We often hear from members that one of the most frustrating aspects of Washington workers’ compensation is claim validation (i.e. verifying that the employee’s injury or illness occurred during the course of their employment). Oftentimes, it feels like an employer is on the hook for an employee’s injury, even if the injury happened off duty or there was a preexisting condition that made the employee more prone to injury. While the bar is low for what qualifies as an allowable claim, there are important steps you can take to help your claims manager get a claim rejected or keep claim costs down if the claim is accepted.
Over the next few months, we’ll be writing a series of articles exploring different aspects of claim validation. In this first article, we start by examining the required elements for claim validation (or “prima facie”) that must be met for a claim to be allowable. If these prima facie elements are met, then a claim is considered valid unless you can present contradicting evidence:
- Course of employment –The employee was acting in the course of their employment when the injury or illness happened;
- Legal definition of injury –The employee’s descriptive statement of the injury or illness meets the legal definition;
- Causal relationship –A medical opinion must relate the diagnosed condition to the employee’s description of the injury on a more probable than not basis. In simple terms: it’s more than 50% likely that the injury caused the condition; and
- Timely filed – Injury claims must be filed within one year after the day of the injury (we will discuss timing for filing occupational disease claims in another article).
The Washington Department of Labor and Industries (L&I) will default to accepting a claim if the prima facie elements are met, even when there are suspicious circumstances or other factors that cast doubt on the validity of the claim. When that happens, it’s easy to feel frustrated with the system or feel like your employee is taking advantage of you, but don’t despair. With the assistance of your claims manager, you can challenge the validity of the claim if there’s justification for doing so. In our next article, we’ll explore how you can help your claims manager in the process of challenging claim validity (hint: documentation is your friend!).
If you have questions about the validity of a current workers’ compensation claim or want to explore strategies for challenging it, give us a call. We’ll share how our workers’ comp programs can support you with this and much more.
