation attorney.

L&I claim closure and maximum medical improvement (MMI)

Your L&I claim cannot close before you reach maximum medical improvement. Again, the same applies to self-insured employers. Maximum medical improvement is sometimes calls medical fixity. You achieve it when there’s nothing more that doctors can do for you. Unfortunately, it doesn’t mean you’re healed. In short, it means that doctors don’t think you’ll get better with more medical treatment. Yet, many times, it’s unclear if you’re at maximum medical improvement. After all, it’s a doctor’s opinion. Therefore, it’s possible your claim is closing while your medical provider thinks you need more treatment. If that’s so, then it’s a red flag. You definitely want to contact an attorney.

Future employment issues

L&I must address future employment concerns before a claim can close. For example, if you have total disability. That’s one example where L&I can’t just close the claim. At very least, they have to pay for your disability. Total disability means you have physical or mental impairment. It impacts your ability to find or maintain a job. Any type of job within your skills. Not only the job at the time of your work injury. However, total disability doesn’t mean you’re helpless.

L&I has to evaluate and decide if you’re employable. For that, they consider your age, education, skills, and training. They also consider your experience and any previous limitations. Furthermore, they take into account limitations from your work injury. One way for L&I to resolve total disability is with L&I pension. Therefore, you should think if you have total disability. If you do, and if your claim is closing without pension, then call an attorney.

Permanent partial disability

We refer to permanent partial disability as PPD. Some work injuries or occupational diseases cause permanent conditions. For example, a loss of body function can be permanent. L&I has methods to assess your level of PPD. On top, there are several evaluation techniques. For assessments, a PPD rating medical expert must examine you. Many times, an IME performs the PPD rating. Other times, the attending provider can perform the PPD rating. After the rating, L&I decides the amount of your PPD award. One red flag is when you have permanent limitations without PPD rating. Or, when your rating seems low considering your symptoms. Another red flag is when you don’t receive a PPD award. Finally, it’s possible that some doctors disagree with your PPD rating. All these cases are red flags. It’s important you talk to an attorney.

Unresolved problems in your L&I claim

Some L&I claims start to close when there are ongoing issues. That’s a red flag. For example, closing a claim while there are time-loss compensation payment problems. On top, closing a claim with outstanding medical bills. And so on. You know your claim. You can tell if there are any lingering issues. If there are, then it’s critical to resolve them before the claim closes.

L&I claim closing when it should

There are plenty of cases with no red flags. Very often, L&I claim closure is appropriate. However, improper claim closure is also common. When you L&I claim closes, then L&I sends you a letter. If your claim closed and you didn’t receive a letter, then you must speak with an attorney. Usually, the closing letter contains a payment order or notice of decision. After that, the decision becomes final in 60 days. This means you have 60 days to protest or appeal. Personally, I always think it’s a good idea to talk to an L&I attorney if your claim is closing. You can always receive free information and tips that can help.

Reopening L&I claim

Say your L&I claim closes inappropriately. Now, you can appeal and fight claim closure. If successful, L&I will keep the claim open and work to resolve the remaining issues. However, say your claim closes after they fix all remaining problems. In this case, you can still reopen your L&I claim in the future under certain circumstances.

Reopen L&I claim after it closes

These are certain requirements for reopening a claim. They are:

1) There must be an aggravation. This means that a condition in your claim got worse. More explicitly, for physical conditions, there must be objective medical findings. A doctor has to determine that your work injury condition deteriorated. In addition, you must show some medical tests to support the doctor’s opinion.

2) The aggravation requires more medical treatment or justifies higher disability rating.

3) The aggravation occurs between two specific dates. The first date is when the claim closed. It can also be the last date when L&I denied an application for reopening. Then, the second one is the most recent reopening application date.

Reopening due to new medical conditions

Sometimes, L&I can reopen a claim when a doctor finds new conditions. The conditions must relate to the workplace injury or work illness. This is true even if the condition wasn’t known prior to claim closure.

The 7 year L&I claim reopening rule

Many work injury claimants reopen a claim within 7 years of claim closure. If that’s the case, all L&I claim benefits may be available after reopening. This includes medical treatment, time loss compensation, and loss of earning power. On top, it includes increase in PPD, and even L&I pension benefits. But, if you reopen a claim after 7 years, you can only get more treatment. Unless the director of L&I grants you other benefit under their discretion.

L&I Claim Appeal: How Long Will My Workers Comp Appeal Take?

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The Department of Labor and Industries (L&I) decides when work injury claimants receive benefits under their L&I claim. When L&I makes a decision about entitlement, the decision is usually in writing. Frequently, the decision is labeled “Notice of Decision”. However, decisions can also be under “Payment Order”, “Wage Order”, or any other written document. That’s where an L&I claim appeal comes into play.

L&I claim appeal vs claim protest

Any party that disagrees with a written decision can protest or appeal it. For jurisdiction, a protest stays with L&I. However, an appeal takes the disagreement to the Board of Industrial Insurance Appeals (BIIA). In fact, there are many reasons a claim protest may be strategically better than an appeal, and vice versa.

I get questions about protests and appeals regularly. The most common question is: How long will it take to get a decision? Often times, L&I makes decisions following a protest very quickly. Surprisingly, sometimes I receive decisions just days after filing my client’s claim protest. When this happens, it makes me wonder whether L&I really took the time to fully reconsider if the decision is correct. In contrast, I’ve seen cases where L&I protests have gone months and even years without checking or addressing them. Yet, there’s some good news. With some prompting and nudging, the Department of Labor and Industries usually acts on protests relatively quickly.

Workers’ compensation claim appeal in Washington State

L&I appeals are different. First, the Board of Industrial Insurance conducts a mediation process. There, one or more mediation conferences take place, where the parties discuss and try to reach resolution without litigation. Afterwards, if mediation does not produce an acceptable outcome, then the case advances to litigation.

If the parties cannot agree or settle the claim, then it usually takes much longer to get a decision in an appeal. That’s because appeal hearings are essentially a legal proceeding. The appealing party has the burden of proving that L&I’s decision is wrong. This requires that party to present testimonies. Therefore, there can be significant costs associated with an L&I claim appeal under this path. For most benefits, at least some of the testimony must come from experts like doctors, therapists, and vocational counselors. This presentation of testimony takes time.

Board appeal and petition under a work injury claim

Once the parties finish presenting their evidence, the hearing judge reviews and compiles all the materials. Then, the judge issues a written Proposed Decision and Order. The decision contains findings of fact and conclusions of law for each issue in the appeal. Furthermore, any party that disagrees with the Proposed Decision and Order may file a Petition for Review. The goal of the petition is to ask the Board of Appeals to review the decision. Afterwards, if the Board grants the review, it must issue a follow-on Decision and Order. Once again, the Decision and Order comprises findings of fact and conclusions of law.

Work injury client representation and challenges

Personally, it’s important for me that people that suffer an injury at work have realistic expectations. Clients must understand how much time claim appeals can take. It’s particularly important because many injured workers are without money or access to claim medical treatment during the appeal.

I used to tell work injury clients that claim appeals could take as much as a full year. That’s from the time we file an appeal until we receive a decision. Recently, that estimation has changed dramatically. Currently, it seems that the Board of Appeals is backlogged. It appears they have challenges issuing written decisions. Some of my client cases are waiting 150 days or more for a written decision. Therefore, right now it’s very difficult for me to give accurate estimates.

I’m deeply concerned about the length of time for L&I claim appeals. Remember, many work injury claimants do not have access to financial or medical benefits during the process. Many are barely making it through.

L&I Claims and Causal Relationship Challenges: Diagnoses That Come “Later”

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If you have a work injury or work-related illness in Washington State, then you can file an L&I claim. Your L&I claim should cover all conditions that arise from the work injury or disease. We refer to these conditions as “causally related”. However, in some cases, it can be challenging to determine which conditions are causally related. Especially with L&I came late diagnosis where conditions come up later in the claim.

Work injury medical condition: Causation and aggravation

Under the law, a condition relates to the workplace injury if: (1) The work injury caused or aggravated the condition; or (2) The cause or aggravation was a result of medical treatment for the workplace injury. Clearly, when a diagnosis comes late, it can be difficult to establish the causal connection.

There are many cases where conditions arise in later stages of a workers’ compensation claim. Often, these conditions come up late due to valid and logical reasons. Common reasons include overlooking a diagnosis, or failure to obtain necessary diagnostic studies early. Another reason can be a minor injury at first, which progresses into a severe one later. Moreover, there are other reasons such as new medical conditions that develop during (or as a result of) treatment. Either way, it’s important to ensure that the Department of Labor and Industries (L&I) covers these conditions. Therefore, it’s imperative to show causal relation to the workplace injury under your L&I claim.

Missing diagnosis in a workplace injury

It’s very common for initial work injury or workplace disease diagnoses to be simple soft tissue issues. For example, sprains or strains. These diagnoses should heal quickly within weeks or months. However, when symptoms persist, it may be necessary to take a second look. For whatever reason, more significant diagnoses may not surface up for months or even years. When doctors make the “new” diagnosis so much later, it can raise serious questions about causation. Moreover, it can be particularly challenging if treatment wasn’t consistent, or if it continued over time. This is one reason I always stress the importance of having an attentive attending provider on your L&I claim. In my experience, if your L&I claim medical provider is attentive, then you have lower likelihood for missing diagnoses.

Failure to obtain necessary diagnostic studies

Another common reason for “new” diagnosis that comes in late is when doctors do not request diagnostic studies early. Many work injury claimants I represent experience the frustration of authorization denials for diagnostic studies. For example, when requesting an MRI. In the most egregious cases, I’ve seen IMEs opine there is no diagnosis because there are no “objective” findings for it. However, there are no objective findings because the attending provider’s request for an MRI is denied. Sometimes, it requires litigation to finally get the MRI. Then, when we finally get the MRI, it objectively documents a more severe diagnosis. Here, these may include disc herniation, muscle, tendon or ligament tear. In some cases, it can reveal a fracture or nerve impingement.

Progression of the initial work injury

Occasionally, a diagnosis may not occur until later in your L&I claim because it doesn’t progress until later. For instance, a person may experience a muscle, tendon, or ligament strain as a result of a specific injury at work or work activity. Over time, the damage may progress and become worse. For example, a shoulder stain may become a partial or full thickness tear. The same goes for knee strains that can become meniscus tears. Alternatively, back injuries that turn into full disc herniation. Here, the question we ask if whether a more severe condition developed out of the original work injury? If the answer is “no”, then the more severe injury is not causally related.

New injury during treatment

In Washington State, under the law, injuries that occur during treatment also fall under your workers’ compensation claim. Unfortunately, these kinds of injuries are more common than you’d expect. No one ever intends for them to happen. However, additional injuries can occur during massage therapy or physical therapy. Furthermore, they can even happen as a side effect of an authorized treatment such as surgery.

In my experience, the most critical thing is to ensure there’s a medical report. The report should document the injury – when and how it happened. Workers’ compensation is not about fault. Therefore, it doesn’t matter how the new injury occurred. However, we still need to establish causation. Hence, it’s important to document the fact that the injury happened during treatment.

L&I Claim Late Diagnosis: Final remarks and conclusion

Causal relationship of medical conditions is always an important issue in a workers’ compensation claim. Often, challenges can arise, especially when diagnoses come later. That’s often the case with L&I claim late diagnosis. Yet, regardless of the reason for the late diagnosis, it’s important to establish the connection. Explicitly, the chain of connections between the “new” diagnosis and the original workplace injury or occupational disease.