muse riding Pegasus

Five Common Workers’ Comp Myths and Facts

It is no secret that Washington state has very complex workers’ compensation laws—even a seemingly straightforward claim can become complicated under closer examination. This is frustrating for employers, especially when they have information that could assist in the claims process but aren’t sure if they should provide it or what their next step should be.

To provide clarity amidst all of the complexity, here are five common myths and facts that can help you navigate the intricate world of workers’ compensation claims.

Myth #1: Questioning the validity of the claim will get it denied.

Fact: In Washington state, the Industrial Insurance Act and workers’ compensation laws are clear, indicating “the law is liberally construed in favor of the injured worker.” Meaning, employers who question the validity of a claim, any diagnosed condition on a claim, or who question any benefits a worker may receive in a claim must prove why these are not valid or why the worker is not entitled to those benefits. This requirement of proof can be discouraging for employers, which is why we always recommend employer diligence with performing their investigations into alleged incidents. We also advise employers to keep clear and concise records of their injured workers when they receive notice of a work-related incident occurring and a workers’ compensation claim is filed. Sometimes these records can assist in determining whether a claim is allowed or denied, and they can also assist in the future management of the claim. Remember, if you question the validity of a claim or a benefit an injured worker may be receiving on behalf of the claim, you will need to have documentation to support your question and/or protest.

Myth #2: If they have been given work restrictions, an injured worker is required to return to work immediately.

Fact: There are specific guidelines in Washington state to satisfy what is considered a formal modified duty job offer. In most cases, employers can quickly identify some form of modified duty. They can verbally offer this to the worker without their formal medical provider’s review and approval, and the worker returns to work. However, if the injured worker does not want to return to work without their medical provider approval, they can refuse to do so, and be eligible for time-loss benefits through their claim. If a worker provides you with documentation indicating they have been released to modified work, you are still required to create a modified duty job description. Their attending medical provider must approve that modified duty job description before proceeding. Only after this occurs, can you then formally offer this approved job to the injured worker in writing. Please note that even if your injured worker returns to work without medical provider approval, we recommend you follow the process.

It is best to ensure the worker’s medical provider is aware of what you are asking the injured worker to perform and protect the employer’s interests from a financial and human resource standpoint. Also, it is in the best interest of both the employer and the injured worker to return to some form of modified work as soon as possible after the occurrence of a work-related injury/illness occurs. However, the injured worker is not required to return to work, if you do not follow the appropriate steps.

Myth #3: A prior injury or pre-existing condition of the same/similarly injured body part cannot be allowed on a claim.

Fact: It can be frustrating to know your injured worker may have been injured before or may even have a pre-existing condition to the same body part they injured while performing their job duties. Typically, the workers’ compensation insurance carriers in Washington will require medical documentation to support if a medical condition is either related to and/or aggravated by the original injury/exposure that was filed. One problem with this occurs when a worker has never sought medical treatment for the same and/or similar medical condition. The insurer, then, has no information to make a comparison of the state of the condition before the claim versus after the claim was filed.

Another problem is when the injured worker has sought medical treatment in the past for the same and/or similar non-work-related condition. And if it were not for the injury/exposure occurring at work, the condition would not have worsened and caused the need for the worker to seek further medical treatment and to file a claim.

Yet, another scenario is where the worker may have had a pre-existing condition which they may or may not have sought prior medical treatment for in the past. They then contend that this condition is related to the claim because of over-compensation for the original condition(s) for which the claim was filed. Consequently, it is essential to secure an expert medical opinion to assist in making that determination. Securing medical opinion can clarify if it is a new condition related to the claim and/or if it is a temporary or permanent aggravation to a pre-existing medical condition.

Myth #4: An employer must allow an injured worker to take time off to attend medical appointments and/or therapy visits while their claim is open, or they will be eligible for benefits through the claim.

Fact: The Department of Labor & Industries (L&I) is clear concerning this matter. In most instances, if an injured worker has been released by their medical provider to full duty at their job of injury, or has been formally offered a light-duty job approved by their medical provider, L&I instructs injured workers to schedule their appointments outside of their work schedules. This ensures they can continue to work up to their full schedule of hours that they are available to work. If the injured worker cannot do this, they are then instructed to attempt to work with their employers to make up the time they miss due to attending these appointments by extending their work hours on that day or working extended hours on a different day. If the worker cannot accomplish either of those options, they may either use their earned sick and/or vacation benefits to make up the time missed. Finally, if none of these options can be executed, the worker would then still be required to attend their appointments but would not be paid for any time missed by either the L&I or the employer. There are only two exceptions to these instances:

  1. The worker’s attending provider excuses the worker from being at work to attend appointments or therapy visits, or
  2. L&I has scheduled an appointment for the worker to attend (i.e., Independent Medical Exams or Functional Capacity Exams).

When this occurs, L&I will consider paying the worker to attend these appointments, or the employer has the option of paying the worker 100% salary for the day(s) missed.

Myth #5: An employer can pay for a worker’s medical bills for any on the job injury or exposure instead of filing a claim.

Fact: Washington laws are strict when dealing with this issue. An employer is not allowed to pay for any billing related to the treatment and/or services rendered by a medical service provider for a condition or exposure, which is considered work-related. Although it may sound simple, it is regarded as a form of fraud. There are many instances where employers feel the need to pay for these services because they want to assist their injured workers whenever they can. Examples of these instances may include but are not limited to:

  1. The injured worker may have complications in actually filing their claim with the insurer;
  2. The injured worker may have issues with their medical service provider not wanting to bill the insurer directly due to fee schedules not allowing the provider to receive the full cost of the treatment and/or services;
  3. The injured worker’s claim may have been denied;
  4. The medical service provider that the injured worker sought medical treatment with or received claim-related services from never billed the insurer within one year of claim closure and is now requesting payment from the injured worker.

Under all these circumstances, it is in the best interest of the injured worker to work directly with the insurer and the medical service provider to determine if there is a way for these bills to be paid directly by L&I.

These are just five of the common myths and facts within the complex world of workers’ compensation claims. If a claim isn’t managed effectively, the consequences can be expensive and lasting. Archbright’s claims team will actively manage your workers’ comp claims from beginning to end for you. We help keep your costs down while ensuring appropriate care for your injured employee. Contact us to find out how we can help.

nv-author-image

Amy Fregia

Amy Fregia joined Archbright as a Senior Claims Examiner in 2003. She has worked in claims for 25 years in a variety of industries. She is a Washington State Certified Claims Administrator of the Self-Insured Program and has held a WWCP Professional Designation since 2004.