Ability to Work Assessment
This is where a vocational counselor should be working with you and your doctor to determine whether you can return to work given any physical restrictions you may have that are related to your industrial injury. At this point the vocational counselor will be discussing the return to work priorities (5 parts). For more on this, as well as VR, light duty work, and all things having to do with vocational services, please see our blogs about the vocational process, or call us.
Activity Prescription Form
Your doctor fills this out to list your restrictions worth regarding – things like lifting, pushing, pulling, or time spent sitting/standing, etc.
Affidavit for Time Loss
This is a form you fill out to certify that you haven’t worked during a particular period in the past when you are contending that you should have been receiving TTD.
The order notifying you that your claim has been allowed for treatment and benefits as applicable. An allowance order may also refer to an order issued accepting responsibility for a condition on a claim.
An appeal to the Board of Industrial Insurance Appeals (BIIA) is the next step after a protest if the claim manager has not agreed with your protest and changed the department’s position on an issue. A party may also bypass the protest step and go straight to filing an appeal if they so choose.
The Department of L&I requires that one provider assume the responsibility of the AP to oversee treatment and potential referrals to specialists. You’ll need to meet with your AP regularly, approximately every 6 weeks while your claim is open, even if there is no active treatment.
Board of Industrial Insurance Appeals
This is the court with exclusive initial jurisdiction over workers’ compensation appeals. Matters can be pursued in superior court, and the progressive courts of appeal, but only after first being heard at the BIIA.
An estimation of the total costs of your claim made by the department. This is not a guarantee of approval, awards, or treatment – it’s merely an estimation created for internal use at the department of L&I.
Change of Circumstances
If you’re injured on the job and your employer continues to pay for all or a part of your healthcare benefits and then they stop, you can have this amount added to your monthly wage amount for purposes of calculating time loss. This can be significant in some cases, but you must act quickly.
This is the person working for the Department of Labor and Industries responsible for governing and adjudicating decisions on your claim.
Claim Resolution Structured Settlement Agreement
A settlement that closes your claim in exchange for a dollar amount, paid over time. This isn’t available to all injured workers, and you must be over 50 years or older to begin the process. Sometimes this can be a useful tool but it carries with it a host of cautions that you should discuss with an attorney if the Department offers to negotiate a CRSSA with you. Not the least of which is that once a CRSSA has been approved and received, you will no longer be able to receive monetary benefits, even on a successful reopening.
Effectively the first stage of review when a Department decision or “Order” issued by the claim manager is appealed. The CC has the ability to take further action on a decision or order before it goes on to the BIIA.
Claims Unit Supervisor
This person oversees a unit of claim managers at the Department. Generally, you will not communicate with the supervisor unless there is a problem. You may, however, request to speak with the supervisor if the claim manager has failed to act on your claim.
The order notifying you that your claim has been closed.
Formerly called Qualis, this is a “third-party” review system to determine whether the treatment your doctor is requesting should be authorized. The claim manager does not have to abide by the recommendation made by Comagine, but they often do.
Court of Appeals
If you or another party are dissatisfied with the results of an appeal to the Superior court, the next step in the appeal process is to petition the Court of Appeals for review. This court sits as a panel and reviews the decision of a lower court.
Declaration of Entitlement for Pension
The Department will send a letter once per year to pensioners to request they certify that they aren’t working and continue to be eligible for pension benefits. The letter is rather straightforward but MUST be returned to the Department or benefits will cease. When received, fill this form out immediately and take it to a bank or your attorney’s office for notarization.
The Director of the Department of Labor and Industries is appointed by the state governor. In certain situations you may be able to request the Director, under his or her discretion, to act outside of the normal rules and policies to accommodate extenuating circumstances in your claim. This may be waiving an overpayment or extending the time to complete a retraining program. These circumstances are rare but the option does exist for you to request the director’s intervention.
Functional Capacity Evaluation
This is an evaluation performed by a physical therapist to test the limits of your physical capacities. Often lasting up to 6 hours or longer, the goal of an FCE is to see what you can tolerate physically before a determination is made on your ability to work.
Independent Medical Examination
This is an exam performed by a doctor, generally at the request of the Department of L&I or a Self-Insured Employer for a variety of reasons, including rating exams, causal relation, and challenging the veracity of your doctor’s opinion. See this article for more information.
Industrial Appeals Judge
If your claim must be appealed to the Board of Industrial Insurance Appeals, an industrial appeals judge will handle the matter and make a decision on your case. This is the court that all appeals must first go through before reaching the Superior Court of Washington. This may involve full litigation with testimony, witnesses, depositions, etc., although many appeals are solved during a mediation process prior to full litigation, also with an IAJ.
If you’re receiving time loss or LEP payments from the Department but at the bottom of the payment order it states this is a temporary decision, it means the claim manager is delaying the ultimate decision on whether your benefits are actually due, but is opting to pay them in the meantime anyway rather than make you wait. This can be good if you’re trying to make ends meet while you recover from your injury, but bear in mind that the order will not become final after 60 days (the way a normal, determinative payment order would). This means that if your claim manager later decides you should have been paid benefits, she can issue an overpayment and you will owe the money back. If you see temporary order language on a payment and you don’t know why, call an attorney.
Kept on Salary
After a workplace injury that forces you to miss time from work, your employer may offer to continue to pay your regular wages while you’re off rather than have the state pay time loss. This is more common in higher-risk professions where employers may fight hard to minimize claim costs to prevent their insurance premiums from increasing. Rather than delve into potential ulterior motives for your employer paying your wages even though you’re unable to work, keep in mind that if your employer is giving you KOS, they are likely monitoring your claim very closely and may be active in trying to delay or deny treatment or otherwise try to minimize costs, potentially at the expense of your recovery.
An order created by the department that determines which emlployer(s) are liable for the injury – meaning which employer an injured worker was working for when they were hurt. This can be one or several employers in the case of an occupational disease claim where a worker may have done a similar job with several employers during the development of a condition (ie: a construction worker who develops shoulder problems after 10 years of work with more than one company).
Loss of Earning Power
If you’re able to return to work, but in a pattern less than you were prior to your injury (i.e. you were full-time before the injury but now your doctor says you can only work part-time) you may be entitled to LEP payments. The calculation is fairly complex, but you may be able to receive compensation for at least some of the difference between what you’re currently able to earn and what you would receive on time loss (TTD) payments.
Maximum Medical Improvement
This is the point at which your doctor (or an IME) determines that there is no further curative treatment for your condition.
This is the first conference at the BIIA level after an issue has been appealed and the claim consultant has decided to pass it on rather than issue a further order or, effectively, change the department’s position on the issue. The conference is between you or your attorney, a paralegal or attorney from the Washington State Attorney General’s office, a BIIA Judge, and possibly your employer’s representative or attorney. It’s a semi-formal phone conference where parties discuss the issues on appeal to see if there’s a resolution that can be reached without going on to litigation. Generally, as many as three conferences can take place in the course of approximately 90 days if the parties are making progress toward an agreement.
Medical Provider Network
The Medical Provider Network was set up by the Department of Labor and Industries approximately 10 years ago and dictates certain parameters for doctors to follow if they want to accept L and I insurance, and treat injured workers. There has been a fair amount of criticism about the medical provider network and its policies and many doctors across the state opted out when the network was created and decided to no longer treat injured workers because of it. If your doctor accepts L&I insurance then they are part of the Medical Provider Network. That doesn’t mean that they work for L&I or the state, it just means that they accept Workers’ Comp. insurance not unlike they would accept insurance from Premera, Blue Cross, Molina, etc.
An order accompanying and describing a time loss or permanent partial disability payment.
A pension, also referred to as Permanent Total Disability or PTD, is where your doctor determines that you are no longer able to hold gainful employment due to your industrial injury or a combination of preexisting and industrial-related conditions. If this happens you’re entitled to a check once per month for the rest of your life, and potentially for your spouse or dependents in the event of your death.
Permanent Partial Disability
This is a financial award you may be granted at the end of a claim if you have lasting disability from an industrial injury or occupational disease. The amount is a function of a doctor’s rating exam and the yearly statutorily set amount that a body part is “worth.” For example, in 2020 the amputation value of a leg was $128,553.86. If your injury resulted in a 10% impairment of your leg, your award should be $12,855.39.
Petition for Review
This is the process used to contest a proposed decision and order issued by the Industrial Appeals Judge after hearings have been conducted at the Board of Industrial Insurance Appeals (BIIA). The request for review goes to a three-member panel for review. If the review is not granted or is otherwise unfavorably treated, you can then appeal to the superior court.
If you’re unable to return to work at your job of injury or in other areas with which you have experience, due to restrictions placed on you by your doctor that are related to your claim, or a negative labor market survey conducted by a Vocational Rehabilitation Counselor (VRC), you may be eligible for plan development and retraining. For more on this, as well as AWA, VR, light duty work, and all things having to do with vocational services, please see our blogs about the vocational process, or call us.
Proposed Decision and Order
The decision of the IAJ at the Board of Industrial Insurance Appeals (BIIA). This decision can then be appealed to the three-person board at the BIIA, and then, if the matter is still not settled to the satisfaction of either party, it can be further appealed to Superior Court.
The first step in letting the department of L&I know that you disagree with a decision they have made. This must be in writing and reasonably calculated to say “no.”
Protest or Appeal Language
At the bottom of any determinative order issued by the Department, you’ll notice a block of text outlining your protest or appeal rights. YOU MUST abide by the timeline indicated (often 60 days but variable depending on the order) and protest or appeal IN WRITING if you disagree with the decision being made. If you do not act within 60 days according to that language, the issue becomes final and binding and cannot be undone.
Occupational Nurse Consultant
ONCs are nurses who work for L&I internally that review requests made for treatment or sometimes the causal relationship of conditions to your industrial injury.
Office of the Medical Director
The OMD reviews treatment requests, treatment plans, and acts as another oversight body at L&I.
If you are unable to return to your job of injury or to work via transferable skills, you may be entitled to retraining benefits which come in the form of two options. Option one involves you going to school at an accredited institution to pursue some sort of a certificate or training that will enable you to perform a job that your doctor approves. You can receive up to two years of school or training that costs a maximum of approximately $20,000 (this number fluctuates generally every year). You’ll also receive time-loss benefits during this retraining, and you’ll be checking in with your vocational counselor throughout the process. For more on this, as well as AWA, light duty work, and all things having to do with vocational services, please see our blogs about the vocational process, or call us.
If you are unable to return to your job of injury or to work via transferable skills, you may be entitled to retraining benefits which come in the form of two options. Option two involves the State Department of Labor and Industries setting aside a maximum of approximately $20,000 (this number fluctuates generally every year) for you to use on qualified tuition and expenses for up to five years after your claim closes. You’ll receive nine months worth of time loss benefits at the closure of your claim, but you don’t necessarily have to start school at that time. Additionally, you can work while you’re receiving this nine months of time loss benefits upon closure of your claim. If you don’t use the funds that are set aside for retraining within five years, you lose this benefit. For more on this, as well as AWA, light duty work and all things having to do with vocational services, please see our blogs about the vocational process, or call us.
An exam performed by your doctor, surgeon, or an IME that determines if there is any permanent disability or decrease in physical capacity related to your industrial injury.
Once a claim is closed and that closure goes “final and binding” (once 60 days have elapsed without protest) an injured worker can submit a reopening application if they can show that their industrially related condition is objectively medically worse than it was on the date of closure. Claims cannot be reopened for pain alone – there must be an objective way to demonstrate that the condition has worsened (often through imaging such as x-ray, MRI, etc., or other testing such as NCV/EMG). Within 7 years of the date of first closure, a claim may be reopened for medical treatment (if necessary based on the above) AND monetary benefits. After seven years, the claim may only be reopened for medical treatment.
Report of Accident
There are potentially three ROAs you may see in your file. The first is the injured workers’ report. This is what you would have filled out when you filed your claim. Depending on how you filed it (at the doctor, through your employer, or online) there may also be a doctor’s ROA and an Employer’s ROA. If you see these in your claim file and feel there are discrepancies, alert your claim manager or call an attorney.
If you’ve been found eligible for retraining benefits, you’ll be entitled to use up to the current maximum benefit allowed (this number changes generally each year). This amount is the same whether you choose Option 1 or Option 2.
Revised Code of Washington
The primary codification of the laws of Washington State.
An order created by the Department of L&I that dictates that a particular condition is not part of the claim because there’s no causation of the condition to the industrial injury.
Companies have the option of self-insuring for workers’ compensation in Washington. They have to post a large bond with the state and are generally subject to the same rules as the state in terms of coverage under the Industrial Insurance Act. The company pays and handles claims in-house (or often through a TPA) and does not pay the same rates to the state for insurance as “state fund” claims.
State Fund Claim
Unlike SIE claims where the employer has posted a bond and acts as their own insurer, state fund claims cover the rest (the majority) of work injury claims and are adjudicated by the Department of L&I directly with a claim manager, claim consultants, supervisors, in-house medical review, etc.
If you or another party are dissatisfied with the results of an appeal at the Board of Industrial Insurance Appeals, you must first petition the board for a review of the IAJ’s decision. If the board does not overturn that decision, a party made an appeal the matter to Superior Court. At this point, the record is closed for purposes of introducing new testimony, and the Superior Court judge can only review evidence that has been put into the record at the BIIA’s level.
Supreme Court of Washington
If you or another party are dissatisfied with the results of an appeal to the Court of Appeals, the next step in the appeal process is to petition the State Supreme Court for review. This court sits as a panel and reviews the decision of a lower court.
Temporary Total Disability
Also referred to as time loss, these are wage replacements you’re entitled to if you can’t work due to your industrial injury.
Third Party Administrator
These are companies that act as the Department of L&I on behalf of a self-insured employer. The company will employ a claim manager of their own to make decisions on your claim, request IMEs, authorize or deny treatment, payments, etc.
Third Party Representative
A company that handles L&I claims for an employer, often protesting decisions and actions taken by your claim manager, or otherwise trying to minimize claim expenses by challenging claim validity, treatment decision by your doctor, etc.
Traumatic Brain Injury
This happens when a sudden, external, physical assault damages the brain. It’s one of the most common causes of disability and death in adults. TBI is a broad term that describes a vast array of injuries that happen to the brain. Source: John Hopkins Medicine
A UR is created when Comagine is asked to weigh in on whether a treatment is “proper and necessary” on your claim. These documents will generally include a recommendation to either authorize the treatment or deny it based on certain criteria. If your claim manager bases a decision on a UR and you disagree, all is not lost. Watch for any orders or letters from your claim manager that contain 60-day protest or appeal language at the bottom of the page and keep this timeline! If you don’t, you will likely lose your right to request reconsideration from a higher-level authority.
Vocational Dispute Resolution Office
If you disagree with a vocational outcome or result by your vocational counselor, you can submit a request for review by the VDRO.
This is an early stage in the vocational process where a claim manager assigns a vocational counselor to your claim to look at your potential goals for returning to work, and the barriers present to those goals. Often this is assigned before treatment has even begun other than conservative care, so the process is supposed to be somewhat informal and not too demanding. For more on this, as well as AWA, light duty work, and all things having to do with vocational services, please see our blogs about the vocational process, or call us.
Vocational Rehabilitation Counselor
The Department of Labor and Industries will usually assign a VRC to your claim when your ability to work has been compromised by an industrial injury or occupational disease. The counselor should work with you, your doctor and your attorney to determine the best outcome possible for you within the framework of the Industrial Insurance Act, applicable RCWs and WACs, and L&I guidelines.
Vocational Services Specialist
This is the person a the Department of L&I that oversees vocational services and may act as sort of a supervisor of the vocational activity on a claim.
An order created by the Department of L&I determines your time loss rate. Generally, this is the hourly rate you were making, multiplied by the hours per day you worked and multiplied again by 22 days (the average working days per month). Things like employer-paid medical benefits, overtime hours, tips, bonuses, and housing allowances may be added upon verification. The time loss amount is set by taking 60% of that gross wage, then adding 5% for a spouse and 2% per child to a maximum of 75% of the workers’ gross wage.
Washington Administrative Code
Regulations of executive branch agencies are issued by the authority of statutes. Like legislation and the Constitution, regulations are a source of primary law in Washington State. The WAC codifies the regulations and arranges them by subject or agency.
Work Status Form
Formerly called a Worker Verification Form, you’ll be required by the Department of L&I to fill out one of these forms as often as every 30 days while receiving TTD to certify that you remain unable to work, and are not working while collecting TTD.