Claims Adjudication Tune-Up (CAT-U)
May 2024 Edition
Welcome to the first issue of Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter. This monthly newsletter will share best practices and information, as well as highlight opportunities for improvement. The SI training team puts the newsletter together with input from the SI teams. Every month, expect to see general information highlighting statutes, rules, and case laws, along with “reminders/tips” that highlight common areas of concern identified by our teams.
RCW/statute or WAC/rule: WAC 296-15-425
This Washington Administrative Code (WAC) provides rules for communicating with injured workers during the course of a claim. It highlights the use of L&I-developed templates that are used in the time between claim allowance and closure.
The five instances when an employer must send a department-developed template include:
1. When calculating the worker’s monthly wage (SIF-5A).
2. When starting, stopping, or denying time-loss or loss of earning power.
3. When accepting or denying a new condition.
4. When authorizing or denying treatment.
5. When assessing an underpayment or overpayment.
In addition to providing vital claims communications to injured workers, these L&I-developed templates also inform workers of their right to file a dispute if they disagree with an action taken on their claim. If the department receives a dispute to one of these templates, the department adjudicator will review the relevant documentation and issue an order addressing the issue.
Case Law: Cockle vs Department of L&I (2001)
This landmark case clarified the definition of wages. It decided that an employer’s contribution to health care benefits on the date of injury was part of the worker’s wages under RCW 51.08.178. The court ruled that when an employer pays for these benefits, the employer’s actual contribution to the worker's health care benefits at the time of injury must be included in the worker’s wage calculation. The Court concluded that when an employer stops contributing towards a worker’s health care benefits after an injury, the time-loss compensation rate will increase to compensate for the lost contribution.
Dept. of L&I v. Granger 2007 added that a worker’s wage calculation must include health care benefits when the employer was making the contribution at the time of injury, regardless of the worker’s eligibility for the benefits.
Reminders/tips from the SI teams:
1. When an employer’s contribution to a worker’s health care benefits ends, make sure to adjust the ongoing time-loss rate to include health care benefits. If a process is not already established, you are encouraged to develop a system by which employers can notify third-party administrators when health care contributions end.
2. Ensure that all claim related documents, whether provided to the worker, provider or department, include the department’s claim number, in adherence to WAC 296-15-350 (7).
For more information, email: SITrainerQuestions@lni.wa.gov
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