Category: Medical Conditions (Page 2 of 19)

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

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.

Combine 2 LNI Claims to one workman's comp claim

I Have 2 Or 3 L&I Claims – Can I Combine Them Into One Claim?

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Some work injury claimants have 2, 3 or more L&I claims. In fact, you’d be surprised how many people have more than 1 workman’s compensation claim. Sometimes, you can combine multiple L&I claims into one. In legal terms, when you combine multiple claims into one, we call it “claim consolidation”. When can you consolidate several L&I claims? It depends. You can only combine claims if you meet certain requirements. For one, you can combine claims if they are duplicate L&I claims. Alternatively, you can consolidate L&I claims if they involve a subsequent aggravation.

Duplicate L&I claim

What is a duplicate L&I claim? Say you already have a workman’s comp claim for a work injury or occupational disease. A duplicate claim is when you file a 2nd claim for the same injury or illness. The new claim has the same injury date. And, it contains the same diagnosis or body part.

Sometimes, duplicate claims happen when you file an L&I claim that should be a self-insured employer claim. For example, say your doctor’s office filed a state-funded L&I claim on your behalf. Then, when they discover that your claim needs to be a self-insured claim, they file a second application. The 2nd submission is for the exact same work injury. Another example is when different medical providers file duplicate paperwork. For instance, a worker goes to the ER for an acute injury. After that, the worker follows up with a regular provider the next day. The regular provider may submit an L&I claim. However, they might not realize the ER provider also filed a claim the day before.

Subsequent aggravation resulting in multiple L&I claims

Say that L&I accepts your worker’s compensation claim. Here, under this first claim, L&I accepts coverage responsibility for certain medical conditions. A subsequent aggravation is when you file a new claim for an aggravation of these conditions, when:

1) There is already an open and symptomatic claim;

2) The conditions accepted in the first open claim are susceptible to re-injury; and

3) There weren’t new incidents or additional exposure.

For example, a workplace injury claimant develops a muscle strain lifting heavy objects. The worker files a claim. Moreover, L&I allows the claim and the claim is open. Fast forward, the person is getting treatment. Later, the medical condition gets worse. Eventually, the doctor files a new L&I claim for the worsening condition. Hence, if this happens, the new claim is a duplicate of the original claim.

When should I not combine all my L&I claims?

If the new claim isn’t duplicative and isn’t a subsequent aggravation, then you shouldn’t consolidate claims. In fact, I get calls from work injury claimants telling me their doctor, employer, or self insured third party administrator combined their claims. Every time I hear this – it’s a red flag. Only L&I has the power to consolidate claims.

If anyone thinks that consolidating claims is appropriate, they must ask L&I to do it. The request will be handled by the claim manager. Or, by the adjudicator responsible for the original claim. It’s important for L&I to make a formal decision about consolidation. This way, it gives the parties protest or appeal rights when the consolidation isn’t correct.

Additional examples for consolidating multiple L&I claims

On occasion, work injury claimants simply want to consolidate claims to manage their claims more easily. I certainly understand why they feel this way. Having multiple open claims at the same time can be confusing and difficult. However, unless the claims are duplicative or subsequent aggravations, consolidation isn’t appropriate. It doesn’t matter how much easier it may seem to manage the claims. You simply shouldn’t do it.

To summarize, there are only two circumstances to combine multiple L&I claims. The 1st is when you have duplicate claims. Then, the 2nd is if you have a claim for subsequent aggravation. Most importantly, only L&I can consolidate claims. If anyone else does it, you better contact a worker’s compensation attorney. Finally, by law, convenience alone isn’t a sufficient reason to combine claims.

L&I Claim Denied for Occupational Disease – Why? What can I do?

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Last week, we talked about cases where L&I rejected a work injury claim. Here, we’ll discuss examples and reasons when your L&I claim denied for occupational disease. Remember, an occupational disease is when you develop a medical condition due to your work settings. In contrast, a work injury is when a sudden accident happens at work.

Occupational disease L&I claim

Occupational disease is sometimes called industrial illness. In Washington State, the law that governs this topic is RCW 51.08.140. By law, “occupational disease” means a disease or infection arising naturally (or approximately) out of employment conditions. That’s a complex definition. In simple words, it refers to cases where unique work conditions cause an illness or infection. Usually, these diseases develop over time due to your workplace environment.

The law in Washington State favors work injury claimants. Simply put, it’s more likely that L&I will approve or allow your workers’ compensation claim than not. To allow an occupational disease claim, there must be objective medical evidence. On top, the medical facts must show that your distinctive employment conditions are the reason for the disease.

Why is my L&I claim denied?

You must file your L&I claim on time. Don’t delay or file late. For timing, the rules for an occupational disease claim are different than for a workplace injury. Here, the time limit is 2 years. More explicitly, it’s 2 years from when a medical provider informs you (in writing) that you have an occupational disease.

Generally, filing and timing is almost never an issue. However, the top 1 most common reason for L&I to deny a claim is lack of causation. In other words, it’s when you don’t show how your work conditions caused the disease. Furthermore, if we dig deeper, then there are 2 main issues with showing causation. The first is lack of distinctive conditions at your job. Then, the second is when there are other conditions in your life that are more likely to cause the disease.

L&I claim denied – a deeper dive

Let’s talk about the first issue. Remember, your work environment must have unique conditions that can cause the illness. To meet this requirement, you have to show how your employment, more probably than not, gave rise to your sickness. Your work conditions have to be truly unique. They can’t overlap with conditions you encounter in everyday life. Or in other general jobs. To approve your claim, L&I must be able to connect the dots between your work and the illness. And, unless the connection is obvious, you have to help them.

For example, say you catch the flu at work. There’s no chance that L&I will approve your claim. Why? Because you’re equally likely to catch the flu outside of work. Even if you work in a hospital treating flu patients daily (with one exception for Covid – please refer to other articles on my blog to learn about Covid workers’ comp claims).

Identifying the reason and source of your industrial disease

The second issue with claim denial is causation. Even if you show unique work conditions. Still, you must also show how the conditions are responsible for the illness. One challenge I see often is that there are many different causes for diseases. For instance, Carpal Tunnel Syndrome (CTS) is an occupational disease with many legal contentions. Many times, your employer will contest your claim for Carpal Tunnel Syndrome.

Medical literature supports that certain work activities are risk factors for Carpal Tunnel Syndrome. For example, repetitive forceful pinching and grasping. However, there are other known potential contributing factors. They include age, gender, body weight and pregnancy. Frankly, blaming causation on other risk factors (especially aging) is the most common reason to deny a workers’ compensation claim.

Workers’ comp claim denial due to causation

L&I can deny your claim for more complex reasons. Sometimes, in certain work environments, the medical community is still trying to understand the sources of certain sicknesses. For example, we now know that working in nuclear power plants caused workers to develop cancer. However, workers weren’t aware of these risks when they worked there. Furthermore, the cancer diagnosis came years later. The Hanford nuclear site in Washington State is a good example. Occupational disease claims stemming from working at Hanford remain highly contested.

Another more complex reason is showing exposure. Particularly, this problem arises when workers get exposure to certain toxins at work. In such cases, workers don’t need to show that a specific toxic agent caused the disease. It’s probably already known in the medical literature. Yet, they still must prove their exposure at work. As before, workers must show how the exposure to the toxins (in contrast to other factors) caused the disease. This can be extremely difficult to prove without identifying specific toxins. Moreover, identifying toxins in the workplace requires significant expertise. It can be a very expensive process.

Final notes

Occupational disease claims are complex. They have many moving parts. Plus, there are many reasons why L&I denies industrial illness claims. However, no matter what, if you believe you have an occupational disease, go see a medical provider. Then, file a claim at the provider’s office. After that, if L&I rejects your claim, you only have 60 days to protest or appeal the decision. Use these 60 days to figure out why L&I denied the claim. Assemble evidence to show why they should allow the L&I claim. Advocate for L&I to change their decision. As always, if things get too confusing, contact a workers’ compensation attorney for help.