Is That Claim Valid in Washington? A Brief Refresher
When a claim is initially filed, the first determination must be whether the claim is an injury or occupational disease. These two claim types are handled differently and have separate requirements. We can break down validity for both an injury and an occupational disease.
Industrial Injury Claim
When confirming validity, the first determination by the claim manager is whether the claim was filed timely, as injured workers have one year to file their claim after the date of injury. If timely filed, then there are three requirements for a valid industrial injury claim to be allowed. These include:
- A descriptive statement that satisfies the legal definition of injury.
Per RCW 51.08.100, an injury is defined as a sudden tangible happening, of a traumatic nature, producing immediate or prompt results, and occurring from without, and such physical conditions as result therefrom. Usually, the injury is straightforward but claim managers can seek clarification of the incident seeking a description of the events leading to the incident, the nature of the worker’s condition, and corroboration by any witnesses.
- The worker must have been acting in the course of employment.
To be considered acting in the course of employment, a worker must be acting at their employer’s direction or furthering the employer’s business. Accordingly, an injury does not need to be caused by a work-related activity. Notably, in Washington state no consideration is given to degrees of fault by the worker.
Many considerations on what constitutes a worker to be acting in the course of employment are nuanced and heavily litigated. Injuries that occur in parking lots are usually not compensable, but sometimes coverage is allowed in situations where job duties require the worker to be in the parking lot. Further, injuries that occur when a worker is coming or going from work are usually not compensable, but sometimes coverage is allowed if the worker is within a company-controlled area, if they are in a company car, or if they were exposed to hazards.
3) A medical opinion relating the condition diagnosed to the injury on a more probable than not basis.
Finally, there must be a causal relationship between the injury and the condition diagnosed. The injured worker’s provider must provide a medical opinion determining that the diagnosis was caused by the injury on a more probable than not basis. A mere possibility is not enough for the claim to be allowed.
Occupational Disease Claim
Per RCW 51.28.055, claims for occupational diseases must be filed within two years of the date the worker was notified in writing from a provider that an occupational disease exists. The Department does not have authority to waive the filing deadline.
Similar to an industrial injury, there are three requirements that need to be met for an occupational disease claim to be allowed. These include:
- The disease must arise naturally and proximately out of employment.
RCW 51.08.140 provides that “occupational disease” means such disease or infection as arises naturally and proximately out of employment. For a disease to arise naturally out of employment, the condition must be a natural consequence of the distinctive conditions of employment. The disease must arise from the distinctive job requirements and must be a natural consequence of the work process. A claim is not valid if the occupational disease resulted from activities common to all employment, coincidental to employment, or distinctive to the worker.
- A provider must opine on a more probable than not basis that the disease is related to work activities.
A provider must indicate findings based on a more probable than not basis that the work conditions caused the worker’s condition, which means more than 50% likelihood. The requirement is not met if the provider opines that the work condition possibly, could have, maybe, or might have caused the disease.
- The provider must substantiate the diagnosis with objective medical findings.
The provider’s opinion that work conditions caused the worker’s condition on a more probable than not basis must be substantiated with objective medical findings, which are findings that cannot be seen, felt, or measured. A worker’s subjective reporting and complaints are not objective findings. Examples of objective medical findings include imaging reports or results of standard tests conducted.
Whether the claim filed is for an industrial injury or an occupational disease, three requirements must be met for the claim to be valid and allowed at the Department. If you have any questions or would like to discuss claim validity, please feel free to contact me at , or 971.867.2733.
Posted by McKenzie Brooks.
