WAC 296-27-01103 Determination of work-relatedness.
(1) Basic requirement. You must consider an injury or illness to be work-related if an event or exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a preexisting injury or illness. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment, unless an exception in WAC 296-27-01103 (2)(b) specifically applies.
From the Claim form filed at the Dr.'s Office;
Date of injury: 05/03/04
Part of body injured or exposed: Left Wrist
Describe how your injury occured: Reaching over to get a shampoo bottle behind a(nother) shampoo bottle l(ef)t wrist made a pop sound then got real big & hurt bad.
Were you doing your regular job?: Yes
Where did the injury occur?: Jobsite
List any witnesses: (Manager)
Did you report the incident to your employer?: Yes, (Manager)
Date reported: 05/03/04
Neurologists determination: Work related tendonitis, not carpal tunnel, not RSD (pre-existing condition), unable to treat, agree with AP that claimant should see Ortho Surgeon.
Ortho Surgeon determination: Work related tendonitis requiring corrective surgery ASAP.
Click here to view denial of claim by manager.
In re: (Claimant)
Claim No. Y-246850
State of Washington
Dept. of L&I
Office of Director Paul Trause
PO Box 44291
Olympia, WA. 98504-4291
Dir. Paul Trause,
From the Laws and Agency Rules of the State;
"WAC 296-27-01103 Determination of work-relatedness.
(1) Basic requirement. You must consider an injury or illness to be work-related if an event or exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a preexisting injury or illness. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment, unless an exception in WAC 296-27-01103 (2)(b) specifically applies."
In regards to the above referenced Industrial Insurance Claim we are asking that you accept this letter as an official request for reconsideration to the wrongful determination of denial by the claim manager.
The only known documentation that the claim manger has regarding this claim is the documents provided by the claimants Attending Physician and possibly 2 other Dr.'s that have seen this claimant at the AP's referral. All of the referenced Dr.'s have agreed that the condition of this claim is Tendonitis and is caused by the claimants work (cashier, customer service at a retail / pharmacy). They did consider the existing condition (RSD) and have ruled it out as a cause of symptoms, condition, in this claim.
We would like to understand how the claim manager has determined the denial. At an earlier date she had told the claimant that she was awaiting further information from the AP, yet the Dr.'s Office Staff has told the claimant, patient, that to date no request for further information has ever been received from the Dept., or the claim manager. What Medical basis was considered, due to the claim manager not having anything other than the claimants Dr.'s determinations and objective medical opinions?
Please review this claim and correct this wrongful determination so that this worker may receive the legislated benefits as defined in the State and may return to a more comfortable, fixed and stable, way of life.
Sincerely,
(Claimant)
cc:
E-mail to the Governor, Gary Locke, Sep. 15, 2004
Gov. Gary Locke,
The Dept. of L&I has received my wifes signature to speak with me regarding her Industrial Insurance Claim (Y-246850). I am sure that your Office, as well, has received a copy of this. We again pose the question to the Office that oversees and is supposed to Govern the Dept. of L&I in its Administration of the Industrial Insurance Act.
Why was this claim denied?
We know the reason the Dept. gave, "a pre-existing condition not related to work". We are asking for a explanation to who made this determination and how was it reached because of the fact that the only documents in regards to this claim are from the Claimants AP, The referred Ortho Surgeon and the referred Neurologists whom all agreed that though RSD is present with the Claimant it is not the cause of the shown condition and that condition is tendnitis related to her work.
We would appriciate a written explanation of this occurance at your earliest convience.
Thank you for your time in this matter,
(Claimant)
According to the claim manager (prior to a claim determination) a letter was sent to the Attending Physician (AP) requesting further information of the claimants condition. As stated by the claim manager there was never a response from the Dr's office and based on what was available the claim was denied (09/03/2004).
The Governors Office has been contacted regarding this claim and the following e-mail has been received back from that Office;
..."Thank you for your phone calls regarding your wife's, Cynthia's, industrial insurance claim. Kathy, the claim manager, had not previously written a letter to your doctor(s) to obtain prior medical information. She had called Dr. Sill's office and requested a copy of the May 3rd treatment report. Dr. Sill's staff had faxed that information to Kathy."...
Barbara Kendrick
Constituent Services Manager
Office of the Governor
No letter was ever written by the claim manager as had been stated was the earlier wait on determination of the claim and the resulting denial!
Thank you for your message regarding your wife's, Cynthia's, industrial insurance claim. As I stated in the email I sent you yesterday, please continue to work directly with your claim manager regarding your questions and concerns about this claim.
Again, thank you for contacting the governor's office.
Sincerely,
Barbara Kendrick
Constituent Services Manager
Office of the Governor
(Accomplice to fraud?)
Dec. 8, 2004:
The abeyance is lifted, allowing the claim for medical treatment. The Dept. has changed the allowance date from the date filed of 05/03/04, now recognizing the Tendonitis as an injury occurning on 05/26/04 when the condition was significantly aggrivated at work. Claimant contacted Physicians Office to inform them and to set up the surgery date. The Physicians Office called back the folowing day (12/09/04) and had already called the Dept. Provider line to ask for approval of surgery and was given that approval by QALIS (QALIS enters their determination into the computer system and the claim manager has 48 hours to overturn that decision).
Letter addressed to Physician, dated Dec. 15, 04 from claim manager, copied to claimant, asking the Dr.: