Common Errors In Workers’ Compensation Claims

Common Errors In Workers’ Compensation Claims

The law is favorable to injured workers in many ways.  However, most injured workers would not realize this because of the way their claims are (mis)managed by the Department of Labor & Industries and self-insured employers. Here are some of the most common mistakes we see in workers’ compensation claims. If you believe one or more of these mistakes have been made on your Washington State workers’ compensation claim, call us today for a free, no obligation, legal consultation.

Mistake (1) The Department or self-insured employer will improperly make claim decisions solely based on an “independent medical examination” (IME).

Many clients come to see us after their claim has been rejected.  This is typically on the basis that the Department or self-insured employer’s IME determined a medical condition was not caused by an industrial injury or occupational disease.  We can often get claim rejection orders overturned by getting an opinion from our client’s attending physician in response to an IME. By law, if a physician believes a patient has sustained an injury caused by a sudden and tangible event at work or by distinctive conditions of employment (such as repetitive heavy lifting or other repetitive use), the physician is required to file an application for workers’ compensation benefits.  Such is often sufficient evidence to establish the claim should be allowed because the law provides that the opinion of the attending physician should be given special consideration over that of a one time examiner — an IME.

Mistake (2) The claim manager or physician doesn’t consider the pre-existing conditions of the injured worker.

Another common reason clients call us is when their time loss benefits have been terminated or are about to be terminated, yet they remain unable to work.  Too often, the Department or self-insured employer terminates time loss based on the opinion of the IME physician that the worker is unable to work because of pre-existing conditions– not because of the industrial injury or occupational disease.  The law provides that in assessing a worker’s ability to work, we must consider the worker as a whole person with all preexisting conditions and infirmities. It is incorrect for the Department or self-insured employer to terminate a worker’s time loss based solely on consideration of limitations caused by the industrial injury or occupational disease, disregarding any pre-existing medical or psychological conditions.  We commonly get time loss reinstated for our clients by educating the attending physician of the applicable law and ask the doctor’s opinion of the worker’s ability to work based on a consideration of the worker’s whole person, with all pre-existing conditions and infirmities. The law makes common sense because the whole worker must be able to return to work, not just particular body parts. Therefore, it is imperative that in representing injured workers, we must learn the client’s medical history and all conditions that cause work restrictions or an inability to be vocationally retrained.

Mistake (3) The assumption that the industrial injury or occupational disease must be the sole or even primary cause of the worker’s inability to work.

Another common reason clients call us is when medical treatment is denied because the industrial injury could have also been caused by something other than work. This often happens with injured workers over the age of 35 because they can be said to have injuries or ailments due to ageing. The Department or self-insured employer may say that they do not have to authorize medical treatment because the injury could’ve been due to ageing or a previous injury unelated to work. Under the Washington State Industrial Insurance Act, a condition is considered causally related to an industrial injury if the injury was at least a “proximate cause” of or aggravation of the condition in question. The term “proximate cause” means a cause which in a direct sequence produces the condition complained of and without which such condition would not have happened. There may be one or more proximate causes of a condition. The industrial injury must be a proximate cause of the alleged condition for which benefits are sought, but the law does not require that the industrial injury be the primary or substantial cause of such condition, simply a proximate cause.