Claims Adjudication Tune-Up (CAT-U)
November 2024 Edition
Welcome to Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter. This is where we, at Washington State Department of Labor & Industries (L&I), share best practices and information, as well as highlight opportunities for improvement. The focus of this month’s CAT-U is Self-Insured employers’ authority to close claims.
Washington Administrative Code (WAC) Review: WAC 296-15-450
Per the WAC subsection(2), the self-insured employer has the authority to close all claims filed on or after 08/01/1997, with or without time-loss, unless:
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The department has issued an order resolving a dispute; OR
- The worker did not return to work with the employer of record at the same job or at a job with comparable wages and benefits; OR
- Closure was based on a medical report and that report was not sent to the attending or treating doctor with 14 days allowed for a response.
The take away: If any one of these requirements is not met, you must request closure from L&I.
What is a dispute? In this context, dispute means a ‘disagreement’ or ‘argument.’ It includes orders resolving worker requests for L&I intervention and protests to orders issued by L&I or the employer. A dispute does not include orders issued to accept or deny claim reopening or to allow more time to investigate validity (interlocutory orders).
What qualifies as Return to Work? To meet the requirements for employer closure, the worker must have returned to work for the employer of injury at their original job, or for the employer of injury at comparable wages and benefits (at least 95% of wages and benefits received at the time of injury). Selecting ‘yes’ on the Claim Closure Request form (CCR) means you’re saying that the worker has returned to work based on these requirements.
What is a closing medical report? Closing medical must address all mental and physical conditions, any permanent restrictions, and any ratings for Permanent Partial Disability (PPD). If this report is not created by the attending provider (such as an independent medical examination, or IME; or closing report by a concurrent provider), it must be sent to the attending provider for review, and 14 days given for a response.
This requirement to share the closing report with the attending provider applies even if the intention is to ask L&I to close the claim, per WAC 296-15-450(4).
Communicating Closing Orders: To Whom, and When?
Under WAC 296-15-450(5), the self-insurer must send the closing order to the worker and attending or treating provider. This is true whether it’s a medical-only closure, time-loss closure, or PPD closure.
Medical only closures must be submitted to the department by the end of the month following closure.
All other closures (time-loss and PPD) must be submitted to the department at the time of closure.
Effect: A closing order that is not communicated to the worker’s attending provider (AP) cannot become final for any party.
Background: Kelly Shafer’s claim was closed by L&I order in 2003. A copy of that order was sent only to Ms. Shafer; no copy was sent to her attending provider, Dr. Cook. That same year, Ms. Shafer’s request to reopen her claim was rejected. She appealed, arguing that the closing order was never communicated to the attending provider as required under Revised Code of Washington (RCW) 51.52.050.
The Washington state Supreme Court’s published 2009 opinion found that the closing order never became final for any party, since the attending provider did not receive a copy. The opinion states, ‘…we conclude that a worker’s claim is not closed until the attending physician has received a copy of the closure order. This holding is justified by the role the attending physician plays in the claims process…’
Claim impact: The Shafer decision is clear, and specific to closing orders and attending providers. A closing order that is not communicated to the AP will not become final for any party to the order. One remedy would simply be to send a copy of the order to the AP. The order would then become final 60 days from communication of the order to the AP.
More reading/resources:
Reminders/tips from the SI teams:
What if there is a pending dispute or protest at time of employer closure? While L&I may not yet have issued an order to resolve a dispute, the existence of a dispute or protest that will result in a further department order means the employer will have no authority to issue a closing order for that claim. This is the case even though the department would not yet have issued an order to resolve the dispute. Any employer order issued in these circumstances would likely be found null and void by the department, and the department would need to issue its own closing order.
Does my closing order need to be translated? Yes – you should send claim-related communications, such as templates, forms, and letters to the worker in the worker’s language of choice. This is part of ensuring a means of communicating with injured workers per WAC 296-15-350(9). For convenience, the department has translated employer closing orders into the eight most-frequently-requested languages. From the department website's Forms and Publications page, search for “Self-Insured Closure” for closing order forms, and then select the language you need from the “Other Languages” drop down to download the order. Note that you will need to issue the order in both English and the preferred language.
For more information, email: SITrainerQuestions@lni.wa.gov
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