Claims Adjudication Tune-Up (CAT-U) July 2024 Edition
Welcome to Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter. This is where we share best practices and information, as well as highlight opportunities for improvement. The focus of this month’s edition of CAT-U is time-loss benefits.
Revised Code of Washington (RCW) Review: RCW 51.32.060(5) Minimum and Maximum Time-Loss
(5) In no event shall the monthly payments provided in this section:
(a) Exceed the applicable percentage of the average monthly wage in the state as computed under the provisions of RCW 51.08.018 as follows:
AFTER PERCENTAGE
June 30, 1993 105%
June 30, 1994 110%
June 30, 1995 115%
June 30, 1996 120%
Take away: This is why the Maximum Time-Loss Rates chart in Claims Management Tools covers dates of injury starting with July 1, 1996: all maximum time loss on and after that date is at 120% of the state’s average monthly wage.
(5) In no event shall the monthly payments provided in this section:
(b) For dates of injury or disease manifestation after July 1, 2008, be less than fifteen percent of the average monthly wage in the state as computed under RCW 51.08.018 plus an additional ten dollars per month if a worker is married and an additional ten dollars per month for each child of the worker up to a maximum of five children. However, if the monthly payment computed under this subsection (5)(b) is greater than one hundred percent of the wages of the worker as determined under RCW 51.08.178, the monthly payment due to the worker shall be equal to the greater of the monthly wages of the worker or the minimum benefit set forth in this section on June 30, 2008.
Take away: For injury/manifestation dates after 2008, there are two kinds of minimum time loss that you would want to check for. Use the “Minimum Time-Loss Rates” charts in Claims Management Tools to make the determination:
- A worker who has a time-loss entitlement that’s less than 15% of the state’s average wage (from page 2 of the chart) would get the chart amount, plus up to $60 for eligible spouse and dependents, as their monthly time-loss entitlement.
- When that monthly time-loss you calculated above is more than the worker’s total monthly wages, the worker instead gets as time-loss either 100% of their monthly wage OR the amount from the pre-
July 1, 2008 table on page 1 of the document.
Case Law - The Crabb Decision (2014): COLA and Maximum Time-Loss
Effect: A worker at maximum time-loss will receive the maximum time-loss rate even in a year when they’re not entitled to a Cost of Living Adjustment (COLA).
Background: Joseph Crabb was receiving time-loss benefits at the maximum time-loss rate. Since his 2007 injury, his entitlement rose to match the new time-loss maximum each July 1st. In 2011, the Washington state legislature passed a law amending RCW 51.32.075, effectively freezing COLA entitlements for 2011; no COLA adjustments were paid to workers for 2011.
When L&I also froze Mr. Crabb’s expected maximum time-loss increase in 2011 and kept it at the 2010 amount, he protested the decision. His case eventually made its way to the state Superior Court, where he argued that the 2011 freeze applied only to COLA increases since that was the only law changed. The department argued that the legislature’s amendment to the RCW suspended any 2010 increase in benefits, and that the 2010 maximum time-loss increase was equivalent to the frozen COLA increase.
The Superior Court sided with Mr. Crabb’s argument. They determined that entitlement to maximum time-loss benefits would not be affected; Mr. Crabb was entitled to the 2011 increase in maximum time-loss benefits.
Claim impact: If a worker is at maximum time-loss entitlement, they are entitled to be paid for the increase beginning on the first July 1st after their date of injury. For example, a worker injured on January 1, 2017 and receiving regular time-loss would keep receiving the same date of injury time-loss rate payments until July 1, 2018 when they would first become eligible for a COLA increase. The same worker, if they were at time-loss maximum, would receive the new maximum time-loss amount on July 1, 2017. Only the COLA recipient has to wait until the second July 1st.
More reading/resources:
RCW 51.32.090(9) “Temporary Total Disability”.
Self-Insurance Claim Adjudication Guidelines, Time-loss chapter, “Maximum Time-Loss Compensation Rate”, and “Cost of Living Adjustments”.
Self-Insurance 2024 Quarterly training: “Time-Loss” August 14th and November 6th (check out What’s New in Self-Insurance, or sign up for our email bulletins to get reminders for registration)
Reminders/tips from the SI teams:
Within five days of starting time-loss compensation, the self-insurer must send the Start, stop, or Deny Compensation Benefits template (form F207-225-000) to the worker. If it has not already been done, the self-insurer must also send the Calculation of Monthly Wage as a Basis for Time-Loss Compensation template (form F207-227-000) to the worker with a copy of the SIF-5A. Also, a copy of that Starting Benefits template must be sent to the department, along with the SIF-2. You can find this and more information about what to send to workers and when in Washington Administrative Code (WAC) 296-15-425 “Communicating to injured workers during the course of the claim”
Remember also that once the worker starts getting paid benefits beyond medical bills such as time-loss or LEP benefits, an appropriate request for allowance, interlocutory, or denial must be made to the department. See the Claim Validity chapter of the Claims Adjudication Guidelines for more information on making those requests.
For more information, email: SITrainerQuestions@lni.wa.gov
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