Claims and Rejections: Effectively Navigating a Tricky Claim

What do you do if a former employee who hasn't been with your company for months because they walked off a jobsite and quit submits an injury claim? What if you have an ironclad safety program and have documentation proving that they knew how to run a machine and file a report of accident claiming they were injured on that machine? What if you also had multiple witnesses who stated the former employee told them the injury didn't actually happen on the job? You might think this scenario would be plenty of information for Labor and Industries (L&I) to reject this claim, but unfortunately, you would be wrong. You'd be surprised how hard it is to fight the allowance of bogus claims like this one and how hard it is to navigate the L&I system in general.

For companies in Washington, it can be hard to know what steps to take when you question the validity of a workers' comp injury claim. This was the situation for ROII participant Condron Homes in Spokane - they were saddled with a claim they knew wasn't fair. With the help of ROII and their ROII Claim Representative Joanne Nichols, they knew what roads were dead ends, what proof they could actually pursue, and most importantly, someone in their corner advocating for them.

"With ROII, I felt like I was just the girl down the road," said Alexa Amatto, VP of Administrative Services at Condron Homes. "They emailed me back almost immediately. I was able to leave messages and got a call back in 24 hours. I felt like they really got to know me. They got to know my case. I didn't feel like just another number. It was like a friend helping a friend or a family member. They were on my side the entire time."

ROII's claim assistance services are operated in-house, just like all of our other services, which is just another way ROII sets itself apart from other retro groups. That means all of our ROII claim representatives work for ROII and BIAW. Because who knows the program and needs of our members better than us?

L&I's workers' comp system is daunting - its rules and laws are complicated, and most employers don't understand them. A complicated claim like the one Condron Homes experienced had many moving parts and required a very specific strategy to hopefully get the claim rejected.  Even with everything working in their favor, L&I rejecting a claim is never a guarantee.

Lucky for them, they had their ROII claim representative walk them through each step, explaining the why's along the way. And there were a lot of why's with this claim. Why do we need to offer a light-duty job to someone who quits and doesn't have a legitimate injury? Besides being an ROII program requirement, offering a light-duty job is important because if an injured employee turns it down, they are not eligible for time loss. This is what happened in this case. The injured worker turned down the light-duty job offer, and L&I did not pay out time-loss benefits. 

Ultimately, after an Independent Medical Examination (IME), it was determined that there was no medical evidence to support that this injury was sustained on the job, and in the end, the claim was rejected by L&I. It wasn't easy, and it took four months, but the strategy laid out by ROII and Condron Homes' ability to trust in the plan achieved the result they wanted.     

"To have someone on your side was really comforting. We had ROII backing us. We had someone in our corner. Someone to help us. Someone to advocate for us," said Alexa.

Claims are never a fun experience, but at least you can make the process more streamlined and efficient by utilizing the experts at ROII. We've been doing this a long time, since 1982, and we understand how things work where you work. We've got your back every step of the way.

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