Source: https://apps.leg.wa.gov/WAC/default.aspx?cite=296-14&full=true
Timestamp: 2019-04-24 18:02:54+00:00

Document:
296-14-010 Reciprocal agreements—Industrial insurance. [Statutory Authority: RCW 51.32.110 and 51.32.190(6). WSR 90-19-028, § 296-14-010, filed 9/12/90, effective 10/13/90. Statutory Authority: RCW 51.04.020(1). WSR 84-06-018 (Order 84-3), § 296-14-010, filed 2/29/84; Order 74-29, § 296-14-010, filed 5/29/74, effective 7/1/74.] Repealed by WSR 98-18-042, filed 8/28/98, effective 10/1/98. Statutory Authority: RCW 51.16.035.
296-14-015 Industrial insurance labor-management cooperation program. [Statutory Authority: 1991 c 172. WSR 92-03-053, § 296-14-015, filed 1/13/92, effective 2/13/92.] Repealed by WSR 98-18-042, filed 8/28/98, effective 10/1/98. Statutory Authority: RCW 51.16.035.
296-14-950 Appointment of attorney as special assistant. [Statutory Authority: RCW 51.24.110. WSR 88-08-026 (Order 88-03), § 296-14-950, filed 3/31/88.] Repealed by WSR 93-23-060, filed 11/15/93, effective 1/1/94. Statutory Authority: Chapters 51.04, 51.08, 51.12, 51.24 and 51.32 RCW and 117 Wn.2d 122 and 121 Wn.2d 304.
296-14-960 Limitations of appointment. [Statutory Authority: RCW 51.24.110. WSR 88-08-026 (Order 88-03), § 296-14-960, filed 3/31/88.] Repealed by WSR 93-23-060, filed 11/15/93, effective 1/1/94. Statutory Authority: Chapters 51.04, 51.08, 51.12, 51.24 and 51.32 RCW and 117 Wn.2d 122 and 121 Wn.2d 304.
Time-loss compensation is not paid to workers who voluntarily retired from the work force.
(c) Payment of union dues or medical or life insurance premiums does not constitute attachment to the work force.
(2) When is a worker determined not to be voluntarily retired? A worker is not voluntarily retired when the industrial injury or occupational disease is a proximate cause for the retirement.
Definition of gainful employment for wage.
Gainful employment for wages for the purposes of RCW 51.32.160 shall mean performing work at any regular gainful occupation for income, salary or wages.
Waiver of recovery for worker compensation benefits overpayments.
(1) The decision of the director shall apply to the state fund or to the self-insurer, as the case may be.
(2) In the case of recoupment of an overpayment from any future payments, the director will entertain a request to exercise his or her discretion to waive recovery up to sixty days after communication of the order and/or notice to the recipient that benefits are being withheld to satisfy the previous overpayment.
(d) Whether the claimant reasonably relied upon misinformation from an official source (i.e., a representative of the department or self-insurer, as the case may be) in accepting the benefit payment which gave rise to the overpayment.
(4) The claimant's application for waiver of an overpayment contemplated under RCW 51.32.240 (1), (2), or (3), or 51.32.220(6) shall clearly set forth the reason(s) that he or she believes that recovery of the overpayment in whole or in part, as the case may be, is against equity and good conscience.
When does a presumption of occupational disease for firefighters apply?
RCW 51.32.185 specifies a presumption that certain medical conditions are occupational diseases for firefighters. Those conditions are heart problems experienced within seventy-two hours of exposure to smoke, fumes, or toxic substances; respiratory disease; specific cancers as defined by RCW 51.32.185; and infectious diseases as defined by RCW 51.32.185.
For claims filed on or after July 1, 2003, the presumption may not apply to heart or lung conditions if a firefighter is a user of tobacco products.
When the presumption does not apply, the claim is not automatically denied. However, the burden is on the worker to prove that the condition is an occupational disease.
(1) Tobacco products: For purposes of this rule, tobacco products are limited to those that are smoked, including cigarettes, pipes and cigars.
(2) User of tobacco products: For the purposes of this rule, a user of tobacco products is a "smoker."
(3) Current smoker: A current smoker is a regular user of tobacco products, has smoked tobacco products at least one hundred times in his/her lifetime, and as of the date of manifestation did smoke tobacco products at least some days.
(4) Former smoker: A former smoker has a history of tobacco use, has smoked tobacco products at least one hundred times in his/her lifetime, but as of the date of manifestation did not smoke tobacco products.
When does the presumption apply to former smokers with heart or lung conditions?
(1) Heart problems: The presumption for heart problems will apply if a firefighter is a former smoker and last smoked two years or more prior to the cardiac event.
(c) For lung cancer if the firefighter is a former smoker who last smoked fifteen years or more prior to the date of manifestation of the disease.
What tobacco use shall exclude a firefighter from a presumption of coverage?
The following table summarizes the situations listed in WAC 296-14-310 through 296-14-325 under which a presumption of coverage shall or shall not apply for firefighters due to tobacco use.
What does the term "willful misrepresentation" mean with regard to the receipt of workers' compensation benefits?
This term is found in RCW 51.32.240(5) which provides a fifty percent penalty, in addition to any overpayment, whenever any payment of benefits has been induced by "willful misrepresentation." The law goes on to state that it is willful misrepresentation for a person to obtain payments or other benefits in an amount greater than that to which he or she would have otherwise been entitled. Willful misrepresentation includes making a willful false statement or the willful misrepresentation, omission, or concealment of any material fact.
(1) Willful means a conscious or deliberate false statement, misrepresentation, omission, or concealment of a material fact with the specific intent of obtaining, continuing, or increasing workers' compensation benefits. Failure to disclose a work-type activity must be willful in order for a misrepresentation to have occurred.
(2) The assessment of the fifty percent penalty does not apply to those instances where the misrepresentation is not willful, as defined above. For example, a worker receives wages at the time of injury of $10.25 per hour, but he inadvertently indicates on the report of industrial injury or occupational disease that his pay is $10.75 per hour. The state fund employer fails to submit a completed report form and the time-loss compensation benefit rate is based on wages of $10.75 per hour. When this information is provided to the employer, worker, and medical provider by legal order, no interested party submits a protest within the statutory time frame, but further investigation later reveals the misinformation. An overpayment determination under RCW 51.32.240(1) may be appropriate upon discovery of the correct hourly pay rate, but the worker has not engaged in willful misrepresentation with specific intent to obtain benefits to which he would have otherwise not been entitled.
What is meant by "work-type activity"?
(1) Work-type activity means any activity for which a reasonable person would expect to be compensated or for which a reasonable employer would expect to pay compensation.
(b) The worker or his/her family has no financial interest in or benefits from the worker's job exploration.
Activity done intermittently or as a hobby that does not generate income will not generally rise to the level of repeated work-type activity.
For example, a worker who is receiving wage replacement benefits volunteers two hours each day for a recognized charity greeting customers and operating the cash register. His treating physician is aware of this activity and encourages it to keep him more active, but does not release him to work or to perform this function more than two hours daily. The worker does not initially inform the department of his activity because he receives no compensation and would not expect to. The department learns of the volunteer work when the worker completes a worker verification form indicating the volunteer activity. No willful misrepresentation of a work-type activity has occurred in this case.
What are considered as "wage replacement benefits"?
Wage replacement benefits include temporary total disability (time-loss compensation benefits), temporary partial disability (loss-of-earning power benefits), and total permanent disability or survivor benefits (pension).
As provided in RCW 51.32.240, the penalties equal fifty percent of the total overpayment amount.
When may the department impute wages in cases where willful misrepresentation has been determined?
• There is no employer but the worker has engaged in a repeated pattern of work-type activities or has willfully misrepresented his or her physical restrictions.
Payment of benefits—Aggravation reopening/new injury.
(1) Whenever an application for benefits is filed where there is a substantial question whether benefits shall be paid pursuant to the reopening of an accepted claim or allowed as a claim for a new injury or occupational disease, the department shall make a determination in a single order. Where one of the claims is with a self-insured employer and another is with a state fund employer, such determination shall be made jointly by the program managers for claims administration and self insurance, or their respective designees.
(2) Pending entry of the order, benefits shall be paid promptly by the entity which would be responsible if the claim were determined to be a new injury or occupational disease.
(b) There is uncertainty regarding which of the entities is responsible.
(4) Time-loss compensation shall be paid at the lesser of the two entitlements that may apply to the claim until responsibility has been determined between state fund and self-insured employer, two self-insured employers, or two state fund employers.
(5) If, upon final determination of the responsible insurer, the entity that paid benefits under subsection (2) of this section is determined not to be responsible for payment of benefits, such entity shall be reimbursed by the responsible entity for all amounts paid.
Is the value of "consideration of like nature" always included in determining the worker's compensation?
(b) The worker received the benefit at the time of injury or on the date of disease manifestation.
(ii) The worker was actually eligible to receive the benefit.
Example: At the time of the worker's industrial injury, the employer paid two dollars and fifty cents for each hour worked by the employee to a union trust fund for medical insurance on behalf of the employee and her family. If the employee was able to use the medical insurance at the time of her injury, the employer's monthly payment for this benefit is included in the worker's monthly wage, in accordance with (d) of this subsection. This is true even where the worker's eligibility for this medical insurance is based primarily or solely on payments to the trust fund from past employers.
(c) The worker or beneficiary no longer receives the benefit and the department or self-insurer has knowledge of this change.
If the worker continues to receive the benefit from a union trust fund or other entity for which the employer made a financial contribution at the time of injury or on the date of disease manifestation, the employer's monthly payment for the benefit is not included in the worker's monthly wage.
Example: An employer contributes two dollars and fifty cents for each hour an employee works into a union trust fund that provides the employee and her family with medical insurance. If the employer stops contributing to this fund, but the worker continues to receive this benefit, the employer's monthly payment for the medical insurance is not included in the worker's monthly wage.
(2) This rule does not permit the department or self-insurer to alter, change or modify a final order establishing the worker's monthly wage except as provided under RCW 51.28.040.
How do I determine the value of a benefit that qualifies as "consideration of like nature"?
The amount paid by the employer for the benefit at the time of injury or on the date of disease manifestation represents the amount that may be included in the worker's monthly wage.
Payment of benefits on asbestos-related disease claims.
The department shall furnish the benefits provided under Title 51 RCW to any worker or beneficiary who may have a right or claim for benefits under the maritime laws of the United States resulting from an asbestos-related disease if there are objective clinical findings to substantiate that the worker has an asbestos-related claim for occupational disease; and the worker's employment history has a prima facie indicia of injurious exposure to asbestos fibers while employed in the state of Washington in employment covered under Title 51 RCW.
(1) A worker's employment history will be deemed to have a prima facie indicia of injurious exposure to asbestos fibers if the employment history as contained in the department's file permits a reasonable conclusion that the worker was exposed to asbestos fibers and that such exposure was of sufficient duration to be injurious. "Injurious" means impairing to either a partial or total extent, and may be either permanent or temporary.
(2) Whenever the department has determined to pay benefits pursuant to chapter 271, Laws of 1988, the department shall render a decision as to the liable insurer and shall continue to pay benefits until the liable insurer initiates payments or benefits are otherwise properly terminated.
The department shall render its decision in a final order as provided in RCW 51.52.050.
Initiation of payments by a liable insurer shall be deemed to occur on the date such insurer issues a check or warrant or otherwise remits to the worker, beneficiary, or any provider any payment of any benefits owed by such insurer on the claim for asbestos.
(3) Benefits shall be paid on all pending asbestos-related claims as of July 1, 1988. Pending claims are those which have not been finally adjudicated by order of the department or the board of industrial insurance appeals or by the entry of a judgment of a superior court or decision of the court of appeals or the supreme court.
If any order of the department granting such benefits is appealed, benefits shall continue, if otherwise available, until a final determination is made by the board of industrial insurance appeals or the courts, or upon initiation of payments by a liable insurer.
(4) If benefits are paid by the department from the medical aid fund on an asbestos-related claim, and it is determined by the department that such benefits are owed to the worker or beneficiary by an insurer under the maritime laws of the United States or by another federal program other than the Federal Social Security, Old Age Survivors and Disability Insurance Act, 42 U.S.C., the department shall pursue such insurer or program to recover such benefits as may have been paid by the department.
The determination by the department shall be expressed in a final order as provided by RCW 51.52.050.
(5) Whenever a self-insured employer is determined to be liable, the self-insured employer shall reimburse benefits to the department within ten days after the department order becomes final and binding. Failure to do so shall subject the employer to a penalty as authorized in RCW 51.48.080.
(6) The director's discretion to waive recovery of the benefits paid to the claimant or beneficiary shall be exercised in accordance with WAC 296-14-200 (3)(c).
(7) No information obtained under this section is subject to release by subpoena or other legal process. The department will release information only to those persons authorized access to claim files by RCW 51.28.070.
What is a residence modification?
A residence modification is a permanent change to an existing residence or a repair of a modification previously approved and paid for by the department or self-insured employer, or a modification made when constructing a new residence.
Household appliances such as refrigerators, washers, and dryers, are generally not residence modifications and the department or self-insured employer will approve them only under unique circumstances as approved by the supervisor.
Example: As part of an approved residence modification, the kitchen counters are lowered. To meet the needs of the worker, the department or self-insured employer may approve the purchase of a drop-in range or cooktop.
What is the residence modification benefit?
The residence modification benefit is a sum of money used to modify a worker's residence for purposes of safety, mobility and activities of daily living, when those modifications are made necessary by the nature of the worker's condition subsequent to a catastrophic injury. Activities of daily living are tasks required for self-care, communication and mobility and include, but are not limited to, bathing, bed mobility, dressing, eating, grooming, toileting and transfers.
When may the worker request residence modification benefits?
The worker may request residence modification at any time when his or her allowed claim is either open or the worker has been determined to be permanently and totally disabled.
Can the worker receive additional modification benefits for the same residence?
The department can pay for additional or subsequent residence modifications so long as the cost does not exceed the maximum benefit in effect at the time that each modification request is approved.
Can a worker receive residence modification benefits for more than one house?
No. The department or self-insured employer will pay for residence modifications on only one residence for each catastrophically injured worker.
How can a worker begin the process of requesting residence modification benefits?
The worker may inquire about residence modification benefits by contacting his or her adjudicator. The department or self-insured employer will then refer the worker to a residence modification consultant for evaluation.
How does the department or self-insured employer determine the worker's residence for purposes of residence modification?
The department or self-insured employer will consider modifying a residence when the worker lives in and considers the residence to be his or her permanent residence. It is not required that the worker own or rent the residence.
Will the department pay for professional services needed to design a residence modification?
Yes. However, the department or self-insured employer will not pay for professional services prior to approval of the residence modification.
If approved, the cost of architectural, engineering, predesign and planning services will be included in the residential modification benefit. The cost for services should be included in the residence modification request.
Can a worker apply the residence modification benefit to the cost of building a new residence?
Yes. However, the benefit may be applied only to the cost difference between a standard residence structure and the modified structure.
How is a worker advised that the supervisor has approved or denied the request for residence modification benefits?
The department will notify the worker, contractors, homeowner (if not the worker), residence modification consultant, attending health services provider and employer of the supervisor's decision in writing.
Who receives payment from the department?
(4) A release of lien form signed by the contractors or subcontractors or both.
Authority to use special assistant attorneys general.
WAC 296-14-900 through 296-14-940 implement RCW 51.12.102 and 51.24.110, which authorize the department to use private attorneys as special assistant attorneys general.
Qualifications of special assistant attorneys general.
(4) Have and maintain in force professional liability insurance.
Applying for special assistant attorney general.
(1) Application forms may be obtained from the office of the attorney general, the Washington State Bar Association, or the department.
(b) Inform the department and the office of the attorney general immediately of any changes in his or her qualifications.

References: § 296
 § 296
 § 296
 § 296
 § 296
 § 296