Category: Medical Conditions (Page 1 of 19)

aggravated pre-existing conditions L&I claim

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

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?

/ L&I attorney / 0 Comments

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.

My L&I Claim Doctor Says I Need to Lose Weight Before Surgery: Does L&I Cover Weight Loss Treatment?

/ L&I attorney / 0 Comments

The Department of Labor and Industries (L&I) covers medical treatment after a work injury or occupational disease. For treatment, L&I accepts certain conditions. Typically, L&I doesn’t cover conditions that do not relate to the workplace injury. However, in some cases, L&I allows temporary treatment of “unrelated conditions”. Specifically, when unrelated conditions prevent recovery from an accepted condition. In fact, L&I allows medical treatment of an unrelated condition as “aid-to-recovery”. Therefore, workers can sometimes receive treatment for obesity or being overweight. L&I considers this an unrelated condition.

L&I weight loss coverage

If you weigh too much, it can hold back your recovery after a work injury. For example, when your injuries involve weight-bearing muscles and joints. Explicit examples include foot injuries, ankles, knees, and hips. Additionally, excess weight can make it challenging to attend rehab treatments. Many times, overweight workers find it difficult to undergo physical therapy. Also, a diagnosis of obesity can delay surgery. This is until weight drops to appropriate levels. Hence, if obesity is a roadblock to recovery, then L&I may cover weight loss treatment.

Criteria for weight loss treatment

A worker must meet certain criteria for L&I to allow weight loss treatment. These criteria include:

1) The worker is “severely obese” with BMI of 35 or more.

2) Obesity is the main barrier to recovery. It’s preventing the worker from making progress on their L&I claim accepted conditions.

3) Weight loss is necessary to allow further treatment, surgery, physical rehabilitation, or returning to work.

How to get L&I pre-authorization for weight loss treatment

L&I requires several steps to pursue weight treatment coverage. First, the worker must request weight loss treatment. Here, L&I must pre-authorize the treatment. Otherwise, L&I will not pay for treatment expenses. To receive pre-authorization, your L&I doctor or attending provider needs to:

Notify L&I or the self-insured employer of the worker’s weight and level of function before the injury. Also, your provider must explain how your weight impacts treatment and recovery.
Describe the medical need for L&I obesity treatment. This includes tests, consultations, or diagnostic studies.
If appropriate, your L&I doctor can request nutrition counseling. A Certified Dietician or Certified Registered Dietician Nutritionist are available.

Unfortunately, L&I won’t approve many popular weight loss methods. Specifically, L&I regularly denies coverage of:

Weight loss surgery, drugs, or medication.
Certain programs or special foods that include meals, supplements, and vitamins.
Cookbooks and educational materials.
Exercise programs and exercise equipment.
Food scales and bathroom scales.

Developing a weight loss treatment plan

Next, L&I requires a plan before they can grant the pre-authorization. In state-funded claims, the L&I claim manager will draft a treatment authorization letter. This letter documents the terms of the plan. Work injury claimants must sign the authorization letter. This way, everyone agrees on the terms of the weight loss plan from the start. Therefore, work injury claimants and their providers must develop a treatment plan and specify:

a) How much weight the worker must lose.

b) Time estimate to complete the weight loss process.

c) The diet and exercise plan or the weight loss plan and methods.

d) The medical provider’s plan for monitoring progress.

e) Plans for documenting weekly weigh-ins.

f) Counseling and education from trained staff as appropriate.

Keeping the L&I authorization for weight loss active

L&I authorizes weight loss treatment in 90-day increments. However, work injury claimants must follow additional requirements to keep the authorization active. These requirements include:

i) Losing at least 5 pounds every 6 weeks.

ii) Attending weekly treatment sessions.

iii) Complying with the treatment plan.

iv) Checking in with the attending provider at least every 30 days.

v) Having the program coordinator sign a weekly weigh-in sheet.

vi) Sending the L&I claims manager the weekly weigh-in sheets.

It’s very important for the attending provider to see the worker every 30 days (or less). Also, the provider must notify the L&I claims manager if:

1) The work injury claimant reaches the weight goal.

2) Weight is no longer a barrier to treatment.

3) If the worker isn’t meeting their weight loss goals.

4) The work injury claimant isn’t cooperating with the treatment plan.

When will my L&I weight loss coverage end?

L&I coverage for weight loss treatment can end. One reasons for ending the coverage is when the work injury claimant reaches the weight goal. A second reason is if the worker’s obesity no longer impedes their recovery. Furthermore, another scenario is when the worker fails to drop the 5-pound minimum requirement over 6 weeks. Finally, L&I can end the treatment authorization if the worker isn’t cooperating with the plan.

Personally, I’ve seen good success with L&I weight loss treatments. Yet, the treatment is very bare-bones and basic. L&I uses mainstream programs, such as Weight Watchers or Noom. However, most plans come down to food modifications and calories deficits.

Concerns for workers receiving weight loss treatment

Due to work injuries, workers rarely take part in exercise programs. Although, walking exercises can be a successful and an integral part of L&I weight loss plans. Also, carefully designed strength training can be very beneficial.

In reality, the public nature of this L&I program can be frustrating to workers. Weight loss is often a very personal experience. Therefore, it can get extremely unpleasant having so many people monitoring your weight loss progress. Weekly weigh-ins can be stressful and demoralizing. Particularly, if the worker is having trouble meeting the mandatory weight loss goals.

Summary and conclusions

That said, L&I coverage for weight loss treatment is a huge benefit. Without it, excess weight can hinder recovery and stall the L&I claim indefinitely. Even worse, it can result in suspension of L&I benefits. In conclusion, there are some issues with these weight loss programs. However, they’re still an incredible benefit within the L&I claim process.