Category: PPD (Page 5 of 8)

L&I Claims and the Bias in Independent Medical Exam (IME) Reports

Independent Medical Examinations (IME) are part of every L&I claim and workers’ compensation claim in Washington State. Doctors that perform IME exams must have a certification from the Department of Labor and Industries (L&I). In turn, they provide L&I with an IME report. When performing IME tests, doctors have to abide by certain rules and regulations. These rules are available in L&I’s Medical Examiner Handbook. However, if that’s the case, then why is there bias in almost every IME report?

Bias in workers’ compensation IME exam and report

As a workers’ compensation attorney, in my experience, IME doctors often demonstrate clear bias. In many cases, they ignore relevant sections of the law and ignore accepted conditions under the claim. Furthermore, it’s common to see internally inconsistent exam notes and reports. Interestingly, L&I still accepts the results of bad IME tests. Even though they are undoubtedly contrary to the law and to the facts of cases and claims. Personally, I’m fed up with this trend, which neither helps L&I nor work injury claimants.

The reality of IME exams in L&I claims

Here are some examples of issues from actual cases.

Clearly biased

I recently cross-examined an IME provider who opined that the work injury claimant did not want to return to work. An opinion like that is nothing but biased, especially when it comes to the facts of the case. Looking at the facts, my client has been working and maintaining a job since the time of the examination.

Ignoring the law

In another workers’ compensation claim, the IME doctor states that the injured worker doesn’t need additional treatment. Furthermore, the doctor said that if the claimant needs a new MRI, then the MRI is not a treatment rather it’s diagnostic. The doctor’s response made my blood boil. In Washington State, people that suffer a work injury are eligible to receive necessary and proper health care services.

Ignoring accepted conditions

I recently received and reviewed an IME report. I was shocked when I saw the IME provider arguing that the complex medical condition does not exist. All while the work injury claimant is receiving ongoing treatment for the condition on a monthly basis. On top, L&I accepted the condition as final and binding years ago. At this point in the L&I claim, it’s very possible that L&I will accept the IME’s opinion. I won’t be surprised if L&I uses the wrongful report to make adverse determinations in this workers’ compensation claim.

IME report can be internally inconsistent

I came across yet another IME report the other day. Here, L&I asked the IME examiner to consider 3 possible jobs for my client following the work injury. All three jobs require prolonged standing on feet, which the work injury claimant can’t tolerate because of their industrial injury. In the report, the IME examiner disapproved 2 of the jobs. However, for reasons unclear to me, the IME doctor approved the 3rd job. Even though it also requires prolonged standing. L&I terminated time-loss compensation benefits and closed the workers’ compensation claim.

Some personal notes and conclusions about IME report quality

IME exams are now big business in Washington State. Unfair and biased exams don’t help L&I because as an L&I attorney, I’m ready for a legal fight. The fight is very costly to L&I. These IME reports also don’t help people that had a work injury. It stalls their L&I claims and their ability to return to work.

I believe that L&I needs to revisit the misuse of IME exams. They need to employ corrective measures. That means obtaining unbiased and consistent opinions. IME tests must rely on the facts and the reality of cases and claims. They must also comply with workers’ compensation law in Washington State.

IME Exam in L&I Claims in Washington State

/ L&I attorney / 2 Comments

The Department of Labor and Industries (L&I) sometimes requires injured workers to attend Independent Medical Examinations or IME. In many cases, L&I asks work injury claimants to attend an L&I IME exam to help L&I make claim-related decisions. From L&I’s perspective, an IME provides objective medical-legal examination for the purpose of establishing medical findings, opinions and conclusions about an injured worker’s physical condition.

IME tests in L&I claim appeals

It’s important to note that IME exams can only be performed medical examiners that are pre-approved by L&I. Fundamentally, I don’t share L&I’s perspective on IME examinations. When I represent work injury plaintiffs in appeals before the Board of Industrial Insurance Appeals (BIIA), often L&I medical arguments rely on IME opinion. In fact, it is very common for me to cross examine the same seven or eight IME doctors repeatedly.

IME panels in Washington State

There are several panel corporations that provide IME services to L&I. These include Sunrise Medical, Objective Medical Assessments Corporation (OMAC), Central Seattle Panel of Consultants, Medical Consultants Network (MCN), and others. Interestingly, most of the examiners who perform IME tests are contracted with more than one of these panels. In other words, having a variety of panels offering IME tests does not result in a greater variety of examiners.

IME exams are inherently biased and unfair

On occasion I’m surprised by the outcome of an IME. However, more often I predict the outcome before the examination even occurs. There are several reasons for this. L&I argues that IME tests are an objective process. I’ve had IME doctors testify that they are in the best position to provide opinions to L&I because they have no stake in the outcome. Whether these providers want to admit it or not, they have a bias in favor of L&I.

The Department of Labor and Industries controls the process and procedure of every IME from start to finish. For one, L&I sets the ground rules for these examinations. Moreover, as mentioned earlier, the examiners must be approved by L&I. In addition, examiners are mandated to follow the Medical Examiner’s Handbook written by L&I.

IME examiners are asked to answer specific questions given to them by the claim manager. Typically, along with the questions presented to IME doctors, the claim manager usually provides claim related information. This information can include the status of the claim, the L&I claim accepted conditions and the contested conditions. The IME examiner reviews the medical records provided by L&I and is paid according to fee schedules dictated by L&I. Finally, the examiner must produce a report in accordance with L&I timelines.

IME exams from the viewpoint of injured workers

In my experience, injured workers who are required to attend an IME rarely feel that the process is unbiased and objective. For example, a work injury claimant has no choice when it comes to the IME doctor. In addition, the date and time of the IME exam is set by L&I. Then, if there are any scheduling conflicts for the injured worker, he or she must ask for permission from the claim manger to reschedule.

Frequently, injured workers feel attacked and judged by the IME examiners. It’s very common for work injury plaintiffs to report that the examiners seem to ignore what they are saying. Consequently, the IME process leaves work injury claimants feeling frustrated, insecure, and unheard. People that suffer a work injury contact me all the time to inquire about representation. Many times, they call me because they have been scheduled for an IME, or recently attended an IME. As a result, they are concerned about the future of their claim.

IME notes from an L&I attorney

In my opinion, there are many legitimate reasons for which L&I needs outside, impartial medical opinions to help resolve L&I claim issues. However, I don’t believe that the current IME process is fair. I also don’t feel that the current format of IME examinations accomplishes the goals of the Industrial Insurance Act.

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

/ L&I attorney / 12 Comments

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.