Today I’ll begin discussing what I refer to as the “open and active” phase of a workers’ compensation claim in Washington State. In an allowed claim, the open and active phase is when the claim is open and the injured worker is actively seeking treatment for conditions related to the claim. During this phase there are a number of potential benefits that may be provided under the Industrial Insurance Act. Issues can arise with each type of benefit that may be provided. Because it is one of the most significant benefits provided during a claim, today’s post is about treatment.
Generally speaking, under the Industrial Insurance Act, injured workers are entitled to receive necessary and proper treatment for conditions that are related to the claim. If treatment is denied by the Department of Labor and Industries (L&I) during the open and active phase of a claim, it is usually for one of two reasons: (1) Either the condition being treated is not related to the claim; or (2) The treatment being recommended is not considered necessary and proper.
For a condition to be considered related to a claim, the industrial injury or occupational disease must be a proximate cause of the condition. What that means is that the injury or occupational disease must be a cause of the condition, or it must be a cause of permanently aggravating the condition.
If a claim is allowed, it is generally assumed to have been allowed for the condition or diagnoses listed on the application for benefits based on the initial medical examination. However, as treatment evolves, it is sometimes determined that the original diagnosis was either incorrect or incomplete. If L&I or a third-party administrator (TPA) is asked to cover treatment for a condition that they do not believe is related to the claim, the attending physician may be asked to provide more information about the causal connection. Alternatively, the injured worker may be scheduled for an independent medical examination (IME) to determine causation. If they determine the condition is not causally related based upon the medical evidence, an order will be issued indicating that the Department or Self-Insured Employer is not responsible for the condition and treatment for that condition will not be authorized.
For injured workers, if your doctor has opined that you have a condition that is related to your industrial injury or occupational disease, but an order has been issued denying responsibility for the condition, it is important to seek advice from an experienced Worker’s Compensation attorney as soon as possible. Typically, injured workers have only 60 days from being notified that a condition is not being covered to protest or appeal the decision or it will become a final and binding decision for the remainder of the claim. Experienced Worker’s Compensation attorneys are well-versed in the evidentiary requirements to prove causal relationship of conditions.
Evaluation and guidelines
Assuming a condition has already been determined to be related to the claim, necessary and proper treatment for that condition should be authorized. L&I generally follows medical aid rules and treatment guidelines for determining whether a particular recommended treatment will be authorized. An entity called Qualis evaluates treatment recommendations for medical necessity. Sometimes knowledge of these rules and guidelines can assist injured workers in successfully securing authorization for treatment being recommended. For example, I have been successful in litigating to get L&I to follow its own guidelines for treating individuals who have become addicted to opioid pain medications. While it is often L&I’s procedure to deny payment for opiate pain medications once the individual is no longer in the acute phase of treatment, L&I has a clear and well laid out guideline for tapering injured workers off opioid pain medications and even providing them with more significant medical interventions for addiction if needed.
However sometimes L&I’s rules and guidelines are not consistent with the legal standard for necessary and proper treatment, and treatment is unfairly denied. As a general rule, necessary and proper treatment is treatment that is designed to diagnose, cure, or rehabilitate a condition related to the claim. Therefore even if a particular treatment is not allowed pursuant to L&I’s treatment guidelines, experienced attorneys may present medical testimony and evidence to secure a favorable decision authorizing the treatment being recommended. The drawback is that accomplishing this frequently requires presenting supportive medical testimony before the Board of Industrial Insurance Appeals.
In summary, it is critical during the open and active phase of a claim, that injured workers be provided with necessary and proper treatment for causally related conditions. If injured workers run into issues with the acceptance of conditions or authorization for treatment, it is always a good idea to consult with an experienced Worker’s Compensation attorney.