Self-Insurance and Coronavirus (COVID-19) Common Questions

Self-Insurance and Coronavirus (COVID-19) Common Questions

    Will L&I allow claims for adverse reactions to the COVID-19 vaccine?

    As with any claim, L&I considers the facts specific to each case when deciding whether a claim should be allowed. In cases involving COVID-19, this includes:

    • whether the worker is employed in an industry where they are at high risk for exposure to COVID-19
    • whether the employer required their staff to be vaccinated
    Who is at greater risk of serious illness should they contract COVID-19?

    According to the Centers for Disease Control and Prevention (CDC), people as described below are at increased risk of serious illness if they were to contract COVID-19. For this reason, if the worker expresses concerns about the risk to themselves or someone in their household, claim adjudicators should weigh this factor against the risks of travelling to and/or attending the medical or vocational appointment. The CDC defines serious illness as hospitalization, intensive care, ventilator needed to assist in breathing and in some cases death.

    The following are at increased risk of serious illness with COVID-19:

    OLDER ADULTS – The older a person is, the higher the risk of severe illness when the virus is contracted. Adults over 65 have by far the highest risk.
    PEOPLE WITH CERTAIN MEDICAL CONDITIONS - The CDC lists the following medical conditions as having the potential to put a person at increased risk of severe illness should they contract COVID-19:

    • Cancer (current or history of)
    • Chronic kidney disease
    • COPD (chronic obstructive pulmonary disease)
    • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
      Immunocompromised state (weakened immune system) from solid organ transplant, from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
    • Neurologic conditions, such as dementia
    • Obesity
    • Pregnancy
    • Sickle cell disease
    • Smoking
    • Asthma (moderate-to-severe)
    • Type 1 or Type 2 diabetes
    • Cerebrovascular disease (affects blood vessels and blood supply to the brain
    • Cystic fibrosis
    • Hypertension or high blood pressure
    • Liver disease
    • Pulmonary fibrosis (having damaged or scarred lung tissues)
    • Thalassemia (a type of blood disorder)

    These factors should be considered when making an adjudicative decision as to whether a worker should attend a medical or vocational appointment if the worker expresses a concern about the risk associated with the appointment.
    More information is available on the CDC website: https://www.cdc.gov/coronavirus/2019-nCoV/index.html

    A worker would like to postpone their IME and/or travel arrangements because of concerns about coronavirus. What do I do?

    It is reasonable to postpone an IME, especially if the worker or their household is at high-risk under the criteria provided by the CDC for serious illness from the virus, or when travel to the examination cannot be done safely (such as when an airline flight would be needed). We should do our best to make accommodations. These situations aren’t considered non-cooperation, nor appropriate for assessing no-show fees.
    In compliance with Governor Jay Inslee’s November 13, 2020 COVID-19 Travel Advisory all Independent Medical Examinations (IMEs) that require injured workers living out-of-state to travel to the state of Washington should be cancelled immediately.  Alternatives include conducting IMEs via telemedicine, when appropriate, or a consultation with a provider in the worker’s area.  Please refer to the Temporary Telehealth IME Policy when considering if telehealth is appropriate. It is not recommended that these IMEs be rescheduled or new ones scheduled through the end of the year or until further notice.  Additional information will be made available as updates are received from the Governor.

    Example: The worker is 66 years old and has a chronic medical condition that is considered by the CDC as having a high risk of serious illness from COVID-19. The worker calls requesting that the IME be postponed and explains their situation. This is reasonable and the IME should be postponed.

    Example: The worker does not have any chronic medical conditions but would need to travel to the IME via a taxi and then an airline flight that would make it difficult for social distancing even with proper precautions being taken. The worker calls and expresses their concerns about this and requests that the IME be postponed. If safer alternate travel arrangements or a closer location for the examination cannot be arranged, the exam should be postponed.

    How will the allowed coronavirus (COVID-19) claim losses impact self-insured businesses?

    Self-insured businesses will pay the benefits due on allowed coronavirus claims. However, they can remove these losses when calculating their administrative assessments. These losses must be reported to the Department of Labor & Industries (L&I) for potential audit purposes.

    If a self-insured employer has an employee on temporary light duty and their business is closed due to the pandemic, is the employee eligible for time-loss benefits? Will these losses be included in the employer's assessment determinations?

    The employee is eligible for time-loss benefits unless the employer chooses to keep them on salary. The law is clear in situations where temporary or transitional light-duty work comes to an end, regardless of the reason it's ending. The law recognizes that these workers are restricted from being able to perform their regular employment, or jobs other than the light-duty one.

    Only losses for allowed coronavirus claims should be removed from assessment determinations.

    How will a self-insured employer's assessments be impacted if they choose to continue to pay their employees when their business is shut down or a employee is quarantined and the employee is not working as a result of the pandemic?

    For the Supplemental Pension Fund Assessment

    • If your business location shuts down, then you don't need to report hours for employees whom you may continue to pay wages but aren't working.
    • If your employees are able to work remotely, then you must continue to report their hours.


    For the Administrative Assessment

    • If you pay time-loss benefits to employees while quarantined and they do not contract the disease, then you can deduct from your reported claim costs, and these won't be included in the assessment.
    • If you pay employees their wages during the quarantine, and a claim is filed but they do not contract the disease, then you can also deduct the equivalent amount of time-loss benefits for the quarantined days from your reported costs. These won't be included in the assessment.
    If a self-insured employer pays an employee's wages while the individual is quarantined due to a work-related exposure, is the employer required to provide a Self-Insurance Form 2 (SIF-2 form) and assistance with filing a claim?

    No. For an exposure-related quarantine that does not result in a positive coronavirus diagnosis, a SIF-2 form does not have to be completed as long as the employer continues to pay their regular wages.

    If a self-insured employer receives a Physician's Initial Report (PIR) for a quarantined employee who is not being tested for coronavirus and is still paid their regular wages, are they required to provide a SIF-2 form and assistance with filing a claim?

    Yes. If a PIR is received, a SIF-2 form should be filed. You should request for the claim to be allowed if it meets the criteria (see Workers' Compensation Coverage and Coronavirus Common Questions).

    If a self-insured employer receives a PIR for a quarantined employee and coronavirus testing (or results) is pending, can the PIR/SIF-2 form be held until there are test results?

    No. If an employer receives a PIR, a SIF-2 form should be filed requesting the claim be allowed if it meets the criteria. This is an allowable claim for the quarantine period even if the employee tests negative and the employer is paying the employee their regular wages. If a employee is diagnosed with coronavirus and the employer or third-party administrator (TPA) believes the criteria for allowance are not met, the claim should be submitted with a request for denial.

    If a self-insured employer pays an employee's wages while the employee is quarantined and tested for coronavirus, and the employee receives negative test results, should a claim be submitted for denial?

    No. If the employer paid the employee their regular salary during the quarantine period and the worker receives negative test results, no further action is needed.

    If a self-insured employer doesn't pay an employee's wages while the employee is quarantined due to a work-related exposure, is the employer required to pay time-loss benefits for the quarantine period?

    Yes. If the employer does not pay the employee their regular salary, the employer must pay time-loss benefits to the employee for the quarantine period, up to 14 days. And, the employer is required to provide a SIF-2 form and assistance with filing a claim.

    If an employee doesn't meet the criteria for work-related exposure, is the self-insured employer required to pay the employee time-loss benefits or their regular salary during the quarantine period?

    No. If the exposure is not work-related and an employee is quarantined, then the employer is not required to pay time-loss benefits or regular salary to the employee; however, the employer may consider allowing the use of other paid leave to promote health and safety.

    Are coronavirus-related claims considered an injury or occupational disease?

    Coronavirus claims are considered occupational disease exposures. The first day of quarantine is the date of manifestation (DOM) or the diagnosis date, whichever comes first.

    L&I's Workers' Compensation Coverage and Coronavirus Common Questions page states that a worker must be quarantined by a public health officer or physician. As a self-insured business, I'm having trouble obtaining that documentation. What should I do?

    Benefits for the 14-day quarantine period should be paid without delay. Documentation from a public health officer or physician may be obtained after payment has been made. If a worker self-quarantines, and during the 14-day quarantine period the worker is informed by a public health officer or physician that the quarantine was appropriate, the worker is eligible to receive compensation for the entire quarantine period. As with all wage replacement benefits under the Industrial Insurance Act, the first 3 days are not paid unless the worker is medically required to remain off work on the 14th day following exposure.

    Is quarantine criteria applied differently for health care workers and first responders than for workers in other industries? And should we wait to start time-loss payments until we receive the documentation?

    No, the criteria is the same. The goal is to speed up relief when exposures may be anticipated in any workplace. You should begin paying time-loss benefits immediately if you are not continuing to pay the employee's wages. Documentation may be obtained afterward.

    Who should direct the worker to quarantine?

    Generally, this will be the worker's attending provider. But because this may not always be possible during this time, the directive should include review by a medical professional, whether external (someone you don't employ) or internal (someone you employ). Workers may also be quarantined by the public health officer or according to protocol put in place by the public health officer in your local jurisdiction. Every county in the state is served by a local health agency, which includes a health officer.

    As a self-insured employer, we have protocol for exposures to the coronavirus. If we pay benefits to an employee during the 14-day quarantine period based on that protocol, but the employee never actually sees a medical provider, will L&I object?

    We appreciate your proactive action to immediately pay the employee benefits. For an employee who never actually contracted the coronavirus, you can just state "employee quarantined per medical protocol," and attach a copy of that protocol.

    If we pay benefits based on medical protocol, do we still need a Provider's Initial Report (PIR) from an attending provider to allow and close the claim?

    If an employee follows medical protocol provided by a physician and either recovers or tests negative for the coronavirus and never seeks additional treatment, the self-insurer may request that a claim be allowed or closed based on the protocol. A copy of that protocol should be attached to the request.

    If a self-insurer wants to have an employee seen by a medical provider (in person or by telehealth) before allowing or closing a claim, the insurer may direct the employee to make an appointment with a provider of the employee's choice. The employee must be given an appropriate time period for that to happen. We will not deny claims for the absence of a medical exam without confirmation that the employee was directed to seek treatment and given time for that to happen.

    Where can I find additional guidance on work restrictions and return to work? What is the best way to contact L&I if I have more questions?

    Call L&I's main phone number for self-insurance: 360-902-6901. You may get a voicemail message instead of a person, due to the agency's coronavirus outbreak response and the governor's Stay Home, Stay Healthy order. However, we check these messages regularly and return phone calls within 48 hours.

    Please note: L&I is temporarily unable to fulfill requests for CDs of claim files.

    What's the best way to send information to L&I?

    We encourage you to use Secure File Transfer (SFT) instead of sending paper files to us. To set up this service, contact us.

More information:

Workers' Compensation Coverage and Coronavirus Common Questions

COVID-19 resources