Tara Reck, Managing L&I Attorney at Reck Law PLLC - Workers' Compensation Attorneys

Category: Medical Conditions (Page 2 of 18)

Why Did L&I Reject My Claim After a Work Injury?

Washington State has 2 types of workers’ compensation claims. One is a work injury claim. The other is an occupational disease claim. In this article, we’ll cover why L&I denied your L&I claim for a work injury claim. Next week, I will post another article about why L&I rejects occupational disease claims.

 

What are the requirements to file an L&I claim?

The Industrial Insurance Act governs all workers’ compensation claims in Washington State. Under the law, an industrial injury (see RCW 51.08.100) is something sudden and tangible. It’s an event that produces an immediate result. More simply, it’s when you suffer a work accident that results in an actual injury.

 

Washington State is biased towards workers. Yes, the law favors L&I claim approvals. You can file an L&I claim even for a minor workplace injury. Most likely, L&I will allow it. In fact, the Department of Labor and Industries (L&I) will allow a claim if you satisfy 2 requirements:

  1. There must be a sudden tangible traumatic event. We call this event the “accident”; and
  2. It must cause an immediate physical condition. The law calls this “bodily harm”.

 

Why did L&I deny my L&I claim?

The requirements to file an L&I claim are very simple. Therefore, it can be very confusing when L&I rejects your claim. Some common reasons why L&I can deny your claim are below.

 

L&I claim denial because the work accident didn’t happen

Sometimes, L&I gets information that the accident didn’t happen. Or that it didn’t happen at work. Information like this can come from employers, coworkers, or witnesses. If L&I thinks there’s credible evidence, then L&I will probably reject your claim. On occasion, L&I can question how the accident happened. For example, if they think it’s not as you describe it in the Report of Accident. In such cases, L&I may investigate and try to understand what really went on.

 

Therefore, you must always write down what happened. Use your own words. Do it as soon as you can. Describe to yourself everything in detail. Also, be sure to include the date, day, and time of accident. Write the location of the accident and who saw it. If there’s a video of the incident, then ask for a copy right away. Take phone numbers and email addresses for witnesses. Finally, if anyone says the accident didn’t happen (at all or at work) – ask witnesses to write what they saw.

 

L&I rejected my claim because I filed late

You have 1 year to file an L&I claim. That’s 1 year from the date of the accident. It seems like a lot. However, do not wait to file your claim. You should file as soon as possible. The longer you wait, the more likely it is that L&I rejects your claim. That’s because L&I will question the validity of your claim. Moreover, if you don’t file an L&I claim within 1 year, then L&I rejects your claim automatically. If L&I rejected your claim because of the 1-year limit – there’s (almost) nothing you can do about it.

 

L&I claim denied for lack of medical support

Not every workplace accident results in an industrial injury. To approve an L&I claim, there must be bodily harm. You have to show cause and effect. For example, falling off a ladder is a cause. A broken arm is an effect. Here, a medical professional must establish the connection between the accident and the body harm. In other words, a doctor must say your accident caused a medical condition that needs treatment. Alternatively, it can be a chiropractor, nurse practitioner, psychologist, or others medical professionals.

 

If there’s no supportive medical opinion – don’t be surprised if L&I rejects your claim. Therefore, make sure your provider fills the Physicians Initial Report completely. This form is part of the package they submit to L&I when filing your claim. Explain to your doctor exactly what happened. Make sure they understand how the accident caused the bodily harm.

 

L&I claim rejected because of incomplete report of accident

After a work injury, you must go to a medical provider. There, the medical office files your claim. To file, they fill the Report of Accident form. You must fill certain parts of the form. Other sections are the responsibility of the medical office. The form must be complete. Also, when sending the form to L&I, it must include the initial medical visit report.

 

L&I rejects claims if they don’t receive all the necessary paperwork. Hence, it’s important to fill your portion. Moreover, it’s absolutely fine to ask your provider if they filled their part. In general, issues with the Report of Accident are rare. On top, they are easy to fix.

 

Summary and conclusion

There are many reasons why L&I rejects or denies L&I claims. The purpose of this article is to provide some common reasons (and how to avoid them). There are other reasons too. However, please keep in mind the following takeaway. If you had an injury at work that needs medical attention – file a claim right away. If L&I rejects your claim, you have 60 days to appeal L&I’s decision. In those 60 days you need to figure out why L&I denied your claim. Put together evidence to show why L&I must approve your claim. Then, advocate for L&I to change the decision. If any of these things seems confusing or difficult – contact a workers’ compensation attorney for help right away.

 

L&I Surveillance: I Think I’m Being Watched – What Should I do?

Surveillance in an L&I claim is relatively common. In fact, work injury claimants encounter surveillance in both self-insured claims and state-funded L&I claims. It isn’t against the law. Private investigators usually conduct the surveillance. Moreover, they know exactly what they can and cannot do under the law.

 

Willful misrepresentation in a workers’ compensation claim

The Department of Labor and Industries (L&I) is the administrator for state-funded claims. Here, surveillance is more likely to occur after someone reports fraud relating to a work injury claim. For example, when a person receives workers’ compensation benefits but appears able to work. Another example is when the injured worker is working while collecting time loss compensation.

 

Under the Industrial Insurance Act, there is no such thing as fraud. There’s only willful misrepresentation. The relevant law for willful misrepresentation is RCW 51.32.240. In short, it’s willful misrepresentation to receive payments or other benefits in greater amounts than a person deserves. Simply put, it refers to making a false statement, misrepresentation, omission, or concealment of facts to deliberately obtain or increase benefits. Moreover, it also includes willful failure to disclose work-type activities.

 

L&I claim surveillance

Fraud isn’t part of the workers’ comp ecosystem in Washington State. However, the word “fraud” is a trigger to describe people that abuse or take advantage of the system. In fact, L&I encourages the public to report potential fraud. L&I takes these reports very seriously. For one, they built an entire fraud investigation unit. There, investigators frequently take statements and conduct surveillance. Hence, one of the easiest ways to “avoid” surveillance is to not give L&I reasons to suspect you.

 

Still, I’ve seen cases where people file reports against work injury claimants even when they’ve done nothing fraudulent. Luckily, surveillance in these instances reveals nothing more than workers trying to get through everyday life the best they can. Of course, I’ve also seen surveillance showing that an injured worker is lying about their injuries and limitations. I’m always very disheartened when I see blatant willful misrepresentation. This kind of behavior negatively impacts all workplace injury claimants.

 

 

Self-insured claims and surveillance

With self-insurance, there’s a third-party administrator (TPA) that manages the claim. In my experience, surveillance occurs much more frequently in self-insured claims. What’s more, third-party admins can request surveillance even when there’s no accusation of fraud. Many times, the surveillance is useless. Usually, the film shows workers doing nothing more than struggling to get in and out of cars. Or attending appointments and spending a lot of time at home. Consequently, we only find out about the surveillance later during the discovery phase when the case goes to litigation.

 

Workers’ compensation surveillance and bias

However, sometimes injured workers are surveilled doing normal things. For example, going for walks, grocery shopping, and taking out the garbage. I commonly watch tapes showing workers doing yard work, attending family outings, going out to eat, or walking their dog. Sometimes, attorneys or claim administrators share the footage with treating doctors and independent medical examiners (IME).  They do it to demonstrate that the work injury claimant is more physically capable than they lead on.

 

Depending on the film, this can be very effective in getting doctors to ease up or even remove physical restrictions. Sometimes this is very appropriate. Yet, many times the surveillance video doesn’t present a complete picture. Often, it shows things out of context. This typically leads to significant disagreements and litigation. There’s no easy way to prevent surveillance in self-insured claims. Therefore, it’s always best to ensure that you are being open and truthful. Describe your abilities and limitations to doctors honestly.

 

Takeaways and final notes

To summarize, surveillance is a standard practice in L&I claims. It’s legal and it happens all the time. It’s common in both self-insured and state-funded claims. When surveillance reveals behavior that’s consistent with doctors’ reports, then nothing will come of it. However, there are cases when a work injury claimant engages in activity beyond what they report. In such instances, the claim manager will likely use the footage to terminate benefits. In particularly egregious cases, claim handlers will use the surveillance records to push for willful misrepresentation charges.

 

If you suffer an injury at work and have a claim – it’s best to assume that someone is watching you. Therefore, your outward behavior must match your reports. Finally, it’s important to be honest. Describe your workplace injury and limitations honestly to doctors. Report the injury conditions in simple words the best way you can and you’ll be fine.

Caregiver Work Injury Cases and Occupational Hazards

I represent many healthcare workers in their L&I claim after a work injury. In fact, healthcare work injury occurrences can be very bad. Over time, I learned that healthcare workers face unique hazards in their workplace. This fact applies to all healthcare employees. From doctors to nurses, therapists, counselors, and support staff. Moreover, the safety issues they handle are unlike any other profession.

 

Caregiving workers

Caregiver refers to a worker that attends to the needs of another person with limitations. These limitations can arise after an injury, illness, or disability. At work, caregivers perform various duties. For example, they assist with mobility, transfers, and attending appointments. They also help to administer medication, change clothes, and household chores. Other examples include changing linens, attending to personal hygiene, and coordinating with a healthcare team.

 

Sometimes, caregivers work in pairs or teams. However, it’s far more common to find caregivers working on their own. It’s usually just the caregiver and the individual they are caring for.

 

Caregiver work injury scenarios

The responsibilities of caregivers cover a wide range of tasks. Therefore, they are often susceptible to injury at work. Some common caregiver workplace injuries include:

1) Low back injuries;

2) Neck injuries;

3) Knee injuries;

4) Shoulder injuries;

5) Slip and fall;

6) Hand and wrist injuries;

7) Elbow injuries;

8) Repetitive use injuries;

9) Contact infections and diseases; and

10) Injuries from combative patients.

 

Tips to avoid workplace injuries

For caregivers, there are several ways to avoid work injury. First, you must know your work environment. When lifting patients, make sure to use proper techniques and poses. Furthermore, take the time to fully assess every situation and possible outcomes. Think before taking actions. It’s also very important to practice good hygiene and wash your hands regularly. Finally, ask for help when you need it!

 

You cannot avoid all injuries. But you can try. If you get hurt at work in Washington State, you are covered under the Industrial Insurance Act. However, it’s very important to report your injury in a timely fashion. Make sure to document how the injury happened at work. Most importantly, you should seek proper medical attention without delay.

 

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