Claims Adjudication Tune-Up (CAT-U)
September 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 Reopenings.
Revised Code of Washington (RCW) 51.32.160“Aggravation, diminution, or termination”
(1)(a) If aggravation, diminution, or termination of disability takes place, the director may, upon the application of the beneficiary, made within seven years from the date the first closing order becomes final, or at any time upon his or her own motion, readjust the rate of compensation in accordance with the rules in this section provided for the same, or in a proper case terminate the payment: PROVIDED, That the director may, upon application of the worker made at any time, provide proper and necessary medical and surgical services as authorized under RCW 51.36.010. The department shall promptly mail a copy of the application to the employer at the employer's last known address as shown by the records of the department.
Take away: This RCW authorizes the director to reopen a claim for benefits (including time-loss, loss of earning power, permanent partial disability, etc.) if the worker files within seven years of the date the first closing order became final. In this case, compensation refers to benefits other than medical: time-loss, loss of earning power, permanent partial disability, etc.
(1)(c) Applications for benefits where the claim has been closed without medical recommendation, advice, or examination are not subject to the seven-year limitation of this section. …The time limitation of this section shall be ten years in claims involving loss of vision or function of the eyes.
Take away: Reopened claims that were closed without “closing medical” may be reopened for all benefits, regardless of how long they’ve been closed.
Reminders/tips from the SI teams:
Watch Out for Over Sevens/Tens!
Be careful to recognize claims that are over seven (or ten) years old before you start paying time-loss benefits. A claim with a reopening effective date that is over seven years* from the date the first closing order became final is not eligible for time-loss, loss of earning power, vocational or permanent disability benefits. Only the director of the Washington State Department of Labor & Industries (L&I) has the discretion to authorize these payments. If that happens, the worker and employer would receive an order clearly granting the specific benefits authorized. For more information, see the “Reopening Applications on Claims Closed Over 7 Years” section in the Claim Adjudication Guidelines Reopenings chapter.
Medical Received on a Closed Claim: What to Do.
A medical bill, chart note, or medical form such as an Activity Prescription Form received after a department or employer closure must be reviewed carefully to determine whether action needs to be taken. Depending on the claims closure status, it could prompt a reopening of the claim, a protest to closure, or both! Or, it could simply be a bill needing to be paid.
Medical with a date of service after the mailing date of the closure order may be a protest if the order is not final, even if it does not say so directly. A service date that is after the closing order becomes final could be an attempt to reopen the claim. In either case, there are specific and timely actions that the department must take in response. Don’t start issuing payments or authorizing treatment unless the claim has been reopened.
Fortunately, action to be taken is simple. First make sure the incoming document has been stamped with the date received, as required by WAC 296-15-350, and the L&I claim number is on the document. Then fax or mail it to the department. It’s best to do this within five working days of receipt, even if it’s not clearly a protest to ensure compliance with WAC 296-15-480.
For more information, email: SITrainerQuestions@lni.wa.gov
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