What to Do If Workers' Comp Claim Is Denied in Washington

Workers’ compensation is a vital safety net for injured workers in Washington. It provides essential benefits to those who suffer work-related injuries or an occupational disease.

These benefits include coverage for:

• Medical bills: Ensuring that injury victims receive the necessary medical treatment.
• Lost wages: Compensating for income lost due to injury.
• Travel expenses: Reimbursing travel costs related to medical appointments.
• Vocational rehabilitation: Assisting with retraining if the injured worker is unable to return to the same type of work.  
• Death benefits: Paid to the victim’s family in the tragic event of a fatality.

But what happens if your employer protests your claim or it is denied? Unfortunately, many injured workers in Washington face this reality, leaving them confused, frustrated, and burdened with mounting bills.

It’s important to remember that a workers’ comp denial isn’t necessarily the end of the road. The workers' compensation attorneys at Lehmbecker Law are here to guide you through the steps to take if your workers' comp claim is denied in Washington.

How Many Workers’ Comp Claims Are Denied?

While the exact number of denied claims varies, research estimates that around 7% are rejected annually. For the roughly 2.8 million workplace injuries reported in 2022, that would translate to nearly 200,000 individuals facing the initial hurdle of a denied claim.

Why are so many claims denied? The reasons can vary, but one surprising factor stands out: incorrect information. A retrospective study from the early 2000s revealed that a staggering 78.8% of denied claims involved errors in medical reports.

That doesn't mean the fight for compensation ends there. Initial denials are far from the last word. In fact, approximately 47% of respondents to a recent survey who ultimately received benefits reported having their claims initially rejected.

So what can you do if your claim gets denied? Seeking legal guidance can be a game-changer.

Studies show that workers with legal representation typically achieve better outcomes and receive more compensation than those who navigate the process alone.

Common Reasons for Workers’ Compensation Claim Denial

The justifications for denial can be diverse and potentially complex, but the following reasons are all common.

• Your injury or illness wasn’t work-related: This is the most common reason for a denied claim. The injury must have arisen out of and in the course of your employment to be covered by workers' compensation. For example, if you slip and fall on the ice while walking to your car after work, your injury wouldn’t be considered work-related.
• You didn’t report the injury or illness within the required time frame: In most states, you must report a work-related injury or illness to your employer within a certain period, typically 30 days. If you wait too long to give notice of an injury, your claim may be denied.
• You don`t have enough evidence to support your claim: The burden of proof is on you to show that your injury or illness was work-related. That means you must provide documentation to support your claim, such as medical records, witness statements, and accident reports.
• You were intoxicated when your injury occurred: If you were intoxicated or under the influence of drugs at the time of the injury, it could be grounds for denial.
• You were engaged in horseplay or misconduct: If you were injured while engaged in horseplay, misconduct, or other unsanctioned and inappropriate behavior, your workers' compensation claim likely won’t succeed.
• You have a pre-existing condition that contributed to the injury: If it’s discovered that a pre-existing condition contributed to your injury, your workers' compensation benefits may be reduced or denied outright.

What to Do When Your Workers' Comp Claim Is Denied

Facing a denied workers' comp claim can be frustrating and confusing. Keep in mind, however, that there are still steps you can take to seek compensation. Here's a breakdown of your options.

Step 1: Understand the Denial

Start by carefully reviewing the rejection letter from the Washington State Department of Labor & Industries (L&I). It should explain the specific reasons your claim has been denied. This insight will be crucial for choosing your next steps.

Step 2: Pursue Your Rightful Benefits

You can take one of two courses if you believe your denial is unwarranted.

Protest to L&I

With this approach, you’ll register your concerns with your claims manager at L&I. You’ll need to gather any additional evidence that may strengthen your case and submit it with your protest within 60 days of receiving the denial.

Appeal to the Board of Industrial Insurance Appeals (BIIA)

This is a formal legal process requiring more careful preparation. You'll file a written appeal to the BIIA outlining why you disagree with the denial and providing supporting evidence.

The deadline for this option is 60 calendar days from the denial date (15 for decisions regarding vocational benefits). If the board doesn’t receive your written protest in that time, the decision will stand.

Step 3: Seek Professional Legal Help

Lastly, consider consulting a qualified workers' compensation attorney. Their advocacy can significantly increase your chances of success.

Among other things, your lawyer can:

• Advise you on the best course of action: They’ll assess your situation to identify potential weaknesses and recommend the most effective strategy.
• Gather evidence and build your case: They know how to collect and present evidence that strengthens your claim.
• Represent you in hearings and appeals: They have the knowledge and experience to navigate the legal system and fight for you effectively.

Don't give up if your application for workers’ compensation benefits has been turned down. With reliable legal support, you can still secure the compensation you need.

How to Protest a Workers’ Compensation Claim Decision

Here’s how to proceed if you decide to protest your denial with L&I.

Step 1: Identify Your Claim Manager

You’ll find the name of your claim manager on any official L&I correspondence you’ve received. This person will be your first point of contact for challenging the decision.

Step 2: Write a Compelling Protest

Compose a concise yet cogent letter outlining why you disagree with the denial.

Make sure to include:

• The specific decision you're protesting: State the nature, type, and date of the L&I denial you're challenging.
• Strong supporting arguments: Clearly explain why you believe the decision is wrong, providing evidence to strengthen your case, such as medical records, witness statements, or accident reports.

Keep in mind that you have only 60 days from the denial date to file your protest. Don't miss this crucial deadline!

Step 3: Address Claim Closure (Optional)

If L&I closed your claim completely, your protest should also include your current medical information. Explain and verify your condition and treatment plan through written updates from your doctor or healthcare provider. Include a prognosis if available. Don't forget to include your name and L&I claim number on every page of your protest.

Step 4: Submit Your Protest

To submit your protest online, you can upload it through the My L&I hub of the Department of Labor and Industries website.

If you’d prefer to mail it, send your printed protest to the following address:

Claims Section

Department of Labor & Industries

P.O. Box 44291

Olympia, WA 98504-4291

What Happens Next?

L&I will review your protest and issue a new decision that affirms, modifies, or reverses the original denial. If your protest is successful, your employer's insurance company will become responsible for all medical expenses related to your injury. Otherwise, you can proceed to appeal the decision to BIIA.

How to Appeal a Workers' Comp Claim Denial

Washington offers injured workers an avenue to push back against unfairly denied workers’ comp claims: appealing to the Board of Industrial Insurance Appeals (BIIA).

Time is of the essence with this option, as there are strict deadlines for filing a workers' compensation appeal. More specifically, you’ll have 60 days to address claim and payment decisions and only 20 days for medical provider billing decisions.

Essential Elements of Your Appeal

To ensure that your appeal receives due consideration, make it a point to include the following:

• Your name and claim number (include on every page).
• The date of the decision or order you’re appealing.
• A description of the decision or order.
• The reason(s) you disagree with the decision.
• Your mailing address and phone number.
• The city in which you’d like the proceedings to take place.
• Any supporting information.

If your appeal doesn’t include each of these elements in its proper place, it may be rejected, resulting in BIIA affirming the original decision.

Submitting Your Appeal

You can submit your appeal electronically through the BIIA website.

Alternatively, you can mail a printed appeal to the following address:

Board of Industrial Insurance Appeals

PO Box 42401

Olympia, WA 98504-2401

Another option is to visit the BIIA office in Olympia to deliver your appeal in person.

Note: While you can file an initial protest with L&I, you can also appeal directly to the BIIA without this step. The BIIA will notify L&I and give them a chance to reconsider their decision. If they affirm it, your appeal will proceed to a hearing.

What Happens to Medical Bills When Workers' Comp Is Denied?

When your workers' compensation claim is denied in Washington State, the burden of your medical bills falls on you. This can be incredibly stressful, especially after you’ve sustained a work-related injury. The good news is that help might be available in other forms.

Personal Health Insurance

If you have a personal health insurance policy, it might cover some or all of your bills, depending on your specific plan, deductibles, and copays. However, your insurer might deny coverage if they don't consider your injuries work-related.

State Programs

You might also qualify for assistance from Washington State’s Basic Health Plan or Apple Health (Medicaid) based on your income and the size of your family.

Negotiation with Providers

Another option is to attempt to negotiate reduced rates or payment plans directly with medical providers, especially for future treatment. It will help to emphasize the financial hardship you’re facing due to the claim denial.

Regardless of the course you take, it’s imperative to document everything. Keep detailed records of all medical bills and communication with L&I, your employer, and various healthcare providers. These documents will be critical for future appeals or legal actions.

You must also adhere to all applicable deadlines, as missing them can permanently waive your rights to pursue these options.

When Do You Need a Workers' Comp Lawyer to File an Appeal?

Initiating a workers' comp claim can be complicated, and appealing a denial adds another layer of uncertainty. While consulting a lawyer is always helpful, there are specific situations where their guidance becomes crucial.

Consider seeking legal support if:

• The denial reason seems unfair or questionable: An attorney can assess your case, identify potential flaws in the denial, and advise you on the best course of action.
• Medical evidence is ambiguous or disputed: Your lawyer can ensure that your medical records accurately reflect your injury and gather expert opinions if needed.
• You face legal complexities: From meeting deadlines to preparing for hearings, a skilled attorney can ensure that you meet all requirements and present your case effectively.
• You’re seeking maximum compensation: Your legal professional’s experience can help maximize your potential benefits.

An attorney can empower you throughout the appeals process, offering valuable guidance and advocating for your rights.

Get Help with Your Workers’ Compensation Claim

An unfavorable L&I decision can feel like a heavy blow. Fortunately, you don't have to face this challenging time alone. Lehmbecker Law is here to guide you through the appeals process and pursue the compensation you need. Contact us for free consultation.