How and When to Reopen your Claim
A L&I claim may be reopened within 7 years from the date the first closing order becomes final, for full benefits. That means, time loss, medical benefits, vocational services, disability awards, all benefits that are available under the law. If it has been more than 7 years since the claim was first closed, the claim may be reopened for medical benefits only. The Director of the Department has discretion to provide full benefits in certain circumstances in these ‘over 7’ reopenings.
Keep in mind, the time limit is 7 years from first claim closure, not the date of injury, not the date you returned to work, not the date the final installment of any PPD was paid. If a closing order was protested or appealed, and ultimately set aside, that is NOT the first claim closure. You are looking for the first final claim closing order. That is the start of the 7 year clock.
In a nutshell, a claim will be reopened only where there is medical evidence, based on objective medical findings, that the industrially related condition has worsened, or become aggravated, since the claim was closed. Your own subjective descriptions of increased pain, loss of function, or inability to work are not enough. A claim can not be reopened solely for vocational services. The Department is looking for increases in objectively measurable findings. Worsening in measures of atrophy, nerve damage, degenerative changes, muscle wasting, range of motion, sensation. Worsening which is evident on MRI, CT scan, EMG. I tell clients, we are looking for concrete, objectively measurable changes in their work related condition.
Reopening requests, or aggravation applications as they are sometimes called, should be forwarded directly to the Department, even if your employer was self-insured. There is an actual form, which you can get here:
http://www.lni.wa.gov/FormPub/Detail.asp?DocID=1591
However, an informal written requests, with or without supporting medical information, will start the ball rolling. If there is such an informal request, the Department will forward you the reopening application to complete. There is a portion of the form for you and a section for your medical provider to complete.
You can go to any medical provider to complete a reopening application. If you had a good relationship with the physician who treated you while your claim was open, that is a great place to start. Your primary care provider is ok, an appropriate specialist may be even better. If you have a copy of the closing medical report, take it with you. This will help the physician in comparing your current findings on exam to those at the time your claim was closed. The medical provider will be paid by the Department for performing the exam and completing the paperwork, whether the claim is ultimately reopened or not. If the physician recommends a diagnostic study to complete the exam, the request should be forwarded to the Department along with the reopening application. The Department will approve many diagnostic procedures in order to gather all the medical information necessary to review the reopening application. Again, if the Department authorizes such a study, they will pay for it. The Department will likely schedule you for a medical exam, called an Independent Medical Exam, or IME. (We can discuss some other time whether there is anything ‘independent’ about these exams)
When in this process should you talk to an attorney? There is no hard and fast rule, although I tend to be in the ‘earlier is better’ camp. The Department will issue an Order either reopening the claim or denying the application. You can protest or appeal a denial, and an attorney will most definitely be helpful, if not indispensable. However, earlier involvement has its up side. An attorney with a good relationship with the Department can nudge a claims manager in the right direction, help make sure all necessary diagnostic studies have been done (on the Department’s nickel), help the attending physician articulate the objective findings which have worsened or respond coherently to an IME report. It is, of course, quicker and less expensive if your claim can be reopened without having to litigate the matter. Getting an attorney involved early in the process will only serve to make sure all possible avenues are being examined before the Order is issued.
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I am truly searching for direction. My claim seems to be stalled. Some of your information is giving me a much needed insight.
Thank You,
Marion
I slipped on wet floor at work. Tore shoulder rotor cuff and ligaments. Three months later lower back problems started.
L&I doctor would not suggest any tests at their costs. I have been to emergency 3 times. Now in process of independent exam. Spoke with claims manager who told I could go in for 12 additional shoulder sessions. They did pay for MRI but I believe will not work with me for back. What else can I do?
Unfortunately, there is one key piece to the puzzle which you did not mention. Does your attending physician believe the low back condition is related to the fall at work? At a very basic level, it does not matter what you or I believe. Without medical evidence of a causal relationship between your fall and your low back complaints the Department will not accept the diagnosis under the claim, and will not be responsible for treatment. If, on the other hand, your treating orthopedist will state that, on a more probable than not basis, the fall injured your back, or even aggravated a pre-existing condition, then we have something to work with. I would suggest a careful review of your chart notes or emergency room reports to look for any mention of back pain, stiffness or symptoms. When did this first show up in the medical records? Talk to your medical provider about the mechanism of your fall, how you landed, when the symptoms started, and how they progressed. All of this information is important for the medical provider to have in order to formulate an informed opinion on whether the condition diagnosed in your low back is causally related to your fall at work. Again, with medical evidence and testimony we have something to work with to help get the condition accepted under the claim and treatment authorized.
In 2005 I began having trouble with elbows, due to repeative lifting. A claim was eventually opened, but for a year my employee had me to countinue to do same job. After therapy failed to help, I then had elbow surgery by a general orthopedist. I didn’t recover well and an IME Dr. recommended a more involved operation and referred me to a Hand Surgeon. After that surgery my wrist became very painful and my hand surgeon sent a request to my claims manager for a bone scan and a MRI arthrogram on my wrist. These ended up being requested 2 different times and I would call and leave messages to check the progress. Nothing was ever approved and my claim was closed. I appealed and was finally granted a mediation hearing. It was agreed on that I should get the diagnostic tests done.(14 months of pain since the first request.) It turns out I have a tear in the cartiledge in my wrist with degenerative changes. I have a phone conference next week with the judge and my employers hired attorney.I still would like to get my claim reopened. There is surgery to correct this problem. This is my dominate extremity. I’m feeling like I need to get some support from an attorney. Should I wait to see what the attorney has to say then set up a meeting with someone from your office? I have a lot of paperwork that you might be interested in. P.S. My employer is privately insured.
With the information in hand from the recent diagnostics studies the employer’s attorney may be willing to agree to set aside the closing order and send the claim back to the Department for treatment and benefits. If they are not willing to do this, you should definitely contact an attorney for help. By the way, your rights are the same whether your employer is self-insured or not.
Hello, I injured my lower back, (2 herniated disc’s), in 2003 and spent 2 years dealing with L&I, doctors, therapists, specialists and even an accupuncturist. After a long, (2 year’s), and frustrating battle my claim was closed with a small settlement and me being declared with a permanent, partial disability of the injured area.
I have suffered with this since then and just recently re-injured the same discs to the point of seeking medical attention for the pain and lack of mobility.
Am I allowed to re-open this claim since it is an old injury rearing it’s ugly head?
And what are my rights as far as treatment goes? I am not seeking any type of compensation other than whatever medical treatment I may need. Also, I am no longer employed with the employer that this was filed under at the time of my injury as they “let” me go after the case was closed.(they were a privately insured school district)
thank you so much!
Teri
You can file an Application to reopen your claim, and if the claim is reopened you may receive both medical treatment and time loss, if appropriate. Although, I noticed you said you “reinjured” your back. If your condition was made worse by a new injury, this is a new claim –assuming you reinjured it at work. A Reopening Application is more designed to cover those situations where the condition has worsened over time, with no intervening event, accident, or injury.
my husband applied for ssdi in 2007 .
6/24/09 . he went to the ssi office today to see if he could followup and get ssdi now that he is 65 . they told him he was “all set” in 2007 they said they sent a 30 and 60 day letter and never got a reply . so, they said now there is nothing he can do.
he has not worked , he still is disabled . how come he cannot appeal , or re apply. ??????
what can we do
My hubby injured his knee at work and work cover closed the claim cuz my hubby found work elsewhere. We had scans etc done and there was a lot of fluid and swelling etc, but no one could operate. The swelling went down and the pain became bearable but just in the last week it has flared up in the same spots again and we just need some advice on what we can do. We just want our lives to go back to normal! Work cover QLD discust me, they said even if nick lost his leg, too bad soo sad deal with people are out there working with out arms too just be greatful! what a load of rubbish. Can anyone offer insight. beckelljess@hotmail.com
Hard to tell from the information provide – but my best advice would be to return to an orthopedist, get a full exam of the knee, and file an application to reopen the claim if there is an objective worsening of the work related condition. It may very well be that the condition is worsening over time, and is now in need of treatment.
Hello, I have had a lower back problem for sometime now, the claim was closed 2 1/2 years ago. Last year, I was feeling better and was working when it had snowed out and twisted with some ice melt on my shoulder and felt the pop again. I had a MRI and a spinal injection, witch helped a lot might I add, I had an IME and he said that it was at MME and that I was never going to get better and to learn to deal with what I have without medication for pain management, he then told me that it was closed last time with a PPD and I was settled with some small award, my question is, will they award again for this injury or what is the rule’s for awards. I was only wanting to get better but if they are going to close it at the same category as last time they should pay me for the disablility, Right? Or will they look at it as if they have already paid for this once and won’t do it again?
I am confused on this and really appreciate any help that you can give me.
It sounds as if your low back claim was closed with a small Permanent Partial Disability (PPD) award, and that you have a new claim or reopened your first claim as the condition had worsened. If your condition is again at maximum medical improvement (MMI) the Department will issue an order closing the claim. The first PPD award you received acknowledged you did have some permanent disability from your work injury. For this discussion let’s say it was a Category 2 impairment, which is 5% of TBI (total bodily impairment). It is assumed you still have this level of impairment. You will only receive an additional PPD award if your current level of impairment is greater than what you have already been rated and paid. If your current impairment were rated as Category 2, you would not receive an additional PPD award when the claim is closed. If your current impairment were rated as a Category 3 or above, you would receive an additional PPD award when the claim is closed. Hope that answers your question.
I have a son who had a eye injury on the job, that has left him with a blind spot and catracts, and the eye surgeon says more then likely when he gets older he will be blind in that eye. He is 25 and his goal was to get his CDL to drive truck, that now is not possible because the eye is worse that 20/40 and is not correctable with glasses. Does L&I pay for any education for a different career, that he can do with is vision? the Doctors say he was the 3rd worst eye injury in WA, and can’t believe he has any vision at all in the eye.
Just a worryed mother!
Whether or not your son receives any assistance from L&I for retraining depends on a number of factors. Assuming your son is not working, and is unable to return to work at his job of injury, the Department will assign a vocational counselor to his claim. That vocational counselor will conduct an Ability to Work Assessment. The outcome of that assessment will determine whether further vocational services, including retraining will be made available. In a nutshell, vocational services are only provided where an injured worker can not return to their job of injury, and does not have the transferable work skills to obtain any work within their physical restrictions. If your son has questions or concerns he should talk to an attorney.
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What happens when you have received a PPD award and your condition get worse. It’s only been a year since they closed my case. Can I still reopen?
It does not matter if you received a PPD award when your claim was closed. You can still file a reopening application. I would suggest you return to your attending medical provider for the claim and get an updated medical evaluation of your industrially related conditions. There must be objective findings on exam that your condition has worsened since the date of claim closure. Have your physician help you complete the reopening application, there is a portion for each of you to fill out. If your physician believes diagnostic studies are necessary to fully evaluate your condition they should contact the claims manager for authorization. There is no specific rule of thumb that certain conditions worsen or not within certain periods of time. Medical conditions are as individual as you are, and you won’t know if your condition as objectively worsened until you get a thorough medical exam.
Hi Terri, I have moved to another state since my claim was closed. Am I able to have another Doctor evaluate my current condition where I live now? I was told my next step would probably be a fusion, which I have been putting off till now. Thank you, Denny
You can get medical treatment wherever you are – the trick is finding a medical provider. The medical provider needs to get an L&I provider number. This is easy to do. The provider should call the provider hotline 800-848-0811 to get instructions. If you see a medical provider who does not have a provider number, the provider cannot get paid, and the department will not recognize them as your attending provider. You may be able to find a medical provider in your area who already has a provider number by calling your claims manager and asking for a list of local providers. You can then contact these providers and see if they are willing to see you. If a provider already has a number, this means they have treated a Washington state injured worker in the past, but it doesn’t necessarily mean they are willing to do so again. I’ll be honest, sometimes it is really hard and time consuming to find an out of state physician, especially a specialist like an orthopedic surgeon. Just keep making calls. Ask the front desk at the providers office to call the Department. Most of the time, if they do, they’ll find out the reimbursement rates are respectable and the processes isn’t too onerous.
Once you find a new physician, you’ll need to have that first evaluation and file an Application to Reopen your claim, if it has been closed. It will be helpful if you take a copy of the closing medical exam along with you. Your Physician is going to need to compare your current findings on exam to those documented at the time the claim was closed to determine if there has been a worsening of your condition. If the Physician gets a provider number the Department will pay for that initial exam, whether the claim is ultimately reopened or not. They may also authorize and pay for a diagnostic study requested by your Physician if that is necessary.
Note – even pharmacies need a provider number. We’ve found that the big chain, multi-state pharmacies are generally agreeable to getting a provider number so you can fill your prescriptions and they can bill directly.
I WOULD LIKE SOME ADVISE ABOUT WHAT DIRECTION TO GO, I SLIPPED AND FELL IN 2007, RUPTURED MY HAMSTRING, GRADE 3 WENT TO DR. HE SAID IT LOOKS LIKE A BAD ONE, MIR SHOWED A TEAR, WAS SENT TO THERAPY, DID NOT HELP, THEY SAID IT WAS TO LATE TO DO AN AVUSION, WHICH AT THE TIME I DIDN;T HAVE A CLUE, WENT THROUGH 5 OR 6 INJECTIONS DID NOT WORK . THEY SENT ME TO IME, SAD THERE WAS NOTHING MUCH WRONG, SO BACK TO DR. ONOTHER IME LOOKED AT ME SAID THERE WAS A MAJOR PROBLEM, MY HAMSTRING STILL HAS A 5 CM TEAR THAT CAN;T BE REPAIRED, SETTLED WITH STATE, SAID I WAS 29% DISABLED, NOW I HAVE A GREAT DEAL OF SCIATICA, CANNOT SIT WALK VERY FAR I AM MISRABLE, AND MY ATTENDING DR. QUIT WHAT SHOULD I DO, ANY INFO WILL HELP THANKS
If you are in Washington, you didn’t ‘settle’ – your claim was closed with a PPD award. You can file an application to reopen your claim. There must be medical evidence that the condition covered in your claim has objectively worsened. In your situation, it sounds like you need to find a new physician, and ask whether your current sciatic problems are related to your hamstring injury. I’d suggest you find an orthopedist or physiatrist, make an appointment, and take in the medical records from your prior treatment. Tell the physician you would like to file a reopening application. You can download the form from L&I’s home page, or many doctors have them in their offices. There is a portion you fill out, and a portion the physician completes. The department will pay for the initial exam, whether or not the claim is reopened. The department may also authorize any diagnostic studies which are necessary to evaluate your condition. Whether your claim is reopened, or whether you have a good case worth hiring an attorney to help with, really depends on what the physician tell you about your current condition, the relationship to your original injury, and whether any condition related to your injury has worsened since claim closure.