Industrial Insurance

  1. What type of relationship must exist?
    An employer-employee relationship.
  2. An employee must have sustained an IA within . . . ?
    The course of employment.
  3. What does acting in the course of employment mean?
    the worker at his employer's direction or in the furtherance of his or her employer's business which shall include time spent going to and from work on the jobsite insofar as such time is immediate to the actual time that the worker engaged in the work process in areas controlled by his employer except parking areas.
  4. What is it called when coverage extends to workers injured outside the state?
    Extraterritorial coverage.
  5. What is an industrial injury?
    A sudden and tangible happening of a traumatic nature producing an immediate or prompt result, and occurring from without, and such physical conditions as a result therefrom.
  6. What happens with an intentional injury?
    Where an employer intentionally causes an injury, the employee will receive worker's compensation benefits plus have a cause of action as if the Act had not been enacted.
  7. What is an occupational disease?
    Such disease or infection as arises naturally and proximately out of the distinctive conditions of employment. Claims based on mental conditions based on stress are noncompensable.
  8. What is the effect of the statute of limitations on a claim.
    The statute of limitations is jurisdictional and may be raised at any time.
  9. What is the statute of limitations for industrial injuries?
    Within one year after the day upon which the injury occurred or the rights of dependents or beneficiaries accrued.
  10. Who has the obligation to file the claim?
    The employee.
  11. What if the employee argues that the statute of limitations creates an unfair result?
    Too bad . . . no equity, no discretion.
  12. What is the statute of limitations for an occupational disease?
    Within two years of the date the worker is advised by a physician in writing of the existence of the disease and the right to file a claim of benefits.
  13. How is the amount of benefits determined?
    The schedule of awards.
  14. Which schedule of awards?
    The schedule of awards in effect at the date of injury?
  15. What are the possible award types?
    Time loss compensation, medical aid, and vocational rehabilitation.
  16. What are the two types of time loss compensation?
    Temporary partial disability and temporary partial disability.
  17. How is permanent partial disability established?
    Medical testimony.
  18. How must permanent partial disability be supported?
    By objective findings.
  19. What is the only way that total permanent disability differ from partial permanent disability?
    Duration of the benefits.
  20. What are total temporary disability benefits?
    Time loss.
  21. What are total permanent disability benefits?
  22. How is permanent total disability defined?
    The loss of both legs, or arms, or one leg and one arm, total loss of eyesight, parlysis or other condition permentally incapacitating the worker from performing any work at any gainful occupation.
  23. What is the court's definition of permanent total disability?
    A worker is permanently and totally disabled when as a result of an industrial injury or occupational disease he or she is unable to perform or obtain gainful occupation with a reasonable degree of sucess and continuity.
  24. What is the court's second definition of permanent total disability?
    It is the loss of all reasonable wage earning capacity.
  25. What needs to be studied in order to determine whether a worker is permanently and totally disabled?
    The whole person - weaknesses, strengths, age, education, training, experience, and any other relevant factors which contribute to the ultimate conclusion.
  26. What is the ultimate conclusion?
    Whether the person is disqualified from substantial gainful employment generally available in the labor market.
  27. What type of treatment is a worker entitled to?
    Proper and necessary medical and surgical services at the hands of a physician of his own choice.
  28. Treatment is limited in point of duration do that it does not continue (2)?
    • 1. beyond the time the worker returns to full employment (unless deemed by a suerpvisor of industrial insurance to be necessary to more complete recovery)
    • 2. beyond the date he is placed on the pension rolls (excep where such is deemed necessary protect life or alleviate continuing pain).
  29. When is a worker entitled to full time loss compensation?
    If he temporarily totally disabled as a result of an injury or occupational disease.
  30. Does the incapacity for temporary total disability purposes relate only to the former work?
    No, it relates to any fainful employment - not just the former work.
  31. What does the worker get in full time loss compensation (temporary total disability)?
    Full wages from all employment the Claimant would have received has the Claimant continued working.
  32. How is the benefit calculated for full time loss compensation (temporary total disability) if he is a part time or seasonal worker?
    Average the total wages earned from any representative twelve sucessive calendard months preceding the injury.
  33. How long may the Department pay time loss compensation and vocational rehabilitation?
    The Department may pay the costs of vocational rehabilitation and may continue time loss compensation for a period of fifty-two weeks.
  34. What is the period of extension for time loss compensation and vocational rehabilitation?
    52 week extension.
  35. What conditions are required for time loss compensation (vocational rehabilitation)?
    The Department may pay the costs of vocational rehabilitation and may continue time loss compensation and provide for tuition, books, etc., while the worker is actively and sucessfully undering a formal program of vocational rehabilitation.
  36. What is rule about claim reopening (vocational rehabilitation)?
    Claims may not be reopened solely for vocational rehabilitation purposes.
  37. When does the board obtain jurisdiction?
    Upon an appeal being filed within sixty days of the communication of the Department's order.
  38. What is the significance of the time limit and filing requirements?
    They are jurisdictional.
  39. What is the filing deadline following the issuance of a proposed decision and order?
    Within 20 days or within such time as extended by the board.
  40. What if an appeal is not filed within the deadline?
    The Board shall adopt the judge's decision.
  41. What are the appeal rights if an appeal is not filed within the deadline?
    There is no appeal to superior court.
  42. When can an appeal be taken to superior court?
    After the board renders its final decision.
  43. What are the different types of worker's compensation cases?
    Reject cases, segregation cases, direct appeals, aggravation cases
  44. What are two special types of aggravation cases?
    Jessie Whie aggravation and Picich/Collins aggravation
  45. What are reject cases?
    Where the Department rejects a claim entirely.
  46. What are examples of a reject case?
    Where the worker was not employed by an employer under the act, or where the worker was not acting in the course of employment.
  47. What is a segregation case?
    Where the Department allows a claim, by responsibility for a portion of the worker's conditon has been denied.
  48. What is another name for a segregation case?
    A partial denial.
  49. What is a direct appeal?
    Where the Department has allowed the calim, provided benefits, and then closed the claim, and the appeal is from the Department's original closing order.
  50. What is another name for a direct appeal?
    Appeal of a closing order.
  51. What is the issue in a direct appeal?
    The issue is the condition of the worker on the date of closure.
  52. What must be established in a direct appeal?
    The extent of disability, the need for treatment, and other benefits must be established by medical testimony which is directed to the date of the Department's closure.
  53. Why must the medical testimony by directed to the date of the Department's closure?
    Because the Deparment has had no opportunity to review the worker's condition after the closing date.
  54. What is aggravation?
    worsening of the industrial condition.
  55. What is an aggravation case?
    The claim has been closed, the worker has filed an application to reopen, alleging worsening of the condition, which has either been denied, or allowed, and closed again with alleged inadequate benefits.
  56. What is the filing deadline for aggravation cases?
    Applications filed more than seven years.
  57. What is the significance of the filing deadline for aggravation cases?
    Benefits are limited only to treatment and no other benefits will be awarded.
  58. What is Jessie White aggravation?
    Claim is closed without permanent partial disability award and the aggravation application is denied.
  59. What must be proven in Jessie White aggravation?
    Aggravation must be proved by comparative testimony.
  60. What happens once aggravation is established in Jessie White aggravation?
    The claimant need only rate the disability on the second terminal date as it is "res judicata" there was no disability on the first date.
  61. What is Picich/Collins Aggravation?
    Closure with or without permanent partial disability award, application to reopen granted and additonal permanent partial disability awarded by the Department.
  62. What is the issue in a Picich/Collins aggravation case?
    The aggravation is admitted. The only issue is the extent of disability on the second terminal date.
  63. What are three types of employer appeals?
    Workers' claims, second injury fund cases, diminution cases.
  64. What is a worker's claim case (employer appeals)?
    The employer appeals the Department's adjudication of the worker's rights?
  65. What is the burden of proof in a worker's claim case (employer appeals)?
    The worker and the Department have the burden of proof before the board to establish the worker's rights and the correctness of the Department's order.
  66. Who must proceed first in a worker's claim case (employer appeal)?
    The employer must proceed first with the evidence to establish a prima facie case.
  67. Why was the second injury fund created?
    To encourage employers to hire and retain disabled workers.
  68. When does the second injury fund kick in?
    In the event a second injury employee sustains an industrial injury or occupational disease and suffers an industrial injury or occupational disease which produces total and permanent disability or death.
  69. What is the allocation in a second injury fund case?
    The employer will be charged only with the accident cost which would have resulted from the injury or disease had there been no preeexisting disability.
  70. What is charged to the second injury employer?
    The difference between the charge thus assessed and the "total cost of the pension reserve".
  71. What is a Diminution case?
    The opposite of an aggravation case - the Department determines the disability of the worker has lessened.
  72. What is the exclusive situation in which diminution case?
    Cases where the Department seeks to remove any worker from the pension rolls.
  73. What is the burden or proof in diminution cases?
    The Department, as the moving party, must establish capacity to engage in gainful employment.
  74. What must the causal relationship be between?
    A condition and an injury or occupational exposure.
  75. How must causal relationship be established?
    By medical testimony.
  76. What is the exception to the rule that the causal relationship must be established by medical testimony?
    In situations in which lay people would ordinarily relate, e.g. a layman sees a fellow worker lose a finger.
  77. What is not sufficient causal proof in death cases?
    Mere acceleration of the final stages of disease.
  78. What cause rule does Washington adhere to?
    Proximate cause rule.
  79. What is the proximate cause rule?
    The injury need not be the sole cause, but must at least be a proximate cause or a proximate contributing cause, without which the result would not have occurred.
  80. Proximate cause cannot be too . . .?
  81. Proximate cause is . . . _____ cause and is not always as broad as ___ ___ cause?
    . . . legal . . . but for . . .
  82. What is lighting up?
    If a dormant, latent, or quiescent condition is activated by an injury, the Department is responsible for the condition resulting therefrom.
  83. In a lighting up case, what is said to the be the cause?
    the injury.
  84. In a lighting up case, what is the signficance of the dormant condition?
    It is merely a condition upon which the cause (the injury) operates.
  85. What is the segregation rule for prior disability?
    If a preexisting conditon is active and/or disabling, the Department is not liable for the preexisting disability. The prior disability must be subtracted from the overall disability.
  86. What is the segregation rule for prior disease impairing recovery?
    If a preexisting disease delays or impairs recovery from an injury, the Department is responsible for the time loss and permanent partial disability only to the extent such would have been produced had there been no preexisting disease.
  87. What is to be done where there has been a PPD disability award for prior injury (and there is a new injury)?
    The worker's compensation shall be adjusted with regard to the combined effect of his injury and past receipt of money.
  88. Is hearsay admissile?
    No, except as provided in the ERs.
  89. What is the big medical expert hearsay exceptions?
    Statement for purposes of medical diagnosis or treatment and describing medical history, or past or present symptoms, pain or sensations, or the inception or general character of the cause or external source thereof insofar as reasonable pertinent to diagnosis or treatment.
  90. What is another medical expert hearsay exception?
    Statements in published medical treatises, periodicals, or pamphlets on a subject of history, medicine, or other science or art, established as reliable authority by the testimony or admission of the witness or by other expert testimony or by judicial notice. If admitted, the statements may be read into evidence but may not be received as exhibits.
  91. How much latitude should cross of medical testimony be given?
    Wide latitude?
  92. Why is wide latitude given in cross of medical testimony?
    Because of "superior knowledge of the subject can create a very misleading or even dangerous witness.
  93. What must be considered with regard to medical testimony in ruling on a challenge to the sufficiency of the evidence?
    Inconsistencies in testimony.
  94. Are hypothetical questions allowed of experts?
  95. What is the rule for basis of expert testimony?
    The facts or data in a case upon which an expert bases his opinion or inference may be those perceived by or made known to the expert at or before the hearing. If of a type reasonably relied upon by experts in the particular field in forming opinions or inferences upon the subject, the facts or data need not be admissible as evidence.
  96. What is the significance of physician office records?
    A record of an act, condition, or event shall insofar as relevant, be competent evidence if the custodian witness testifies to its identity and the mode of its preparation, and it was made in the regular course of business, at or near the time of the act, condition or event, and if, in the opinion of the court, the sources of information, method and time of preparation were such as to justify its admission. A practicing physician or psychiatrist qualifies as a business and his office charts and records made in the regular course of business properly identified and otherwise relevant will constitute competent evidence of an act, condition, or event therein recorded.
  97. Is there a physician-patient privilege in worker's compensation cases in Washington?
  98. Which information of the attending physician must be provided shall be made available and when?
    All such information at any stage in the proceeding.
  99. The testimony of the attending physician is given . . .?
    Special consideration.
  100. What is the signficance of res judicata?
    Any order or judgment entered by an agency or tribunal with subject matter jurisdiction over the claim and personal jurisdiction over the party is final and binding. This includes orders that are erroneous as a matter of fact, or alw, or as a mixed question of fact and law. The power to decide includes the power to decide wrong.
Card Set
Industrial Insurance
workers comp