BP BHEAD INT H

AN ACT Relating to determination of benefits for permanent partial disability by industrial insurance self-insurers; and amending RCW 51.32.055, 51.14.120, and 51.14.130.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

Sec. 1. RCW 51.32.055 and 1994 c 97 s 1 are each amended to read as follows:

(1) One purpose of this title is to restore the injured worker as nearly as possible to the condition of self-support as an able-bodied worker. Benefits for permanent disability shall be determined under the director's or self-insurer's supervision only after the injured worker's condition becomes fixed.

(2) All determinations of permanent disabilities shall be made by the department or the self-insurer. Either the worker((,)) or the employer((~~, or self-insurer~~)) may make a request or the inquiry may be initiated by the director or self-insurer on his or her own motion. Determinations shall be required in every instance where permanent disability is likely to be present. All medical reports and other pertinent information in the possession of or under the control of the employer or self-insurer shall be forwarded to the director with the request.

(3) A request for determination of permanent disability shall be examined by the department or self-insurer, and ((~~an order shall issue in accordance with RCW 51.52.050~~)) the department shall issue an order in accordance with RCW 51.52.050 or, in the case of a self-insured employer, the self-insurer may: (a) Enter a written order, communicated to the worker and the department self-insurance section in accordance with subsection (7)(d) of this section, or (b) request the department to issue an order in accordance with RCW 51.52.050.

(4) The department or self-insurer may require that the worker present himself or herself for a special medical examination by a physician or physicians selected by the department, and the department or self-insurer may require that the worker present himself or herself for a personal interview. The costs of the examination or interview, including payment of any reasonable travel expenses, shall be paid by the department or self-insurer, as the case may be.

(5) The director may establish a medical bureau within the department to perform medical examinations under this section. Physicians hired or retained for this purpose shall be grounded in industrial medicine and in the assessment of industrial physical impairment. Self-insurers shall bear a proportionate share of the cost of the medical bureau in a manner to be determined by the department.

(6) Where a dispute arises from the handling of any claim before the condition of the injured worker becomes fixed, the worker, employer, or self-insurer may request the department to resolve the dispute or the director may initiate an inquiry on his or her own motion. In these cases, the department shall proceed as provided in this section and an order shall issue in accordance with RCW 51.52.050.

(7)(a) If a claim (i) is accepted by a self-insurer after June 30, 1986, and before July 1, 1995, (ii) involves only medical treatment and the payment of temporary disability compensation under RCW 51.32.090 or only the payment of temporary disability compensation under RCW 51.32.090, (iii) at the time medical treatment is concluded does not involve permanent disability, (iv) is one with respect to which the department has not intervened under subsection (6) of this section, and (v) the injured worker has returned to work with the self-insured employer of record at the worker's previous job or at a job that has comparable wages and benefits, the claim may be closed by the self-insurer, subject to reporting of claims to the department in a manner prescribed by department rules adopted under chapter 34.05 RCW.

(b) All determinations of permanent disability for claims accepted by self-insurers after June 30, ((~~1986~~)) 1995, shall be made by the ((~~self-insured section of the department~~)) self-insurer under subsections (1) through (4) of this section.

(c) Upon closure of a claim under (a) of this subsection, the self-insurer shall enter a written order, communicated to the worker and the department self-insurance section, which contains the following statement clearly set forth in bold face type: "This order constitutes notification that your claim is being closed with medical benefits and temporary disability compensation only as provided, and with the condition you have returned to work with the self-insured employer. If for any reason you disagree with the conditions or duration of your return to work or the medical benefits or the temporary disability compensation that has been provided, you may protest in writing to the department of labor and industries, self-insurance section, within sixty days of the date you received this order." If the department receives such a protest, the self-insurer's closure order shall be held in abeyance. The department shall review the claim closure action and enter a determinative order as provided for in RCW 51.52.050.

(d) If a claim (i) is accepted by a self-insurer after June 30, 1995, (ii)(A) involves only medical treatment and the payment of temporary disability compensation under RCW 51.32.090 and a determination of permanent disability has been made according to subsections (1) through (4) of this section, or (B) involves only medical treatment and a determination of permanent disability has been made according to subsections (1) through (4) of this section, (iii) is one with respect to which the department has not intervened under subsection (6) of this section, and (iv) concerns an injured worker who has returned to work with the self-insured employer of record at the worker's previous job or at a job that has comparable wages and benefits, the claim may be closed by the self-insurer, subject to reporting of claims to the department in a manner prescribed by department rules adopted under chapter 34.05 RCW. Upon closure of a claim under this subsection, the self-insurer shall enter a written order, communicated to the worker and the department self-insurance section, which contains the following statement clearly set forth in bold-face type: "This order constitutes notification that your claim is being closed with medical benefits and/or temporary disability compensation as provided and with award for permanent partial disability set forth below, and with the condition that you have returned to work with the self-insured employer. If for any reason you disagree with the conditions or duration of your return to work or the medical benefits, temporary disability compensation provided, or permanent partial disability that has been awarded, you may protest in writing to the Department of Labor and Industries, Self-Insurance Section, within sixty days of the date you received this order." If the department receives such a protest, the self-insurer's closure order shall be held in abeyance. The department shall review the claim closure action and enter a determinative order as provided for in RCW 51.52.050.

(e) If within two years of claim closure the department determines that the self-insurer has made payment of benefits because of clerical error, mistake of identity, or innocent misrepresentation or the department discovers a violation of the conditions of claim closure, the department may require the self-insurer to correct the benefits paid or payable. This paragraph does not limit in any way the application of RCW 51.32.240.

(8) If a claim (a) is accepted by a self-insurer after June 30, 1990, (b) involves only medical treatment, (c) does not involve payment of temporary disability compensation under RCW 51.32.090, and (d) at the time medical treatment is concluded does not involve permanent disability, the claim may be closed by the self-insurer, subject to reporting of claims to the department in a manner prescribed by department rules adopted under chapter 34.05 RCW. Upon closure of a claim, the self-insurer shall enter a written order, communicated to the worker, which contains the following statement clearly set forth in bold-face type: "This order constitutes notification that your claim is being closed with medical benefits only, as provided. If for any reason you disagree with this closure, you may protest in writing to the Department of Labor and Industries, Olympia, within 60 days of the date you received this order. The department will then review your claim and enter a further determinative order." If the department receives such a protest, it shall review the claim and enter a further determinative order as provided for in RCW 51.52.050.

Sec. 2. RCW 51.14.120 and 1993 c 122 s 2 are each amended to read as follows:

(1) The self-insurer shall provide, when authorized under RCW 51.28.070, a copy of the employee's claim file at no cost within fifteen days of receipt of a request by the employee or the employee's representative. If the self-insured employer determines that release of the claim file to an unrepresented worker in whole or in part, may not be in the worker's best interests, the employer must submit a request for denial with an explanation along with a copy of that portion of the claim file not previously provided within twenty days after the request from the worker. In the case of second or subsequent requests, a reasonable charge for copying may be made. The self-insurer shall provide the entire contents of the claim file unless the request is for only a particular portion of the file. Any new material added to the claim file after the initial request shall be provided under the same terms and conditions as the initial request.

(2) The self-insurer shall transmit notice to the department of any protest or appeal by an employee relating to the administration of an industrial injury or occupational disease claim under this chapter within five working days of receipt. The date that the protest or appeal is received by the self-insurer shall be deemed to be the date the protest is received by the department for the purpose of RCW 51.52.050.

((~~(3) The self-insurer shall submit a medical report with the request for closure of a claim under this chapter.~~))

Sec. 3. RCW 51.14.130 and 1993 c 122 s 3 are each amended to read as follows:

(1) The self-insurer shall ((~~request allowance or denial of~~)) issue an order allowing or denying a claim within sixty days from the date that ((~~the~~)) notice of a claim is ((~~filed~~)) received by the self-insurer, if sufficient information is received to make such determination. If a determination can be made, the self-insurer shall notify the injured worker, in writing, that he or she may make a written protest and request reconsideration of the order to the department within sixty days of the date the order is received. If the department receives such a protest, it shall review the claim and enter a further determinative order as provided for in RCW 51.52.050. If a determination cannot be made due to lack of information, the self-insurer shall notify the worker and the department self-insurance section, in writing, that additional information is necessary to make a proper determination. In these instances, an interlocutory order may be requested, subject to the provisions of WAC 296-15-160. If the self-insurer fails to ((~~act~~)) notify the worker within sixty days, the department ((~~shall promptly~~)) may review the claim and intervene and adjudicate the claim if appropriate.

(2) Upon the application of the worker made within seven years from the date the first closing order becomes final, the self-insurer may reopen or deny the claim in accordance with RCW 51.32.160. The self-insurer shall notify the department and the worker of the reopening or denial of a claim in writing.