Category: Medical Conditions (Page 1 of 19)

The L&I Claim Process: Overview of Common Medical Steps

Every L&I claim is different. The conditions and circumstances of each workers’ compensation claim are unique. However, many L&I claim cases follow a similar process.

A common process and pattern in L&I claims

Most L&I claims that come across my desk follow the same pattern. More explicitly, the pattern consists of the following steps:

1. A doctors diagnoses the injury as sprain or strain

2. The attending provider prescribes physical therapy

3. Doctors perform clinical exams

4. Medical providers proceed with diagnosis studies

5. L&I subscribes the worker to a pain management program

6. Doctors identify more complex diagnosis

7. L&I sends the worker to an independent medical exam (IME)

8. L&I closes the claim because of pre-existing conditions.

Too many claims follow this L&I claim process, blindly. Many workers fall in a gray area. They do not receive what they deserve under the law. The purpose of this article is to explain the L&I claim process and the steps above. Hopefully, workers can figure out where they stand in the process and decide what to do next.

Work injury happens

A worker suffers an injury on the job. Usually, the injury isn’t visible. However, there’s no question that the worker is in pain. Sometimes, the worker goes to the emergency room (ER) or urgent care right away. Other times, they wait several days. Most commonly, workers hope that the problem will go away on its own.

Sprain or strain diagnosis

The first step in the L&I claim process is when the worker first sees a doctor for the work injury. Usually, the doctor diagnoses the worker with a sprain or strain. A sprain or a strain is a soft tissue injury. It includes muscle injury and injury of the tendons. The treatment for sprain or strain diagnosis typically includes:

Rest
Modification of daily activities
Over the counter anti-inflammatory medication for pain

Sometimes, a doctor orders an x-ray of the affected body part. An x-ray can help determine the diagnosis. On top, it can rule out a fracture. If there’s no fracture, then doctors expect sprains and strains to resolve quickly. Typically, with minimal treatment.

Physical therapy

On occasion, the worker continues to complain about pain. In actuality, there’s no real medical improvement. Then, doctors typically prescribe physical therapy. Some attending providers also call for more diagnostics, such as an MRI. Yet, in my experience, L&I denies MRI exams early in the workers’ compensation claim process. Normally, L&I wants workers to at least attempt physical therapy.

However, many times pain complaints continue. Moreover, physical therapy doesn’t always improve the worker’s pain. That’s when things can start getting messy in your L&I claim process.

What happens in my L&I claim if physical therapy doesn’t help

Say that rest, activity modification, pain medication and physical therapy are not helpful. Next, doctors usually look for signs of more serious problems. Here, doctors may perform certain clinical exam and tests. It all depends on the body part and suspected condition. L&I considers these exam results to be objective medical evidence. For example, say the work injury claimant has persistent low back pain. Then, doctors may perform a straight leg raise exam. This exam checks for potential radiculopathy or nerve impingement.

Additionally, there are other tests that we call “provocative tests”. They help doctors determine more complex workplace injuries. Examples of such complex injuries include:

a) Elbow, wrist, or shoulder impingement

b) Knee and shoulder tear

c) Other spinal disc herniation or displacement

If provocative tests suggest a medical problem, then doctors order more diagnostic studies. Frequently, they include imaging studies. For example, MRI tests and CT scans. Also, doctors often order nerve conduction studies like EMG.

Pain management program (SIMP) and work conditioning

In an L&I claim, the Department of Labor and Industries (L&I) considers pain complaints as subjective. In contrast, diagnostic results are objective. However, objective diagnostics may not explain subjective symptoms and complaints. In such instances, L&I can refer the work injury claimant to an L&I pain management program like SIMP. Or, to a work conditioning or work hardening program. Typically, this is the final treatment attempt before claim closure.

A serious diagnosis & causation

Alternatively, a diagnostic study may objectively find more serious problems. If that’s the case, then causation is going to be the next issue in your L&I claim. There are several serious conditions that doctors often detect through MRI, CT scan or EMG. The list of serious problems we see in L&I claims at our office includes:

1) Disc herniation

2) Spondylosis

3) Spondylolisthesis

4) Facet arthropathy

5) Spinal cord impingement

6) Disc degeneration

7) Bone spurs

8) Meniscus tears

9) Rotator cuff tears

10) Shoulder joint arthritis

11) Knee joint osteoarthritis

12) Loss of cartilage

13) Cubital tunnel syndrome

14) Carpal tunnel syndrome

15) Lateral epicondylitis, and

16) Brachial plexus impingement

to name a few.

From L&I’s standpoint, these diagnoses are challenging. That’s because their cause is rarely a single trauma or injury. Therefore, when a provider identifies the diagnosis, L&I immediately starts questioning causation. At times, L&I asks the attending provider for an opinion about causation. But, very often, L&I calls for an independent medical exam (IME) instead.

Independent medical exam

Most IME doctors find that these kinds of diagnoses do not relate to your L&I claim. There are exceptions, but they are rare. The opinions of IME doctors usually read something like this:

“Diagnosis is pre-existing and unrelated to the industrial injury for which this claim was filed.”

The reason is that most of these conditions have other causes. They include:

a) Natural aging

b) Genetics

c) Gender

d) Weight

e) Diabetes

f) Alcohol use

g) Use of tobacco.

In short, it’s easy for IME doctors to blame the cause on reasons that do not relate to the L&I claim. Unfortunately, in my opinion, IME doctors err and attribute causes to pre-existing conditions too often.

Pre-existing conditions and IME reports

Personally, I take issue with these IME opinions. They completely ignore the laws on pre-existing conditions. Legally, there can be more than one cause for a medical condition. An industrial injury may aggravate or worsen a pre-existing condition. It doesn’t matter whether the pre-existing condition was symptomatic before the work injury. If the work injury causes worsening, then the condition is causally related under the L&I claim. Yet, IME doctors rarely include this in their analysis. They just indicate that a condition is pre-existing. Thus, according to IME doctors, it’s unrelated to the L&I claim.

Segregation order

Eventually, L&I receives the IME report. In turn, L&I will likely issue an order stating it isn’t responsible for the condition. We call this a “segregation order”. Meaning, L&I has segregated the condition from the workers comp claim.

If you receive a segregation order, it’s a good idea to consult with an L&I attorney. Disagreements over causation are one of the most common issues in L&I claims. You have to appeal this decision to the Board of Industrial Insurance Appeals for resolution. Most likely, you’ll want an attorney by your side for the appeal.

aggravated pre-existing conditions L&I claim

Aggravation of Conditions in L&I Claims: A Simple Guide for Workers

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In L&I claims, you often hear the term “aggravation of conditions” or “aggravated conditions”. Your L&I doctor or claim manager may mention “aggravation of pre-existing conditions“. Sometimes, aggravation refers to other claim-related conditions. In short, the term “aggravation” can be very confusing in workers’ compensation claims. The purpose of this article is to help work injury claimants clear the confusion.

What is aggravation of conditions in an L&I claim?

Aggravation of condition is when a medical or mental condition gets worse. For workers, there are 2 important scenarios. These 2 scenarios do not relate to one another. They happen in very different parts of your workman’s comp claim. However, it’s important to pay attention and keep track of aggravation of conditions in both.

Aggravation of pre-existing conditions after a work injury (scenario I)

Say that you suffer an injury on the job. In addition, say that you have some pre-existing conditions. For example, your pre-existing condition can be from another injury or from birth. In workers’ compensation, it’s important to consider if your new work injury triggers symptoms for pre-existing conditions. If it does, we refer to it as aggravation of pre-existing condition.

Aggravation of condition after your L&I claim closed (scenario II)

Here, let’s assume you suffered a workplace injury a while ago. You opened an L&I claim. After that, you received treatment and benefits. Eventually, your L&I claim closed. After some time, there’s aggravation of conditions that relate to your L&I claim (which is already closed). We call this scenario aggravation of claim-related conditions.

New work injury and aggravation of pre-existing condition

If you have pre-existing conditions prior to the work injury, it’s important to track and monitor them. Many times, a workplace injury “lights up” these conditions. Then, whenever this happens, the Department of Labor and Industries (L&I) must decide about coverage. Here, L&I has to determine if they need to provide treatment for the aggravated pre-existing condition. For that, L&I relies on 2 components. The first is proximate cause. The other is lighting up or aggravation.

Proximate cause and pre-existing conditions

As before, say you have a workers’ comp claim for a work injury. Moreover, one of your pre-existing conditions requires treatment. If you can show proximate cause, then L&I must cover your aggravated pre-existing condition. For us, legal professionals, the term “proximate cause” has a specific legal definition. In short, it means you must meet 2 criteria to prove proximate cause.

First, you must show how the work injury caused the aggravation. For that, you have to demonstrate the sequence of events. Then, you must also show that without the work injury, there wouldn’t be aggravation of pre-existing conditions. Also, remember, there can be more than one proximate cause. Yet, for L&I to provide medical coverage, it’s enough to show that the work injury was one proximate cause. It doesn’t have to be the only one.

Lighting up and aggravated pre-existing conditions

A pre-existing condition can be asymptomatic. Meaning, there were no symptoms or disability before the industrial injury. Then, a work injury happens. In turn, the work injury lights up or activates a pre-existing condition. If that’s the case, the worker is eligible for treatment and benefits for their full disability. That includes the aggravated pre-existing conditions.

Sometimes, workers with pre-existing disabilities have a greater need for treatment than other workers. That doesn’t matter. L&I must cover all these conditions and disabilities. Even when they require more attention.

On occasion, a pre-existing condition is symptomatic. For example, if there’s a pre-existing disability before a new work injury. Here, it’s important to check if the new injury aggravated the pre-existing condition. In other words, if it made it worse. If so, then L&I needs to cover the condition under the claim. However, there’s one exception. L&I will not cover the condition if the natural progress of the condition made it worse. This can get very tricky. As always, if you’re not sure what to do, call a workers’ compensation attorney.

Aggravation of pre-existing degenerative conditions

Often, we see aggravation of pre-existing conditions with so-called “degenerative” characteristics. These tend to impact the spine, knees and shoulders. In short, the human body ages. It wears out and degenerates as we get older. In the process, some people experience symptoms. Others don’t.

The following are some examples of degenerative conditions:

1) Degenerative disc disease of the spine

2) Shoulder tears due to aging

3) Degenerative meniscus tears

4) Arthritis in the back, shoulders and knees.

In general, a workplace injury isn’t the originating cause of degenerative conditions. However, it can make them become symptomatic. Also, it can accelerate them or make them worse. Consequently, under the law, L&I cannot reject the degenerative condition. In fact, L&I must cover it under the claim.

Aggravation of conditions and reopening an L&I claim

For workers, the second important scenario is aggravation of claim conditions. If your L&I claim closed, you can reopen it due to aggravation of claim-related conditions. More specifically, it’s very important to reopen the claim when aggravation of conditions results in:

1) Permanent disability (which can lead to L&I pension benefits)

2) Increase in permanent partial disability (or PPD)

3) Need for treatment.

Objective medical findings to reopen an L&I claim

You can file an application to reopen your L&I claim. When L&I evaluates the application, they will look at the following criteria. To reopen the claim due to aggravation of conditions, you must show 3 things:

a) That the aggravation resulted in one of (1), (2) or (3) above.

b) The work injury was a proximate cause for the aggravation.

c) That the aggravation occurred between the terminal dates.

An explanation of terminal dates

Upon reopening, L&I looks at two terminal dates. T1 is the first terminal date. That’s the most recent date when L&I decided to close your claim. Or, it’s the most recent date when L&I decided to keep your claim closed. Then, the second terminal date is T2. That’s when you apply to reopen the claim. How does L&I use these dates? It’s complicated. Let’s look at an example.

Say that Jane Doe suffers an injury at work. Her work accident caused lumbar disc herniation. In addition, let’s assume that she received treatment. Her claim closed in January 2018. After that, Ms. Doe tried to reopen her claim in January 2019. Back then, L&I decided to not reopen the claim. Furthermore, Ms. Doe didn’t protest or appeal the decision. Fast forward, let’s assume that Ms. Doe filed a new reopening application in January 2023. Hence, the first terminal date T1 is January 2019. That’s when L&I decided to keep her claim closed. Then, the second terminal date T2 is January 2023.

Reopening your L&I claim based on aggravation of conditions

To continue, let’s further assume Ms. Doe took an MRI in January 2018. The MRI showed 1 millimeter disc herniation. Later, she had another MRI in January 2019. It showed 1 millimeter disc herniation in the same spot. Finally, another MRI in January 2023 showed 3 millimeter disc herniation. All in the same exact location.

For reopening, L&I will look at all the events between T1 and T2. Clearly, the disc herniation worsened between January 2019 and January 2023. This falls under aggravation of claim-related conditions. So, there’s sufficient objective medical evidence. However, Ms. Doe must also show that the disc deterioration didn’t happen because of natural progression. For that, she must obtain a medical opinion that the work injury is one cause for the aggravation.

Conclusion

This example illustrates the process of reopening a claim after aggravation. Even simple cases can require highly technical and in-depth analysis. Therefore, many medical providers don’t even attempt or advise patients on reopening. They assume L&I will deny reopening. I certainly understand their frustration and hesitation.

However, it’s important for medical providers to know that reopening is possible. An effective partnership with an experienced workers compensation attorney is imperative. This can make the process much smoother.

In summary, aggravation of condition comes up a lot in L&I claims. The term can describe one of two very different scenarios. One involves aggravated pre-existing conditions. The second scenario involves re-opening a claim because of aggravation. While different, it’s important for workers to understand aggravation of conditions and pursue their rights under the law.

Pre-Existing Conditions in Workers Compensation: What Will Happen to My L&I Claim?

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Pre-existing conditions can be a big concern for work injury claimants. Many workers worry that pre-existing conditions will prevent them from getting L&I benefits. This is a reasonable concern. After all, pre-existing conditions can complicate your L&I claim.

What are pre-existing conditions in workers’ compensation claims?

A pre-existing condition is a condition that a worker already has, before a work injury or occupational disease. Furthermore, it can be a physical condition or a mental condition. There are many types of pre-existing conditions. For example, common pre-existing conditions include:

1) A congenital condition that existed since birth

2) Accidents or injuries during childhood or adolescence

3) Past injuries that happened outside of work

4) Many conditions that arise from the natural aging process.

Work injury and pre-existing conditions

The Department of Labor and Industries (L&I) oversees workers’ compensation claims in Washington State. After a work injury, L&I sometimes uses pre-existing conditions to deny medical coverage. However, Washington State law provides protection for work injury claimants. In fact, certain sections of the law specifically address pre-existing conditions after a work injury. Under the law, the workman’s comp legal system protects workers with pre-existing conditions in two ways:

a) Disability: L&I must consider pre-existing conditions when they evaluate your overall disability; and

b) Aggravation: Sometimes, a work injury or occupational disease aggravates pre-existing conditions. In such cases, L&I must take responsibility for aggravated pre-existing conditions.

We take the work injury claimant as we find them

When a work injury happens, L&I must accept injured workers as they are. Funnily enough, there’s a saying among worker’s compensation professionals: “We take the injured worker as we find them”. This phrase can be a bit confusing. Let’s explain what it means.

When claim managers handle an L&I claim, they must evaluate the long-term impact of the industrial injury. During their analysis, L&I has to consider the worker as a whole person. In other words, future-looking analysis and disability evaluation must include pre-existing conditions. In fact, L&I’s analysis may combine pre-existing conditions with new ones that arise from the work injury. This is a requirement under the Industrial Insurance Act in Washington State.

To simplify things, let’s review some examples. After a workplace injury, say that new medical conditions do not show total disability. However, if you combine pre-existing conditions with the new ones, then together they result in temporary total disability. Hence, the law entitles the worker to temporary or total disability benefits. Another name for this L&I benefit is time-loss compensation. In workers’ compensation, we call this “combined effects” of pre-existing and claim-related conditions.

Aggravated pre-existing conditions in an L&I claim

Another important aspect of L&I claims is aggravation of pre-existing conditions. Here, a work injury can activate or aggravate pre-existing conditions. Consequently, L&I must take responsibility for these pre-existing conditions. But, before going over the details, let’s first talk about symptomatic vs asymptomatic conditions.

At the time of the work injury, a certain medical condition may be symptomatic or asymptomatic. A symptomatic condition refers to one that produces symptoms. Also, a condition is symptomatic if it’s disabling or needs treatment. Symptomatic conditions can be a combination of all three of these effects. Or, a condition is asymptomatic if there are no symptoms. In other words, if it’s not disabling and the person doesn’t need treatment.

A workplace injury may “light up” or activate a pre-existing asymptomatic condition. In such cases, L&I must provide coverage for the pre-existing condition. Similarly, a work accident can worsen or aggravate pre-existing symptomatic conditions. For those, L&I needs to cover the conditions under the L&I claim. In addition, the law acknowledges there may be more than one cause for a condition. Similarly, more than one cause can activate or aggravate pre-existing conditions. However, for L&I coverage, it’s enough to show that the work injury is one of the causes.

How to take advantage of pre-existing condition legal protections

Many people have pre-existing conditions before they suffer a work injury. If you are one, then it’s important to follow the 2 recommendations below:

i) Admit that you have pre-existing conditions (if you know of them); and

ii) Describe your conditions and any symptoms caused by the industrial injury. Here, you must explain how the new symptoms are different than before.

These steps can be very confusing. Let’s talk about them in greater length below.

Disclosing pre-existing conditions after a work injury

You cannot hide pre-existing conditions. It never works. Don’t waste your time trying. If you try, it’ll create bigger problems later in your L&I claim. So, it’s very important to be open and honest. Tell your L&I doctor about your pre-existing conditions. If your conditions were symptomatic before the work accident, then let your doctor know. Also, if you didn’t have symptoms before the work injury, then tell your doctor. It’s important for the doctor to know everything from the start.

Sometimes, L&I may ask for a list of providers that have treated you for the conditions. If they ask for the list, then you must give it to them. The list and your treatment history will assist L&I and your treating providers. With it, they can determine if your pre-existing conditions impact your workplace injury and how. Also, it’ll be easier to consider pre-existing conditions when the decide your L&I benefits.

Pre-existing conditions before and after the work injury

Let’s say you have symptomatic or disabling pre-existing conditions. Here, it’s very important to describe your conditions as they were before the injury. Next, it’s equally important to explain how they changed because of the work injury. You must describe the conditions accurately and in detail.

Personally, I often recommend my clients to practice describing the conditions with family and friends. On top, I recommend writing down everything you remember about the condition before and after. Finally, think if your friends or family members saw your symptoms. If so, have them write down what they saw prior to the injury. Also, ask them to document what they observed after the workplace injury.

What happens if L&I doesn’t cover pre-existing conditions?

For some, a work injury doesn’t impact pre-existing conditions. In such instances, L&I won’t take responsibility and won’t provide coverage. For example, let’s imagine you have pre-existing migraines. Your industrial injury doesn’t activate or make them worse. Thus, L&I won’t take responsibility for your migraines. Furthermore, the migraines weren’t activated or aggravated. Therefore, there’s probably no legal action you need take if L&I denies benefits for these migraines.

However, L&I does need to consider the “combined effects” when assessing your total disability. They must consider your migraines together with your L&I claim conditions. Unfortunately, L&I sometime ignores pre-existing conditions when performing total disability evaluations. This is a red flag. If this happens, it’s important to speak with a workers’ compensation attorney or L&I attorney.

Secondly, L&I may deny pre-existing conditions when they think they’re congenital. Other times, L&I will blame certain conditions on aging. Most commonly, we see this happening with degenerative conditions. Many medical diagnostic tests show arthritis and neuropathy. Other exams reveal muscle and cartilage tears. Sadly, L&I often concludes that these conditions are not related early in the L&I claim process, without proper diagnostics.

IME exams and pre-existing conditions

Almost always, L&I will schedule an Independent Medical Examination (IME). Unfortunately, I can tell you the IME outcome ahead of time. Most likely, the IME exam will say that: (1) The pre-existing conditions weren’t caused by the work injury; and that (2) they were not activated or aggravated by the workplace accident.

When this happens, you must provide L&I with a different medical opinion. For that, it’s best to have an attending provider (AP) who’s a strong advocate. Your L&I attending provider can (and should) review the IME report. The attending physician may also provide a non-concurring opinion to L&I on their own. However, not every work injury claimant has a caring attending provider. If you don’t have one, it might be best to call a workers’ compensation attorney. Many good L&I lawyers can help address this issue.

Summary and final comments

To summarize, pre-existing conditions can complicate workers’ compensation claims. Yet, work injury claimants don’t need to worry if they have pre-existing conditions. The law in Washington State provides many protections. Workers can take very simple steps to take full advantage of these protections. On occasion, pre-existing conditions may cause problems in L&I claims. When those arise, it’s important to consult with a workers’ compensation attorney.