Claims Adjudication Tune-Up (CAT-U) June 2024 Edition
Welcome to Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter, where we share best practices and information, as well as highlight opportunities for improvement. The focus of this month’s edition is claim validity.
RCW/statute or WAC/rule: WAC 296-15-420
This Washington Administrative Code (WAC) provides rules for requesting Washington State Department of Labor & Industries (L&I) to issue Allowance, Interlocutory or Denial orders. When addressing claim validity, the self-insured employer (SIE) must request one of these orders within 60 days of claim receipt (with the exception of allowance orders for medical-only claims).
Allowance: Send in a completed Claim Allowance Request form, a copy of the SIF-2, and SIF-5A.
Interlocutory: These orders provide the SIE with an additional 30 days, beyond the initial 60 days, to reach a final validity determination. If after 90 days the SIE needs more time to reach a validity determination, they may request a further 30-day extension. One 30-day extension may be requested for injury claims and two 30-day extensions for occupational disease claims. When requesting an interlocutory order or extension, the SIE must provide a good cause reason for the request, a completed Interlocutory Request form, and a complete copy of the claim file (excluding bills).
Denial: If a SIE determines that a claim should be denied, they must request denial by sending L&I a completed Claim Denial Request form and a complete copy of the claim file (excluding bills). Additionally, the SIE must notify the worker that they sent L&I a denial request.
Case Law: Longview Fibre Co. v. Weimer
This case clarified the definition of an injury to include the result of an ordinary bodily movement, performed in the course of employment. In this case, Weimer, felt a sharp pain in his lower back as he bent over to pick up an item at work. Weimer’s provider testified that the act of bending over at work aggravated his underlying back condition. The court ruled:
“A back injury precipitated by a bodily movement during the course of employment constitutes a compensable injury within the meaning of the industrial insurance act (RCW Title 51) regardless of whether or not it occurred as a result of an unusual or awkward angle of the body or involved unusual exertion. ... An internal bodily injury caused by a bodily movement made in response to a requirement on the job is, as a matter of law, compensable under the industrial insurance act, even if the injury only aggravates a preexisting condition.
This case overruled the requirement set in the Boeing Co. v. Fine case that the worker demonstrate that their injury resulted from doing work at an unusual or awkward angle.
Reminders/tips from the SI teams:
- When determining if an injury occurred in a parking lot, have the worker show on a map (or schematic) where the injury actually occurred. By doing this, you will be able to determine if the area, where the worker was injured, meets the definition of an area where parking would occur. For example, a crosswalk from a parking space to the worksite would not constitute a parking area, as cars are not expected to park on the crosswalk.
- Under RCW 51.32.090(7), injury/manifestation occurring on or after June 6, 2024 are entitled to time-loss compensation or loss of earning power for the first three days following the injury, if the worker is disabled on the 7th day. For workers injured prior to June 6, 2024, the first three days are only payable if disabled on the 14th day. Attempts to return to work do not break the continuity.
For more information, email: SITrainerQuestions@lni.wa.gov
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