Medical Treatment in a Workers Compensation, Industrial Injury, or Occupational Disease Claim

There are often stumbling blocks placed in front of injured workers when they’re trying to get medical treatment.

Some of the Obstacles Can Include:

  • That the condition being treated is not proximately caused by the Industrial injury/disease;
  • That the treatment proposed is not reasonable and necessary;
  • That the Industrially related conditions have reached maximum medical improvement.

Employers, and sometimes the Department of Labor and Industries, will go to great lengths to try to establish that a current condition is not proximately caused by the Industrial injury. They will often arrange their own independent medical exams. In the course of these exams opinions can be raised that a condition was “pre-existing” or is “due to aging”.

What Constitutes an “Industrially-Related” Condition?

What the employer’s doctors and the Department doctors often forget, is that under Washington law, if a pre-existing condition was not symptomatic, and is made symptomatic by the effects of an injury, thereafter it is deemed to be Industrially related. This can be a complicated medical legal issue and often requires the help of an attorney to resolve.

Do not let the Department of Labor and Industries, or an employer, under value your claim, or deny benefits because of allegations of pre-existing conditions or age-related conditions without consulting an attorney first.

Guidelines May Differ

The Department of Labor and Industries has its own guidelines for determining whether or not some surgeries are “medically proper and necessary treatment”.  However, their guidelines are not the same criteria that a reviewing court would use. The Board of Industrial Insurance Appeals has different criteria and this can result in overturning the Department’s decision and getting treatment that the Department or Employer had denied.

Generally speaking, an Industrially related claim is only ready for closure when the condition and disability are best characterized as being essentially permanent, fixed and stable, that is, with or without treatment, the condition will be enduring and that no fundamental or marked change will be otherwise expected.

Proving the Necessity of Medical Treatment

Often Employers and/or the Department may argue that certain treatment measures are not covered because they were not “pre-authorized”. While the Washington administrative code would indicate that certain procedures are to be pre-authorized, the Board of Industrial Insurance Appeals has, in many instances, forced the Department and/or Employers to pay for those procedures so long as it can be shown that the treatment was medically proper and necessary. Again, the help of an attorney can be tantamount in such situations.

Have More Questions?

There are often questions that come up as to whether or not the treatment is curative or palliative. Each of these terms has a particular meaning and effect on whether or not you can get the treatment paid for or authorized. You should consult an attorney if you are having problems getting your treatment authorized.