Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-14 - Industrial insurance › Section 296-14-4126 - How does the department calculate the amount of overpayment charged to a claimant when a determination of "willful misrepresentation" has been made after initial claim adjudication?

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Overpayments are assessed in cases where there has been willful
			 misrepresentation. The overpayment calculation in these claims includes all or
			 part of wage replacement benefits and may include permanent partial disability
			 benefits, vocational, medical benefits, and/or other medical aid fund benefits
			 paid on the claim for the period as described below.
(a) The period of overpayment will begin with
			 either the first date of willful misrepresentation or the first date of the
			 repeated pattern of work or work-type activities.
(b) Medical benefits: Medical benefits paid
			 on a claim may be included when a treating physician's opinion of the need for
			 further treatment related to the claim, or his/her opinion of a condition's
			 maximum medical improvement was changed by the willful misrepresentation. Only
			 those medical services to which the worker would not have been otherwise
			 entitled are included in the overpayment.
(c) Vocational benefits: Vocational benefits
			 may be included when it is determined, because of the willful
			 misrepresentation, that the vocational services would not have been provided
			 but for the misrepresentation.
(d)
			 Permanent partial disability benefits: Permanent partial disability benefits
			 will be included when the worker's willful misrepresentation results in the
			 receipt of permanent partial disability benefits to which the worker would not
			 otherwise have been entitled.
(e)
			 Other medical aid fund benefits: Other medical aid fund benefits may be
			 included such as travel and lodging.
(f) Wage replacement benefits:
(i) The overpayment will include all of the
			 wage replacement benefits resulting from willful misrepresentation when the
			 worker has:
(A) Misrepresented his/her
			 physical restrictions or engaged in a repeated pattern of work or work-type
			 activities; and
(B) The worker
			 would have been released by a physician to return to the job of injury had the
			 repeated pattern of work or work-type activities been disclosed. In cases where
			 a treating physician is unwilling or unable to render an opinion in this
			 situation, the opinion of a consulting physician or independent medical
			 examiner may be used; or
(C) In the
			 case of total permanent disability benefits, the work or work-type activity is
			 such that the imputed wages are equivalent to gainful employment; or
(D) In the case of survivor benefits, the
			 willful misrepresentation was such that the beneficiary would not have been
			 entitled to benefits were it not for the misrepresentation.
(ii) The overpayment will include
			 all or part of the wage replacement benefits to which the worker would not
			 otherwise have been entitled were it not for the repeated pattern of work or
			 work-type activities when the worker has:
(A)
			 Misrepresented his/her physical restrictions or has engaged in a repeated
			 pattern of work or work-type activities; and
(B) The department would have determined that
			 the worker returned to work; or
(C)
			 A vocational counselor would have determined that the worker was employable in
			 accordance with department rules.