You can always reopen an L&I claim for medical treatment. Even if you have an old claim. It doesn’t matter how old the claim is. However, if your claim closed over 7 years ago, it will impact your L&I claim benefits. While L&I covers medical treatment, you might not receive other benefits under the claim.
What is an over-seven claim?
The term “Over-Seven Claim” is commonly used by workman’s compensation professionals. That way, we all know what we’re talking about when we use that phrase. The term refers to an L&I claim or self-insured employer claim that closed over seven years ago (or ten years for eye claims).
To reopen an over-seven claim, the requirements for reopening are the same as all claims. This is true for old claims as well. However, once reopening is complete, there is special treatment for over-seven claims. Here, in this article, we’ll first discuss the reopening process and then talk about L&I benefits and limitations.
How to reopen an old over seven claim
To start, you must first file an Application to Reopen Claim. If you look at it, the form requires information from both the work injury claimant and their medical provider. In turn, after L&I receives your reopening application, L&I has sole authority to decide what to do next. This is true for both a state-funded L&I claim and self-insured employer claim. In other words, the Department of Labor and Industries (L&I) determines if there’s merit to reopen your claim.
A work injury claimant can submit a request for reopening without supportive medical documentation. However, without medical evidence, L&I won’t be able to determine whether reopening is appropriate. Therefore, it’s typically best for the injured worker and their doctor to work together on the claim reopening application. Collaboration with your medical provider is very important.
Medical criteria to reopen an old claim in Washington State
The following explanation applies when reopening any claim. Not only an old workers’ compensation claim. To meet the criteria for reopening, you must show an aggravation or objective worsening of your conditions. Remember, these conditions must relate to the work injury. Furthermore, you must show that the aggravation or worsening happened since the latter of: (1) The last date the claim closed; or (2) The most recent date L&I issued an order stating the claim will remain closed.
For aggravation, you must show the following:
- A causal connection between the accepted condition at the time of claim closure and the current condition;
- A medical opinion stating that the condition is worse than before; and
- Objective medical findings to support the medical opinion.
Sometimes, the requirement to provide objective medical evidence doesn’t apply. For example, in case of mental health conditions.
Showing aggravation and worsening of conditions
L&I can give your medical provider a copy of the closing medical records. If you need it – ask for it. These records can help your doctor assess if your condition is getting worse. Also, L&I can authorize additional diagnostic testing if it helps in deciding on reopening. Finally, L&I also has the right to compel the work injury claimant to attend an Independent Medical Examination (IME). The purpose of the IME exam is to determine if reopening is appropriate.
L&I benefits after reopening an over-seven claim
You can apply to reopen an old over seven claim any time, to receive medical benefits. After filing the reopening application, several situations may arise. First, if the claim doesn’t meet the criteria for reopening, L&I will issue a decision denying the reopening. Second, if the claim can be reopened and time-loss is not an issue, L&I will issue an over seven reopening order and notice for medical benefits. The notice informs the work injury claimant that their claim is reopening only for medical treatment.
Of course, medical benefits are just one kind of benefit that L&I provides to workers after they get hurt on the job. Typically, workers’ compensation professionals refer to other benefits as “disability benefits”. The most common disability benefits include time-loss compensation (TLC), loss of earning power benefits (LEP), permanent partial disability awards (PPD), and pensions (TPD). Simply put, work injury claimants with an old over-seven claim don’t receive disability benefits. Even after L&I reopens their claim. With one exception.
Requesting disability benefits for an old over-seven claim
The director of L&I has discretion to grant disability benefits in an over-seven claim. A worker with an old claim can ask for disability benefits any time during the reopening process. Or, they can ask for disability benefits after L&I reopens the claim. If you’re requesting disability benefits in an over-seven claim, the claims manager or claim adjudicator must prepare a briefing paper. Later, they will hand the briefing paper to the L&I director for consideration.
By law, RCW 51.32.160(1)(a) grants the Director the authority to readjust the worker’s rate of compensation on their own motion. Once the Director exercises discretion to approve or deny benefits, L&I will issue an order and notice. The order will notify the work injury claimant of the Director’s decision.
How likely am I to receive benefits for an old claim?
On occasion, the Director will exercise discretion to grant additional disability benefits in over-seven claims. However, this is an exception. It isn’t a rule and it’s not very common. In fact, Washington State Courts said that the meaning of the words “may adjust the rate of compensation” in RCW 51.32.160(1)(a) empowers the Director to modify the value of a worker’s disability benefits. Hence, the Director has the “discretionary authority” to determine the worker’s eligibility for disability benefits.
As always, any party can protest or appeal L&I decisions. This also includes the Director’s decision to grant or deny disability benefits. However, we must remember that for an over-seven claim, the decision to grant or deny disability benefits is discretionary. Consequently, Washington State Courts determined that the standard of review on appeal is “Abuse of Discretion”. In other words, the appealing party must show that the L&I Director abused his discretion in making the decision. For that, they have to convince the Board of Appeals or a higher court that no reasonable person would have made the same decision. Therefore, most lawyers would agree that abuse of discretion is difficult (if not impossible) to prove.
Summary and conclusions
In summary, you can reopen a workers’ compensation claim as long as certain criteria are met. The criteria for reopening are the same for all claims. It doesn’t matter if a claim closed long ago. The age of the claim is also not important.
If your L&I claim closed less than seven years ago, you can reopen it for both medical treatment and disability benefits. However, if you claim closed over seven years ago or more (ten years for eye claims), you can only reopen it for medical benefits. In over-seven claims, the Director of L&I can exercise discretion to grant or deny disability benefits. But, if the Director denies disability befits in an old over-seven claim, it’s very difficult to successfully appeal and reverse the decision.