An open L&I claim gives you a right to medical care for necessary and proper treatment related to your job injury.
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 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. Medical care usually ends when the claim finally closes.
You can pick another doctor from the list of approved examiners, if your doctor isn’t getting the job done. 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.
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 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 to you if they unreasonably delay your benefits.
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.”
In the normal case, medical care ends when the claim closes. There are very few exceptions.
Lifelong L&I Medical Care Benefit 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. 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. Read More…
Problem: Claim not open, so L&I denies the medical bills.
Solution: Open a new claim or re-open a previously closed claim.
Problem: Medical treatment is determined to not be for an accepted condition, because L&I is unaware of how your need for this treatment is related to the job injury.
Solution: Get your doctor to help with this issue. The attending physician has a lot of say about your medical condition and how it relates to your job of injury. Make sure he says it, in writing, to L&I or the Self Insured employer.
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 care. L&I can and should pay for this complication. 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. 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 mental health condition.
Problem: L&I sends you an order denying medical treatment saying it is unrelated to your job injury.
Solutions: That denial order should be appealed. 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.
Problem: I have a job injury and healthcare insurance, but 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.
Problem: L&I or the self insurer is refusing to authorize medical care or refusing to pay medical bills or other benefits, in a timely fashion.
Solution: Don’t let them do this, they can be assessed a 25% penalty. You can request a penalty by writing to L&I.