Category: Medical Treatment (Page 25 of 36)

What Does My L&I Claim Worth? An Overview of Workers Compensation Claim Benefits

What’s the value of my L&I claim? What’s my workers’ compensation case worth? I get these questions all the time. And, my answer is always the same: “It depends”. For a better answer, it’s important to review the value of your L&I claim benefits.

What is the value of my workers’ compensation claim?

Knowing the value of your workers’ compensation claim or L&I claim in Washington State is tough. Calculating it isn’t easy. Remember- first you have to file your claim. Then, if the Department of Labor and Industries (L&I) allows it, you may receive various L&I claim benefits. Some of these benefits have a monetary value. Furthermore, the value is unique to each L&I claim because every claim is different.

The purpose of this article is to help you figure out the potential value of all available benefits. Remember, there’s no one-size-fits-all answer. There is no formula to calculate the exact value of your workers’ compensation claim. But, if you want to get a rough estimate, you can sum up the total value of all L&I claim benefits.

L&I claim benefits: Medical treatment

It’s very difficult to put a dollar amount on the value of medical treatment. For many, and in my opinion as well, it is invaluable. Generally, if your claim has been allowed, then L&I (or the self-insured employer) will cover your medical bills and expenses. That is, so long that the treatment is for conditions that relate to your work injury claim.

It is important to keep in mind that certain treatment recommendations must go through an authorization process. However, once you receive authorization, then L&I will cover your treatment 100%. This means that there are no out-of-pocket expenses. For example, co-pays or deductibles. It’s also reassuring knowing that you have a path to medical recovery. It’s always good to know that L&I will cover your medical bills for your L&I claim treatment.

Time-Loss Compensating – a key benefit

Say that you have an L&I claim. Also, say that L&I already allowed your claim. In addition, let’s assume that you’re unable to work. Then, you are eligible for monetary wage replacement benefits. Time loss compensation (TLC) is one such benefit. It’s what you get when you are temporarily incapable of working.

Your time loss wage rate is based on what you were making at the time you got injured at work. A single male of female individual with no dependents receives 60% of their wage. For time-loss calculations, take the 60% at the time you got hurt on the job. If you are married or have children, then you’ll receive a higher percentage.

Loss of Earning Power under an L&I claim

In some cases, after a work injury, some people are still able to work with limitations. For example, some work injury claimants can work less hours than before. Others might perform a light duty job that pays less than their job of injury. If you can after your injury, and your new salary is lower than before – you’ll receive compensation for lost wages.

Loss of Earning Power (LEP) covers this situation. It’s an L&I benefit. L&I pays it when you’re doing limited work that results in 5% (or more) decrease in your wage-earning capacity. This is a significant monetary value in any workers compensation claim. The specific value varies from individual to individual. As explained earlier, it all depends on your earnings at the time of injury at work or occupational disease manifestation.

Vocational services in L&I workers compensation claims

Some people are permanently incapable of returning to your work. If you are one, you can be eligible for retraining. If L&I approves your retraining, they will pay for your retraining program for up to two years. The total cost is approximately $18,000. But that’s not all. In addition to the $18,000 cost of retraining, L&I will pay time-loss compensation benefits. L&I will pay it throughout your entire retraining program.

The topic of vocational services in workers compensation claims is very broad. It is also very complex. There are many steps and services. You can read about important topics relating to vocations services by following the resources below:
1) Option 1 vs Option 2
2) Vocational services plan development
3) Job analysis
as well as many others. You can also refer to the high-level summary of vocational services in L&I workers compensation claims.

Permanent Partial Disability in L&I claim

Permanent partial disability (PPD) refers to loss of bodily function because of a work injury or work illness. The degree to which you lose bodily function is what we call PPD rating. In this context, you have to go through a PPD rating exam by a qualified medical professional.

There are many rules in PPD rating exams. Say that your permanent condition if for parts of the body that can be amputated. For example, an arm or a leg. Here, the PPD rating is based on percentage of loss of function. Then, there are parts of the body that cannot be amputated. For instance, the spine or mental health disability. In such cases, the PPD rating is based on levels called “categories of impairment”. These categories, and other rules and guidelines, are available in the Washington Administrative Code (WAC).

Either way, a doctor will try to assess the loss of your body function. For that, the examining doctor compares your condition with the condition described in the categories. Then, the doctor selects the category that best describes your level of impairment. The monetary value of the PPD is based on a PPD award schedule. The PPD award schedule is available on the L&I website.

Permanent Total Disability is an important L&I benefit

Total disability is a physical or mental impairment that prevents you from working. Usually, medical professionals or vocational counselors decide if you can work. If your disability prevents you from returning to work in the foreseeable future – we refer to it as Total Disability. L&I considers it to be a permanent condition.

With total disability, you must obtain an opinion from a medical provider. The provider will establish the likelihood that your disability will continue to impact your ability to work in the future. If you are indeed permanently totally disabled (PTD), then you’ll probably receive a pension under your L&I claim.

Pension in L&I claims

An L&I pension means that you receive monthly payments for the remainder of your life. L&I will send you payments so long as you cannot, and do not, return to work. As before, your pension payments depend on the amount you were earning before the injury. The pension benefit provides a source of income for people with severe injuries that can never return to work.

Causation in L&I Claims and Workers’ Compensation Claims

/ L&I attorney / 2 Comments

After you get hurt on the job or suffer a work injury, you file a workers’ compensation claim. From that point on, the Department of Labor and Industry (L&I) decides what is going to happen with your claim. If you work for a self-insured employer, then a third-party administrator (TPA) also makes some decisions. With each decision, L&I issues a formal letter and sends you the decision notice. Regardless, to get treatment, you must show causation to L&I. In other words, you have to show that the work injury impacted your medical condition.

L&I causation and decisions in workers’ compensation claims

Surprisingly, there is lack of consistency in workers’ compensation and L&I decisions. For example, I regularly see inconsistencies in workers’ compensation claims involving the upper extremities. In many cases, these L&I claims are carpal tunnel syndrome, cubital tunnel syndrome, lateral epicondylitis, or radial tunnel syndrome. It is also common to see wrist sprains and strains, trigger finger, and cervical degenerative disc disease. Other conditions that fall under this category include thoracic outlet syndrome and cervicobrachial syndrome. In my opinion, that’s because a variety of occupational and non-occupational factors can cause these conditions.

Work injury claimants with the same medical condition

As an L&I attorney and workers compensation attorney, I sometime represent multiple people with a similar work injury claim. Moreover, they all have identical occupations and they develop the same medical condition. However, they receive very different decisions from L&I regarding their L&I claim. I’ve seen this in people that work as park aides, sheet metal workers, retail cashiers or checkers, and office clerks. Furthermore, this also happens with drywall workers, painters, and stone masons. Other professions include nurses or certified nursing assistants, as well as medical records clerks.

I find it particularly irritating when L&I rejects a claim because there’s no connection between the job of injury and the medical condition or diagnosis. It really rubs me the wrong way. That’s because I can think of multiple examples from within my caseload where one can easily reach an opposite conclusion. But, we need to remember that we’re within the workers’ compensation claim settings. Arguments such as “other workers in the same profession have allowed claims for the same condition” are not relevant. That’s because the law requires L&I to evaluate each workers’ compensation claim separately. Every claim is based on the facts and circumstances particular to the individual injured worker.

L&I claim for Carpal Tunnel Syndrome

I accept the importance of considering each work injury claim based on the individuality of the injured worker. However, I go from being irritated to indignant when the reasons given for an L&I claim rejection are outright false. For example, claim administrators may reject an L&I claim for carpal tunnel syndrome because the work activity does not cause or contribute to the development of the condition. Many times, they state this argument as if it’s a black-and-white fact. It’s not!

The AMA medical guide in workers’ compensation claims

One publication frequently cited in workers’ compensation is called “The AMA Guides to the Evaluation of Disease and Injury Causation”. This publication compiles medical research and literature to provide insight into the risk factors for developing various conditions. Many Independent Medical Examination (IME) reports reference this guide. Especially in the context of L&I causation.

Take an L&I claim for carpal tunnel syndrome as an example. According to the AMA guide, there is very strong evidence that a combination of force and repetition, or force and posture, contribute to the development of carpal tunnel syndrome. In fact, several studies referenced in the guide show that blue collar work is a significant risk factor for carpal tunnel syndrome. Moreover, they report that there is an increased risk of developing carpal tunnel syndrome with frequent wrist flexion and extension in combination with the use of vibratory tools. On top, they mention that carpal tunnel syndrome relates with jobs involving using a forceful power grip for long periods.

Other risk factors include highly repetitive work combined with other factors or with forceful work. Obviously, there are also non-occupational factors that impact the condition. For example- age, gender, genetics, diabetes, and body mass index.

L&I causation: The legal definition of proximate cause

When we speak about cause in workers’ compensation, you have to remember that we’re talking about proximate cause. Proximate cause has a very specific legal definition:

The term proximate cause means a cause which in a direct sequence produces the condition complained of and without which such condition would not have happened.

In my experience, IME doctors often follow this definition when they need to express their opinion regarding causation. Often, IME doctors reference other factors (especially age, gender and genetics) to support their conclusion that the condition would have happened independent of work activity. The problem is, there is more to the definition of proximate cause. Specifically:

There may be one or more proximate causes of a condition. For a worker to be entitled to benefits under the industrial Insurance Act, the work conditions must be a proximate cause of the alleged condition for which entitlement to benefits is sought. The law does not require that the work conditions be the sole proximate cause of such condition.

Simply put, if a person is an overweight female with a family history of carpal tunnel syndrome, she has several risk factors for developing carpal tunnel syndrome. When she is diagnosed with the condition, those risk factors cannot be ignored. However, if she also works in a job where she spends much of her workday forcefully grasping and operating a tool like a sander, then I would argue that you cannot exclude work activity as a proximate cause of her carpal tunnel syndrome.

Summary and some personal notes on L&I causation

I find it unacceptable that L&I ignores work activities that significantly increase the risk of developing conditions like carpal tunnel syndrome, in the presence of other risk factors. Even worse, this kind of exclusion happens inconsistently across the board. The legislator enacted the Industrial Insurance Act to provide protections for ALL workers. That means all workers deserve the exact same level of consideration. Regarding the facts, supporting medical literature and studies, and application of the law.

If an L&I claim manager rejects a workers’ comp claim because he or she only applied part of the definition of proximate cause, and they completely exclude work activity from the definition or consideration, then the rejection is unfair. When the worker is then saddled with the financial burden of proving that the rejections is incorrect based on the law and facts, the very intent and purpose of the Industrial Insurance Act has failed. And, when the purpose and intent of the Industrial Insurance Act fails, it hurts injured workers, their families, their employers, and society in general. The health of our workforce is critical to the health of our society.

L&I Claim for Thoracic Outlet Syndrome and Cervicobrachial Syndrome

/ L&I attorney / 0 Comments

I am a workers’ compensation attorney and L&I attorney representing work injury claimants in Washington State. Over the years, I’ve seen a wide variety of work injuries and occupational diseases. As a result, I’ve learned a lot about a wide range of medical diagnoses. I also recognize diagnoses that are likely to complicate an L&I claim. Potentially, resulting in a highly complex workers compensation claim. In my experience, an L&I claim for Thoracic Outlet Syndrome and Cervicobrachial Syndrome are likely to become very convoluted. Thankfully, our office has vast experience handling these conditions and claims.

What is Thoracic Outlet Syndrome?

In order to understand thoracic outlet syndrome, you need to understand some basic facts about human anatomy. The human body has a network of cervical nerve roots. They join to connect signals between the brain and the shoulders, and upper extremities or arms. Doctors often call this network the brachial plexus. Injuries to the brachial plexus cause pain, numbness, tingling and even paralysis of the shoulders and arms.

The medical community is still working to fully understand brachial plexus injuries. There seems to be a general consensus that there are at least two primary varieties of thoracic outlet syndrome (TOS) that can result from brachial plexus injuries. These are: (1) Vascular thoracic outlet syndrome; and (2) Neurogenic thoracic outlet syndrome. Vascular TOS occurs as a result of trauma to the arteries or veins around the brachial plexus. Neurogenic TOS occurs when the brachial plexus nerve fibers suffer from compression.

From the viewpoint of the Department of Labor and Industries (L&I), the worker must meet certain criteria to allow a diagnosis of neurogenic TOS under an L&I claim in Washington State. Those criteria are available in the L&I treatment guideline.

L&I claim and treatment guidelines for Thoracic Outlet Syndrome

The L&I medical and treatment guidelines for TOS are complex. In short, the diagnosing medical provider must produce certain clinical exam findings that are corroborated by an electrodiagnostic study showing that the brachial plexus nerves are being compressed.

Historically, a third kind of TOS called “disputed” TOS was recognized by some. According to the L&I treatment guidelines for TOS, “disputed” TOS occurs when there are positive clinical exam findings of neurogenic TOS, but the electrodiagnostic study is normal and does not confirm impingement of the brachial plexus nerves. In the past, work injury victims with disputed TOS diagnosis were facing challenges in their L&I claims. That’s because the treatment guidelines only include true neurogenic TOS and vascular TOS.

Until recently, if an injured worker was diagnosed with disputed TOS, L&I would issue an order or decision stating that thoracic outlet syndrome is not an accepted condition on the workers compensation claim. Luckily, that’s no longer the case.

What is Cervicobrachial Syndrome?

In February 2019, L&I updated its thoracic outlet syndrome treatment guideline to include cervicobrachial syndrome. According to L&I, the symptoms of cervicobrachial syndrome mimic those of neurogenic TOS but lack the required electrodiagnostic results to diagnose true neurogenic TOS. The symptoms of Cervicobrachial Syndrome include pain and muscle spasm in the cervical or brachial region.

Symptoms may also include neck and headache, and sometimes numbness and tingling in one or both upper extremities. However, cervicobrachial syndrome does not include other common characteristic of TOS such as decreased reflexes, dermatomal sensory loss, specific muscle weakness or atrophy of the upper extremity, and abnormal electrodiagnostic tests that corroborate the presence of objective brachial plexus involvement.

Thoracic Outlet Syndrome and Cervicobrachial Syndrome in L&I claim

Thoracic outlet syndrome may develop when workers experience extended periods of time or postures limited to carrying heavy shoulder loads. Workers that their work involves pulling shoulders back and down, or reaching above shoulder level, can also develop thoracic outlet syndrome. This is because those kinds of work activities tend to cause swollen or inflamed mid-back, shoulder and neck muscles and tendons. When swelling occurs around the brachial plexus, it compresses the nerves and blood vessels between the neck and shoulders. And, the result is thoracic outlet syndrome.

L&I claim for jackhammer operators, welders and aircraft assemblers

In the worker’s compensation setting, neurogenic and disputed TOS are more commonly diagnosed than vascular. L&I acknowledges that certain work activities may exacerbate neurogenic TOS. These activities include lifting overhead, holding tools or objects above shoulder level, reaching overhead, and carrying heavy weights. Occupations often associated with neurogenic thoracic outlet syndrome include dry wall hangers, plasterers, welders, beauticians, assembly line workers, shelf stockers and dental hygienists.

With respect to cervicobrachial syndrome, the medical community still doesn’t fully understand the types of activities that cause the condition. However, some activities thought to cause cervicobrachial syndrome include sprains and strains. Especially those involving the cervical or brachial region, shoulder joint dislocation or fracture, rheumatoid arthritis, and degenerative disease (i.e., arthritis).

In my experience, in workers’ compensation claims, common work activities that seem to contribute to the development of cervicobrachial syndrome include prolonged use of vibratory tools such as jackhammers, repetitive heavy and overhead lifting, and working in prolonged and awkward overhead postures. I’ve seen the condition impact laborers, dental hygienists, aircraft assemblers, steel workers and more.

Treatment for Thoracic Outlet Syndrome and Cervicobrachial Syndrome

Going back to L&I claims in Washington State, it is easier to get authorization for thoracic outlet syndrome and cervicobrachial syndrome treatment that follows the L&I treatment guidelines, rather than treatment that falls outside the guidelines. While neurogenic TOS may respond to surgical treatment, L&I favors non-surgical or conservative treatment. That’s because L&I conducted a study of surgical outcomes and the results were bleak.

Surgically, it is not easy to access the brachial plexus region. Also, there’s high risk of damaging other important nerves including the phrenic nerve, which innervates the lungs. Damage to the phrenic nerve during surgery can cause permanent asthma and reduced lung function. Therefore, L&I says surgery should only be an option in severe cases of true neurogenic TOS that do not improve with conservative treatment and interfere with work or daily life activity.

Conservative treatment options for thoracic outlet syndrome and cervicobrachial syndrome are similar. Treatment focuses on reducing inflammation of the affected muscles and tendons, while simultaneously increasing strength, mobility and overall function. In my recent experience, effective treatment involves the use of Botox injections. They help calm muscle spasm and inflammation and reduce the impact on the brachial plexus. L&I can authorize this conservative treatment under the 2019 amendment to the L&I medical treatment guidelines.

Conclusion and L&I improvements

I’ve worked through many challenging and complex cases involving disputed thoracic outlet syndrome diagnosis. Hence, it was very encouraging to see the February 2019 update to the medical treatment guidelines. They include cervicobrachial syndrome! However, I believe that the administration of L&I claims for thoracic outlet syndrome or cervicobrachial syndrome has to improve.

According to the L&I guidelines, early diagnoses is very important. Work injury claimants with early and accurate diagnoses are far more likely to return to work than workers whose diagnoses came in weeks or months later. Unfortunately, in my experience, administrative delays make early diagnosis difficult if not impossible. L&I, Independent Medical Examiners (IMEs), and even some attending providers are quick to relegate injuries to mere sprains and strains. As a result, TOS and cervicobrachial syndrome diagnoses often experience delays. Sometimes indefinitely.

I believe that L&I can do a much better job at encouraging and supporting accurate and early diagnoses. This would dramatically improve outcomes in many L&I claims. Unfortunately, in nearly every case of thoracic outlet syndrome or cervicobrachial syndrome that I’ve encountered, the accurate diagnosis has not been made until more than a year following the original injury or onset of symptoms.