When to request a segregation order on a newly contended condition in Washington
The Department of Labor and Industries recently addressed when it believes a request for a segregation order is appropriate on newly contended conditions.
A condition is “contended” if it is diagnosed and coverage is being sought due to a causal relationship. If the worker or provider is contending that a new condition is related to the industrial injury or occupational disease, the insurer will need to decide whether they believe it should be accepted on the claim. Factors the insurer will need to consider include:
- The description of the initial injury.
- The length of time between the date of injury and the onset of symptoms related to the additional condition.
- Prior medical records for the new condition.
- A medical opinion giving a causal relationship regarding whether a contended condition is related to the covered injury on a more probable than not basis.
However, an example of a condition that is not “contended” is if a chart note mentions a finding, symptom, or history, but no actual diagnosis or relationship to the current claim. If information is received regarding an obviously unrelated condition that is not affecting recovery, and not contended by anyone to be related to the industrial injury or occupational disease, the insurer may send a letter notifying all concerned that the condition is not covered under the claim.
WAC 296-15-425 requires use of a template when denying a condition contended on a claim. Within five days of determining whether or not the condition should be accepted under the claim, the worker must be notified with the appropriate template.
- Accept Newly Contended Condition (form F207-220-000), or
- Deny Newly Contended Condition (from F207-221-000)
These templates advise the worker to call the insurer with questions and that he or she has the right to dispute the decision to the department if there is a disagreement. If a dispute is received, the department adjudicator will review the file and issue an order directing the self-insurer to either accept or deny the condition.
If no dispute is received, the Department will not issue an order regarding acceptance or denial of new conditions under a claim. As history has shown, “dispute” and “protest” are nuanced, and there are no “magic words” to constitute a dispute. If the template denying the condition is sent, and no further treatment for that condition is sought, then there is not likely a dispute to the segregation of the condition. However, there are times that the template segregating the condition is sent, but the worker or provider continues to seek treatment without filing a formal “dispute”. If payment for the treatment continues, the worker could assume, over time, that despite the template, the condition has been accepted. The continued receipt of medical reports, activity prescription forms, and bills for a condition segregated in a template can be construed as a dispute and the matter can be forwarded to the department for resolution by order.
It is essential to note that this requires claim managers to actively analyze what is happening on the claim and take timely actions. Actions should not be contradictory. They should not issue a template that says one thing (segregation) but engage in inconsistent behavior (payment of treatment for the segregated condition). On the other hand, If the worker does not continue to seek treatment or pays for the treatment through other means, there is not a dispute.
If you have any questions regarding when a segregation order is appropriate, please feel free to contact me at (971) 867-2733 or .
Posted by McKenzie Brooks.
