When should you be receiving Time Loss?
The obvious answer is, ‘When you can not work because of your injury’. But as with most things in the workers compensation world, it is not always as easy as the obvious answer. Several hurdles must be maneuvered before you are entitled to time loss payments.
First, there must be medical certification that you are unable to work because of your work related injury. At the beginning of your claim this should come from your attending medical provider. Unfortunately, this is one of those areas where it does not matter if you think you can do your regular work – it matters what a medical provider thinks. So, get yourself to a Doctor as soon as you can. The certification will address your ability to return to work at your job of injury. There is no magic time loss form for your doctor to complete. Although the claims manager may send your medical provider an Activity Prescription Form, this specific form is not required to collect time loss. The same information can be found in the providers chart notes or any other form used by the Doctor’s office. You will not receive time loss for the day of injury, or the 3 days following the injury, unless you remain off work for 14 days.
You will also be required to sign a Worker Verification Form to certify you have not worked, and to let the Department know if you have applied for any public assistance. (note – self-insured claims may not use this particular form) The Department may send you this form, or you can complete it on-line in the Claim and Account Center. You can mail it, fax it, or drop it off at a service location. If you have an attorney, your attorney will make sure you get one to complete when necessary.
Time loss can be paid even before the Department issues an order formally allowing your claim. If there is medical certification and worker verification, provisional time loss benefits should be paid pending the Department’s review of the claim and allowance or rejection of the claim. Of course, if the claim is ultimately rejected, these provisional benefits will need to be repaid. (in limited circumstance, the Director may waive repayment if recovery would be against equity or good conscience.)
As the claim progresses, your medical provider may be asked by your employer to release you to light duty or modified work of some type. (see previous posts on light duty work) The Employer should provide a specific job description which allows your medical provider to assess whether you can perform the work described. If your physician releases you to this work, you will not be entitled to time loss benefits. However, if this temporary light duty work pays less than your regular work, you may be entitled to Loss of Earning Power benefits to make up some of the wage loss. If this light duty work interferes with your recovery and your physician again certifies you are not able to work, your time loss should resume. Likewise, if the employer no longer has light duty work available, time loss should be paid.
If you leave your employment, and take another job with another employer, you may still be entitled to time loss if your physician subsequently indicates your injury interferes with your ability to work at either your job of injury or your new job. I had a worker call the other day who had changed employers several months after her injury. About a year later she had surgery for her work related injury. The claim was open and the surgery was approved treatment. She wanted to know if she should have received time loss while she was recovering from surgery and unable to work at her new job. Absolutely, yes! It does not matter that she was working for a different employer, she should have received time loss, and we will be following up on her claim to make sure she does.
If you move out of state you are still entitled to time loss benefits. There is no rule or law which requires that you reside in Washington to continue receiving benefits under your claim. We have clients in a lot of different states, and several foreign countries. While medical treatment may be a challenge, there is nothing about a move, in and of itself, which limits the payment of time loss benefits.
If your injury is serious and permanently prevents a return to work at your job of injury a vocational assessment will be conducted. You should receive time loss during this process. If the vocational assessment concludes you are employable, your time loss benefits will stop.
This is really only a very basic outline of when time loss should be paid. As a general rule, if you have an open claim, are not working because of your injury and are not receiving time loss benefits, you should talk to an attorney about your specific circumstances. There may be some arguments to be made that benefits should be paid. It is always worth taking a look, and may result in the payment of significant back due benefits.
WELCH&CONDON 
Thank you for your comments, very informative and easy to follow.
One question: If an IW is going to have a IME so L&I can close a PPD, but the IW is also receiving LEP while working light duty, does the LEP end with the closed PPD?
The wages being received are about 50% of the wages at the time of injury.
Thank you,
Nick Schwartz.
I have been on L&I for going on 4 yrs. I have 2 seperate claims as L&I would not combine 2 injuries onthe same arm as being connected,one being an elbow injury, the other a shoulder injury. After 3 surgeries on elbow & 1 surgery on shoulder, my primary Dr. inadvertadely for some reason released me back to my job of injury. How can I be released to my job of injury when I cannot do that job(hairdresser)anymore?? And also when my other claim prevents me from going back to work.? Also when I was released to my job of injury my time-loss payments stopped, but my claim remains open still as of this writting it has been 1 yr since I was released to work but cannot work & am working with a Vocational counselor for retraining which they have turned down because they said they need more medical info to close my case, because they don’t agree with my Dr., rating of 4%, saying the state says I’m a 1%…Help what can I do? I have a lawyer but nothing seems to get resolved. Would like to get out from under the states thumb and get on with my life but the state just won’t let me.
You ask some valid questions, which I can’t specifically answer with the information given. Yes, if your own medical provider releases you to return to your job of injury without restriction, your time loss benefits will stop, and you will not be provided vocational services. Your claim may remain open for a time to finalize an impairment rating. However, your ability to return to your regular work needs to be evaluated with respect to each injury, and possibly with respect to the cumulative effects of both injuries.
You do mention you have already hired an attorney. My best advice is to schedule an appointment and take a list of questions with you. Your attorney should be willing to take the time to answer the questions you have about your claim, and be able to explain where the claim is headed. The answers may not be what you want to hear, but at least you’ll have the information you need to decide what’s next for your own life.
Are there any penalties if L&I causes a delay in time loss benefits on a state fund claim? My first time loss check was issued quite promptly, but my second one has not yet been issued, and I have been off work over three more weeks since then. I thought that they were supposed to pay time loss in a timely manner. I send them the information they request in a timely manner, and they have all the certification and verification they need. Does L&I ever get penalized for being late with benefits?
The short answer is nope, no penalties against the department for not timely paying benefits. (my answer would be different if you were dealing with a self-insured employer) While the Department is supposed to pay benefits in a timely manner, any number of things could be holding up a time loss check. Call your claims manager. Leave a detailed message if your CM is not available. You should get a call back in two days. The holdup may be something simple like needing a Worker Verification form or an Activity Prescription form. If you cannot get a straight answer on why benefits are not being paid, you should talk to an attorney.
the department issued an order that the self insurance company needs to pay me back time loss. the insurance company is saying since they protested, within 24 hours, they dont have to pay. is this supposed technicality true? or is she just blowing smoke up my ass.
While I like the creativity – there is no magic ‘24 hour rule’. An order by the department awarding benefits become effective and the benefits due on the date issued. There are two exceptions (neither involving how quick a protest or appeal is filed)
If the order awarding benefits was an increase from an earlier order which had been protested or appealed, the increase is stayed pending the order becoming final. So, for example, the original order instructed the self-insured to pay 6 months of back benefits; you protested and a new order was issued awarding 2 years of back benefits – the first 6 months of TL in the first order would have to be paid right away. However, the other 18 months could be held until the order is final.
The other exception involves when a party appeals a wage order, which does not sound like your situation.
I would suggest you call the self-insured section of the department and pass along the information you received from the self-insured employer’s administrator, and ask the department to call them and straighten it out. You’re not likely to get anywhere arguing with the TPA yourself. But I suspect a polite phone call from the department will solve the problem (mostly because they will be reminded of the potential for a penalty) .
Warning – if the back benefits are paid and the order is reversed, you could be facing an overpayment.
My last time loss from my self-insured company was through March 2, 2013. My actual claim is “Open” in the state file, but in the notes it is pending closure as of March 8, 2013. The state is disputing falsification of documents with my self insured company at my request; and indicated to me the official Open/Close will not begin until this falsification is resolved; and the state informed me that could take months. The date is now March 22, 2013 and I am still without time loss pay. My claim manager of course is a real gem, whom never calls me back and I am forced to speak only through faxes and typed letters-where she never answers all my questions when she does respond. Is there a law pertaining to pending closure cases that indicates injured workers are required time loss pay, even if the state determines my case does close (which I’m doubtful will happen given the amount of fact my physicians have and no fact the IME physicians opinion is upheld with).? I appreciate your time, thank you.
The payment of time loss is not required up to the date of claim closure. Time loss is dependent on your ability to work. If you’ve been released to work, either your job of injury or alternative work which you are capable of performing and which exists in the regular labor market, then you are no longer entitled to time loss benefits. If your physician has indicated you cannot work, then this information should be provided to both the self-insured employer and the department, with a request to pay time loss. I suspect the SIE has a physician who has indicated you can return to work, while your physician may disagree. If this is the case, get legal advice as soon as possible. If the medical evidence is strong, you may well still be entitled to the payment of benefits.
I have hao re-open my claim for a 2ntime. My doctor has said that my condition has worsen and the dept of L&I has re-opened my claim. They are denying me time loss because I was not attached to the workforce when the re-opening claim was submitted.. I was not working the first time My claim was re-opened and time loss was paid then but not no. Can L&I do that..My DOI was 04/24/2010, I had an MRI that shows degeneration of a facet joint and multi level dehydration of the lumbar spine. It has not been 7 years since my DOI.
This is an interesting one. When your claim was closed with a PPD award it is an acknowledgment that you were able to due some type of work. Ifa claim is later reopened because the condition has worsened, you may be entitled to time loss, but it is not automatic.
Where the claimant never returned to work there is an argument that he has voluntarily retired from the workforce. If there is a voluntary retirement no time loss or pension benefits are payable.
You cannot argue that you did not return to work because your injury never resolved enough for you to work, because the claim closure with PPD is a final and binding determination that you were able to work at that time.
So, why didn’t you return to work? There may be an argument that you were trying to return to work, and therefore have not voluntarily removed yourself from the work force. It is going to be very fact specific. Can you present evidence that you were actively looking for work, submitted applications, had interviews? Did you have a job, even for a short period of time? Were you trying to start a business, did you get a business license or permit, apply for a small business loan? Were you collecting unemployment, leaving a trail of documentation that you were seeking work? On the flip side, if you were collecting Social Security Disability or retirement, and made no attempt or effort to return to work, then there may well be a good argument that you voluntarily removed yourself from the work force, and are not entitled to time loss or other wage replacement benefits.
I have a question, I was hurt at work a year and a half ago. I was only off work for 2 weeks which I was paid for. I went through physical therapy. And returned back to work but my condition continued to get worse. A year and a half after the injury I was sent to a specialist and had discovered I had a labral tear in my hip. And needed surgery. During this year and a half I was working I also went back to school (that I paid for myself) because I knew I could not do this type of work anymore (certified nurses aid) it required a lot of lifting. I finished school and had to quit my job because I had to do my internship in a clinical setting, which would be a 40 hour a week job but I just would not get paid for it. At this same time, I was finally approved for my surgery. I scheduled it for right after I was done with my internship. I was offered two jobs after my internship at which I had to turn down due to my scheduled surgery. So my question is am I entitled to time loss benefits ? My Dr. said I cannot work for 6 weeks and sent all of the paper work to L & I, And L&I already sent me a check for the first two weeks. But I am not sure if I should cash for fear I will have to pay it back.
Without knowing more – I’m inclined to say you are entitled to time loss. You are not able to work, at any type of work, while you recover from your surgery. You don’t say what type of work you retrained for – however, keep in mind as you recover, the question is are you released to return to work at your job of injury. If you have restrictions on returning to that type of work, you would be entitled to time loss until you either return to work at something else, or the department conducts an Ability to Work Assessment and determines you are employable at different work based on your new skills. Which means, the time loss may extend past the 6 week recovery period, if you have restrictions that limit your ability to return to the job of injury.
Good Luck!
My time-loss payments were stopped in May as the VDRO agreed with the self insured claim manager and said that I am able to work as a receptionist. I cannot return to my former position as a registered respiratory therapist. My treating physician has repeatedly and strongly disagreed with all the IME doctors regarding my ability to return to any full-time work. I developed complex regional pain syndrome after surgery on my injured foot. This is an accepted and non-disputed diagnosis. The self-insured company is now working on LOEP. Should I be able to continue to receive time-loss as my treating physician continues to tell the self-insured employer that I cannot work in any job? How can they pay me LOEP if I am not working?
It sounds like you are already past the Vocational dispute phase, and that your claim is tracking to closure. You may be entitled to Loss of Earning Power benefits until claim closure. These can be paid based on your ability to do some work, even if you are not actually working.
You will have a chance to file an appeal, but your physician is going to have to be very specific about the objective medical findings which prevent you from doing the job of a receptionist. You may be at the point where you should hire an attorney as it sounds as if there is a true dispute between your AP and the IME.