The policy outlines processes and procedures for disability leaves, retirement, reimbursement of medical expenses and pre-authorization of non-emergency medical expenses.
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CITY OF KIRKLAND DISABILITY BOARD
POLICIES AND PROCEDURES
1. Scope. The City of Kirkland Disability Board (“Board”) policies and procedures shall be applicable to employees as specified in Chapter 41.26 RCW (LEOFF). The term “member” shall mean an active LEOFF I employee, or individual retired for service or disability, who is subject to the jurisdiction of the Board.
2. Effective Policies and Procedures. All members shall be subject to the policies and procedures contained herein. In the event any of these rules as applied to a particular member is contrary to State law, the State law shall govern, but the member shall not be relieved of the responsibility to comply with all other rules contained herein. A member’s failure to follow these rules may result in a loss of benefits under the LEOFF Act. In the event that these rules do not cover a circumstance coming before the Board, the provisions of chapter 41.26 RCW and Chapter 415-105 WAC will be utilized.
3. Regular Meeting. The Board shall hold a regular meeting on the third Tuesday of every other month at 4:30 pm in the Norkirk room at Kirkland City Hall. In the event the date is a holiday, such meeting will be held on the fourth Tuesday. The first meeting of the year is held in January.
4. Special Meeting. A special meeting shall be held at any time upon the call of the chair or any two members of the Board. Each member of the Board shall be given notice at least 72 hours prior to the meeting. The notice shall specify the subject to be considered, and no other subject shall be considered except upon the unanimous consent of all members of the Board present.
5. Quorum. Three members of the Board shall constitute a quorum.
6. Open Meetings. All Board meetings shall be open and public, except periods of discussion about an individual’s claim or application for disability benefits. RCW 42.30.140(2) provides that such consideration is not subject to the open meetings act; however, the Board will make its findings of fact with regard to a specific application while in open session.
7. Staff Support.
a. Staff Assistant. The staff assistant to the Board shall be a regular employee of the City of Kirkland appointed by the City Manager or designee.
b. Legal Advisor. At the request of the Board, a legal advisor shall be designated by the City Attorney to attend meetings or to provide legal assistance, but in cases of conflict of interest, the Board may select an attorney for the Board’s use, with the expenses being paid by the City.
8. Examination by Board Physician. A physician shall be appointed to render such medical service as may be requested by the Board, either on a one-time or continuing basis. No disability retirement shall be approved by the Board without prior examination of the claimant by the Board physician or a specialist of his or her selection. Whenever these rules call for medical reports to be submitted to the Board, the information may be sent to the Board physician instead. If, upon request of the member or the Board, the Board physician believes it is reasonable for the Board to decide the matter at issue without reviewing the actual medical report, then the Board will be provided summaries and evaluations of medical information, but the Board will not retain a copy of the actual medical report. If the Board does not review a medical report, it is not a public record of the City of Kirkland.
9. Disability Leave Requests. When not utilizing contractual sick leave, a LEOFF I employee who misses any time from duty due to injury or illness must file a disability leave application on the day he/she returns to work. If the disability does not come under Paragraphs 10 or 13, such as missing only one shift with the flu, the member’s department head is authorized to approve disability leave on an administrative basis without prior approval of the Disability Board, unless the Board provides otherwise for particular members. The department head shall approve or decline to take action on the disability leave request, at the discretion of the department head. If the department head declines to take action, the department head will so notify the Board and the Board will approve or disapprove the disability leave at the next Board meeting. Otherwise, the department head shall report disability leave requests of particular members, or the taking of specified actions, as requested by the Disability Board. Precautionary reports may be filed when an injury or illness is sustained but no duty time is actually lost.
10. Physician’s Statement Required. After missing three or more work days, a LEOFF I police officer or a LEOFF I firefighter must submit a statement signed by a physician. In addition, the Board may require that specific LEOFF I employees submit a statement signed by a physician, even if such employee misses less work time than that specified above.
11. Approval/Disapproval of Disability Claims; Burden; Evidence. By majority vote, the Board will either approve or disapprove disability benefit claims. The burden of proving the existence of a disabling condition and that the condition was incurred in line of duty shall be upon the applicant. The Board may decide claims solely on the basis of the written information submitted or may conduct a hearing. The Board may compel the attendance of witnesses or the production of evidence at any hearing.
12. Examination May Be Required. The Board may require that a LEOFF I employee who has missed duty time or who submits a claim for payment of medical expenses be examined by a Board physician. No doctor-patient privilege may be invoked with respect to such examination. The Board staff assistant has the authority to schedule appointments immediately with a Board physician on the request of a LEOFF I employee.
13. Release to Return to Duty.
a. The staff assistant, on behalf of the Board, may require any member who returns to duty after a period of disability leave to receive a release to return to duty from a Board-appointed or approved physician.
b. Under any of the following circumstances, the member shall obtain prior approval before return to duty:
(1) Major surgery
(2) Musculoskeletal injuries
(3) Psychiatric disorders
(4) Any other significant illness or injury which may interfere with fitness for duty
(5) Disability leave and/or sick leave of more than six shifts for shift personnel
(6) Disability leave and/or sick leave of more than ten working days for day personnel
For the purposes of this subparagraph, “approval” means that the member has submitted a physician’s written release to the staff assistant prior to returning to duty. This will authorize return to duty, subject to formal approval or disapproval at the next Board meeting.
c. The employee must return to active service at the earliest possible time he/she is fit to return to duty. A return to duty is on a trial basis for six months. Further leave due to the same disability within six months is counted as a continuation of the prior leave and does not begin a new six-month leave period. During the disability leave, the employee shall participate in recommended physical, medical, or therapeutic treatments for rehabilitation. The employee shall not engage in any activity while on disability leave which is contrary to the directives of a physician.
14. Disability Retirement. The Board will execute the provisions of chapter 41.26 RCW as described in WAC 415-105-050 through 415-105-180.
15. Medical Expenses
a. General provisions. The Board will pay for the necessary medical services for a member which are not payable from some other source, as provided for in RCW 41.26.150. The Board will only approve claims for purchase of nonemergency durable medical or supportive equipment costing over $100 in advance of purchase (example: orthotic). Other claims must be submitted to the Board within six months of the billing date. The Board will not pay for medical services which become necessary because of, in the judgment of the Board, dissipation or abuse by the member. The Board shall have the right of subrogation to recover its costs if some third party may be responsible for the payment of the cost of the member’s medical services. Except as the Board may otherwise provide, the staff assistant is authorized to approve and pay a claim which: (1) meets the criteria of subsections 15 (f), (l), (m); or (2) is for payment of Medicare premiums; or (3) is for a balance or $250.00 or less or $500.00 or less with preauthorization by the Board chairman on an expense as to which Medicare or health insurance has paid its customary share. In addition, the Board may also identify particular categories of claims, such as a member's reoccurring expenses for one conditions, or a claim that is submitted between meetings which requires Board approval, to be paid by the Staff Assistant without prior Board review. This Section 15(a) is subject to the following additional provisions:
b. Cosmetic Services. The Board will not consider a claim made by a member for cosmetic services which are for the sole purpose of beautifying the body. In determining whether a medial service constitutes a “cosmetic service,” the Board shall give primary consideration to the insurance carrier’s determination whether the service is cosmetic.
c. Elective Services. The Board will consider each claim made by a member for elective medical services on a case-by-case basis. In determining whether a medical service is “elective” the Board shall give primary consideration to the insurance carrier’s determination whether the service is elective. The Board will consider claims for elective medical services, subject to the following:
The member must be examined by the Board physician or a specialist of the physician’s selection, and two qualified physicians, one of whom is not affiliated with the primary physician. All examining physicians shall submit written medical opinions identifying whether, and the extent to which, a medical necessity exists for the elective service in terms of the member’s ability to perform his job with average efficiency; remain as an active member, or sustain life. RCW41.26.150.
d. Prescriptions required. The Board will only pay the cost of drugs or medicines which are prescribed by a physician.
e. Dental charges. The only dental charges which will be paid are those incurred by a member who sustains an accidental injury to the teeth and who commences treatment by a licensed dentist within 90 days after the accident, with treatment to be completed within two years from date of injury. For dental procedures necessary to correct or prevent physical problems, approval must be obtained from the Board, except that a member may be reimbursed prior to Board approval consistent with 15.(a).
f. Routine physicals. Routine physical examinations will only be covered to a maximum cost of $350 in 24 months, except that the Board will pay the cost of an annual pap smear or prostate examination.
g. Weight loss programs and fitness clubs. The Board will not approve payment of claims for expenses of membership in weight-loss programs, physical fitness clubs, health spas, or other programs of this nature, unless such treatment is prescribed by a physician as a medical necessity and equivalent treatment could not be obtained at less expense.
h. Alcohol or drug dependency. The Board will only approve payment of claims for the treatment of alcohol or drug dependency by a State-approved treatment program prescribed by a physician and only to the extent not payable from some other source as provided in RCW 41.26.150(2). Treatment for alcohol or drug dependency after the insurance carrier’s reimbursement limitations have been exhausted will be considered on a case-by-case basis, and shall require prior approval by the Board. A member may be subject to evaluation by the Board-appointed or approved physician. RCW41.26.150.
i. Smoking cessation. The Board will approve smoking cessation programs prescribed by a physician to the extent not payable from some other source as provided in RCW 41.26.150(2). Requests for treatment of smoking cessation after the insurance carrier’s reimbursement limitations have been exhausted will be considered on a case-by-case basis, and shall require prior approval by the Board. A member may be subject to evaluation by the Board-appointed or approved physician. RCW41.26.150.
j. Chiropractic care. The Board will pay residual balances associated with chiropractic services until the insurance carrier’s limitations have been exhausted, after which time a prescription for chiropractic care shall be required from an osteopath or orthopedic surgeon prior to further Board approval of such claims. RCW41.26.150(1).
k. Counseling services. The Board will only approve payment of claims for counseling services if provided by a State licensed psychologist or psychiatrist, unless the member is referred to a State certified counselor by a physician or the Employee Assistance counselor.
l. Corrective lenses. The Board will authorize payment for corrective lenses prescribed by an optometrist or ophthalmologist subject to the limits listed below (rates shall be updated every two years). Upon the member's election and with a prescription of an appropriate medical provider the Board will authorize laser eye surgery up to $1,000 within a 5 year period, in lieu of 5 years of the eye wear benefit.
Lenses (maximum of 4 lenses in 24 months)
$ 83 per pair
$123 per pair
$143 per pair
$134 per pair – Soft
$166 per pair – Hard
$199 per year – Disposable
$139 – every 24 months
m. Hearing aids. The Board will pay up to a maximum of $2,500 toward the cost of each hearing aid ($5,000 per pair) during any 36 month period when medical necessity is established by a qualified medical provider or audiologist. 2-year warranty required. Regular maintenance beyond a 2-year warranty and batteries at a reasonable cost will be eligible for reimbursement. Replacements allowed, but not more frequently than once every 3 years.
n. Claims for payment of medical services. Claims for payment of medical expenses shall be submitted on forms provided by the Board, together with any supporting information. The member must indicate whether there is a possibility of payment from some other source. The Board will offset against the approved amount of medical expense claim any benefits which the member could have received through Medicare or medical coverage offered by the City of Kirkland or another employer. The Board will process the claim as if the member were receiving Medicare benefits or medical plan benefits. For example, even if the member will not receive medical plan benefits, the Board will only pay that part of a claim which the medical coverage plan would not have paid for a fully eligible individual. Similarly, even if the member will not receive Medicare benefits because the member did not participate in Medicare, the Board will only pay that part of a claim which Medicare would not have paid for a fully participating individual. The Board will approve a claim for reimbursement, on a quarterly or annual basis, of amounts paid by the member in Medicare premiums only. The Board’s decision to approve or deny claims may be made solely on the basis of written information submitted. A member whose claim is denied may file a request for reconsideration within 10 days of notification of the denial.
The Board will then schedule an opportunity for the member to appear before the Board. The member shall have the burden to show that the claim is for necessary medical services not payable from some other source.
o. Flu shots. Members will be notified in advance each year of when the City will be offering flu shots. In the event they cannot participate in the City plan, the Board will pay up to the amount the City pays for flu shots. This amount may fluctuate from year to year.
16. Amendments. These policies and procedures may be amended by submission and reading of the proposed change at any meeting of the Board. Public notice of the proposals shall be given and a vote thereon shall be taken at the next meeting. If approved by at least three members of the Board, the amendment shall be adopted and shall be in immediate effect. The rules in effect on the date of provision of medical services or application for disability leave or retirement shall be the policies and procedures that govern the Board’s action.
AMENDED this twentieth day of March, 2007
Rex Lindquist, Chair
Kirkland Disability Board