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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 / 1 Comment

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.

Workers’ Compensation Vocational Rehabilitation – Who Gets Them and Why?

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After a work injury, some workers may no longer be employable. To address this, the Department of Labor and Industries (L&I) can provide workers’ compensation vocational rehabilitation services. However, L&I doesn’t have to offer vocational rehabilitation. In fact, it’s up to L&I to choose who gets these services.

Who gets workers’ compensation vocational rehabilitation benefits?

In Washington State, the Industrial Insurance Act governs the workers’ compensation system. Under the law, some workers’ compensation benefits are entitlements. What does that mean? It means that L&I must provide these L&I claim benefits to workers when they meet certain conditions. For example, if a worker has temporary total disability, then L&I must provide time-loss compensation.

Another example is when workers require medical treatment. After a workplace injury, L&I must provide proper treatment for conditions that relate to the work injury. Whenever a work injury claimant has permanent partial disability, L&I must give a PPD award. However, if workers are unable to return to work, nothing mandates L&I to provide vocational rehabilitation services.

Who decides to give L&I vocational rehabilitation services?

There are many types of vocational services under an L&I claim. Early return-to-work in one example. Vocational retraining and vocational counseling are also important services. However, all workers’ compensation vocational rehabilitation benefits are discretionary. L&I decides who receives vocational services and who doesn’t.

Yet, on many occasions, L&I does provide workers’ compensation vocational rehabilitation. Interestingly, it’s up to the Director of L&I to decide who receives them. Although, on occasion, the Director of L&I can designate others to assist with these decisions.

Why does L&I provide vocational services?

If there’s no requirement for L&I to offer vocational services – why do they provide them? That’s a good question. The answer is – it boils down to cost. Say that L&I doesn’t provide vocational services to a work injury claimant. Then, ask yourself: Can the worker go back to work without receiving vocational benefits? If the answer is No, and if L&I denied vocational services, then L&I may be on the hook to provide them with an L&I pension.

L&I awards a workers’ compensation pension when the worker has permanent total disability. In fact, a workman’s compensation pension is one of L&I’s most significant monetary benefits. It’s a lifetime annuity. With an L&I pension, L&I pays the worker twice per month, for life. Therefore, it’s very costly (to L&I). Consequently, vocational benefits are one way for L&I to ensure employability. By doing so, L&I can avoid long term disability and pension payments.

What can I do if L&I doesn’t provide vocational services?

However, L&I sometimes declines vocational benefits. Unfortunately, if L&I decides to not award vocational rehab services, it’s nearly impossible to reverse their determination. The only way to change the decision is to prove that the Director of L&I abused their discretion. Then, to prove abuse of discretion, you must show that no reasonable person would make the same decision.

What if I receive workers’ comp vocational rehab services?

Some workers end up receiving vocational benefits from L&I. If you are one of those workplace injury claimants, then I strongly recommend you follow the below.

First, if you want to return to work and you receive vocational benefits – be thankful. Some L&I vocational programs are very good! In fact, my office often hires paralegals straight out of retraining programs.

Second, you must cooperate with your vocational service providers. Here, cooperation means you must meet with your vocational counselor and adhere to their guidance. You’ll have to provide them your education history and work experience. Moreover, they’ll expect you to collaborate and explore options to return to work.

Final takeaways

You must cooperate with vocational services. If you fail to cooperate, then L&I can suspend all benefits under your L&I claim. Don’t do it. It’s not worth it. Navigating the vocational process can be simple. However, in some cases, it can also feel confusing, hostile, and scary.

From my perspective, the most important thing is to fully engage in the process. If you want to return to work, then give it all you got. Workers’ compensation vocational rehabilitation can be an incredible benefit. Take full advantage of it. Pay attention to what’s happening around you. Track the actions and various recommendations throughout the vocational process.

Finally, as always, problem can arise along the way. For some, the vocational process seems hostile. For others, there can be lack of transparency. If that’s the case, it’s always a good idea to speak with a workers’ compensation attorney.