Your Right to Medical Care

You may choose your own physician and have the medical bills related to your job injury or disease paid for, so long as the treatment you receive is found to be necessary and proper. There are some exceptions; here is the rule WAC 296-20-065

This is medical care for your L&I claim which covers job related conditions, while your claim is open. This is not health insurance.

You can pick another doctor, if your doctor isn't getting the job done.

Your doctor can help you see specialists. Some specialties must be pre authorized by L&I/SI, others do not need pre authorization.

Your doctor or the specialist can prescribe diagnostic tests. Some tests must be pre authorized by L&I/SI, others do not need pre authorization.

L&I pays your doctor for treatment of the accepted conditions. This doctor takes a discounted rate from L&I. The doctor cannot bill you the difference between his usual rate and the rate L&I pays.

Medical care should be proper and necessary before it will be authorized. DLI defines this in WAC 296-20-01002 under "proper and necessary."

In the normal case, medical care ends when the claim closes. There are very few exceptions.

Lifelong Right to Medical Care is easy to say, hard to get. You need an open claim and the care requested must be proper and necessary, and causally related to your L&I claim.

Common medical bill problems and solutions:

Problem: Claim not open.
Solution: Open a new claim or re-open a previously closed claim.

Problem: Medical treatment is determined to not be for an accepted condition.
Solution: L&I/SI are often not aware of all your injuries and natural complications. Complications include obvious and not so obvious. For example it's obvious that if you hurt your right arm, you will end up overusing your left arm. At some point your overused left arm may become a natural complication and need medical care. It's your doctor's duty to convince the claims manager that your other arm, the overused left arm, should also become an accepted condition.

For example it's not so obvious that if you're seriously injured and out of work you may get depressed. Depression is a natural complication of a serious and complicated job injury. It's a medical condition. It gets better with good mental health care. It can become an accepted condition. Your attending physician is the person who can turn a medical condition into an accepted condition. He/she does it by writing to or speaking with the claims manager, and/or in the example of depression referring you to a psychiatric specialist, who then may convince the claims manager to accept the condition.

Problem: I have a job injury and healthcare insurance, but for some reason my healthcare insurance doesn't want to help with my workers' compensation case.
Solution: Healthcare and medical care for L&I claims are two different systems.

• Healthcare is for non job-related concerns and has nothing to do with your workers' compensation claim.
• Medical care for an L&I claim allows you to see any doctor, who accepts L&I patients, and have that doctor bill the workers' compensation system, either L&I or the self-insured employer. With a job injury you have a right to proper and necessary medical care. See above.

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