An open L&I claim gives you a right to medical care for necessary and proper treatment related to your job injury.
This is medical care for your L&I claim which covers job related conditions, while your claim is open. This is not health insurance. Medical treatment usually ends when the claim closes.
Your first visit to a doctor after an injury is important because this is the doctor who will file your L&I claim. It’s your choice, it is very important so get it right.
You do not have to see a company doctor or work clinic. Your employer may offer to take you to an occupational medicine clinic after your injury. You do not have to agree to see this doctor for your injury. You can advise your employer that you appreciate their concern but you will see your own doctor, and that you will have your own doctor file the L&I workers compensation claim for you. You do have to follow your companies after accident drug testing policy at a facility they choose.
You may choose your own physician from L&I’s list of approved medical examiners and have the medical bills related to your job injury or disease sent directly to L&I for payment. There are special and complex rules for out of state treatment and non typical medical providers.
You can pick another doctor from the list of approved examiners, if your doctor isn’t getting the job done. There are some exceptions; here is the rule WAC 296-20-065. Having a good and supportive doctor is very important.
Your doctor can refer you to specialists. Some specialists must be pre authorized by L&I or the Self Insurer.
Your doctor or the specialist can prescribe diagnostic tests. Some tests must be pre authorized by L&I or the Self Insurer.
The huge problem with the L&I medical care is that there are darn few good doctors who will treat L&I patients. There are many reasons for this.
L&I or the Self Insured employer pays your doctor directly for treatment of the accepted medical conditions. Your doctor takes a discounted rate from them. The doctor cannot bill you the difference between his usual rate and the discounted rate that L&I or the employer pays.
If the Self Insured Employer unreasonably delays authorization of medical care or unreasonably delays payment of medical bills or other benefits, then they are subject to a penalty, RCW 51.48.017. Make them pay a penalty if they unreasonably delay your benefits. That penalty payment is yours to keep.
Medical care should be proper and necessary before it will be authorized. L&I defines this in WAC 296-20-01002 under “proper and necessary.”
Medical care ends with maximum medical improvement (MMI), or when the claim closes. There are very few exceptions.
Maximum Medical Improvement (MMI) is also know as fixed and stable. It is a place in the continuum of medical care where no further improvement in an accepted medical condition is expected. Said another way, in some doctors opinion, “it is as good as you are going to get.”
MMI is an important concept because L&I will not pay for additional medical treatment after MMI is reached. L&I takes the position that payment for medical care is no longer proper and necessary once MMI is reached.
Keep in mind that MMI is not a fact, it is an opinion. L&I likes to push an injured worker quickly to MMI. They will do this with IME doctors. Be sure you and your doctor advocate for the necessary and proper medical care that you need to heal as well as possible.
Lifelong L&I medical care for an L&I claim is easy to say and hard to get. To exercise your right to ongoing job related medical treatment after claim closure, you need an open claim and the care requested must be proper, necessary, and causally related to your L&I claim. You must request and get a treatment order to effectuate this.
L&I pays for medical care if it is related to your job injury or occupational disease. L&I will not pay for conditions which are unrelated to your job injury . To get care for unrelated or denied conditions use your medical insurance (if any) or consider applying for Social Security Disability so you can get Medicare to pay. Read More About Social Security Disability and Medicare
Solution: Open a new claim, protest a recently closed claim, or re-open a previously closed claim.
Solution: Get your doctor to help with this issue. Often L&I is unaware of how your medical treatment is related to the job injury. The attending physician has a lot of say about your medical condition and how it relates to your job of injury. If your job injury has caused a medical problem that needs treatment, make sure your doctor says so, in writing, to L&I.
For example if you hurt your right arm, you may end up overusing your left arm. At some point your overused left arm may become a natural complication and need medical treatment. L&I can and should pay for the medical care for this overuse problem. It’s your doctor’s job to convince the claims manager that your new arm problem, the overused left arm, should also become an accepted condition. If your doctor cares about you, he should do this for you and for himself.
The same is also true for mental health conditions. 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 is a medical condition. Depression gets better with good mental health care. It can become an L&I 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 in the example of depression by referring you to a psychiatric specialist, who then may convince the claims manager to accept the mental health condition.
Solutions: That denial order should be protested or appealed. You have a right to medical care for conditions which are related to your job injury. Protest or appeal.
As a temporary solution, when L&I denies a medical condition as unrelated, and you appeal, medicare or private insurance can step up and temporarily pay for treatment during the appeal period. The two agencies can work out who pays the bills on their own, depending upon the outcome of your appeal.
If the Board of Industrial Insurance Appeals, after a hearing and presentation of evidence, denies a medical condition as unrelated, and that order becomes final, then that opens the door for an injured worker to get Medicare or private insurance to provide diagnostic testing and medical treatment.
Solution: Healthcare and L&I medical care are two different systems.
Solution: Don’t let them do this, they can be assessed a 25% penalty. You can request a penalty by writing to L&I.
Solution: This is a huge problem. There are few good solutions; give these a try:
Solution: Same answer as above.