The answers provided to the following questions are brief and are intended for general
information only. If you have questions about the Industrial Insurance Act, as it pertains to
your case, we'll be happy to discuss them with you.
What is the difference between a "self-insured" claim and
other industrial insurance claims?
Larger employers are allowed to self-insure -- that is, set aside funds to pay
claims directly rather than to pay premiums to the Department of Labor and Industries. Most employers
who self-insure utilize service agencies to administer their industrial injury
claims. While, strictly speaking, these agencies are not insurance companies,
they often deal with claims much like a private insurance company would. However,
the identical laws cover both self-insured claims and those directly administered
by the Department.
What determines the amount of compensation I receive in my claim?
The amount of time loss compensation you receive is established by statute, and is determined by your wages at the time of injury. You are paid a percentage of those wages (60%, up to a maximum set by law) with additional percentages for spouse and dependents, all subject to a maximum rate equal to 100% of the average monthly wage of all employment in this state. Compensation for permanent physical or mental impairment is paid pursuant to a statutory schedule of benefits in effect on the date of your injury or when your occupational condition arises.
If I am off work, can I receive both workers' compensation and Social
Security disability benefits?
Yes, under certain circumstances. To qualify for Social Security benefits, you must be unable to work for 12 continuous months before benefits are payable. Also, the standards of proof for Social Security disability are different from workers' compensation in that SSA will consider any and all disabling conditions instead of only those found to be related to your industrial injury. If you qualify for both benefits, there is a maximum amount you can receive in total benefits under both systems. That limitation is 80% of your highest average monthly wage in the five years prior to the onset of your disability. More
information concerning Social Security claims.
How long am I entitled to receive treatment for my injuries?
The law provides that medical treatment is covered until the conditions resulting
from your injuries are judged by medical opinion to have become stable. The
Department or employer is entitled to submit you to periodic medical evaluations
to determine whether or not further treatment will likely improve your condition.
Disputes frequently arise over treatment issues because of conflicting medical
opinions, and legal representation in the claim can often help to resolve such
What causes the lengthy delays in paying time loss and treatment costs,
and awarding permanent disability compensation?
The law states that workers are entitled to "sure and certain relief",
but this is often not the case with many of the nearly 200,000 claims received
by the Department each year. This sheer volume leads to some delay and confusion,
and the frequent reorganizations and transfers of personnel within the Department
often present additional obstacles to speedy resolution of claims. Many workers'
claims simply become lost in the system. In many cases, legal representation
will focus additional attention on a claim being processed by an examiner who
may have a caseload of several hundred claims, and will thereby aid in moving
the claim along to a decision which, if not acceptable, at least can be appealed.
If permanent partial disabilities are paid strictly according to a
statutory schedule of benefits, how can there be any dispute over the amount
I am entitled to receive?
These determinations are made by physicians, who must interpret some rather
ambiguous regulations. Their opinions frequently differ greatly. This is particularly
the case when the Department or self-insured employer has you examined by an
"independent" panel of physicians, who often are conservative, semi-retired
doctors performing many such evaluations every month. Their assessment of your
degree of impairment may be significantly different than your own or another
doctor's. An attorney can assist in obtaining a further evaluation of your disability
and in securing a more fair rating of impairment, which may result in more adequate
compensation for your injuries.
Once I receive an award for permanent disability, do I have any right
to further benefits in my claim?
Yes. Under the Industrial Insurance Act, you have up to seven years from the
date your claim was first closed to apply to reopen it for further treatment
or other benefits. It is therefore important to know if your claim has previously
been closed, and when. In order to reopen your claim, you must have medical
proof that your condition has worsened or has become "aggravated".
You must also demonstrate that it is the same condition arising from your injury,
and that the worsening is not due to some unrelated cause, such as another injury.
The procedure involves filing an Application to Reopen the claim, and attempts
to reopen frequently lead to medical/legal disputes over whether the condition
has, in fact, worsened. A great many applications to reopen are denied on the
first review by the Department, and legal representation in appealing those
denials is usually helpful.
What if I am permanently unable to return to any type of work?
You may then possibly qualify for total permanent disability -- a
"pension" -- under the Industrial Insurance laws. You must
prove there is no form of employment that you can obtain and perform
on a continuous basis. Such claims are usually strenuously contested,
and the Department has grown increasingly conservative in its approach
to pension claims. Cases involving contentions of total permanent
disability usually involve the careful presentation of medical and
vocational proof, almost always best accomplished by a lawyer experienced
in industrial insurance law. More information
about the vocational evaluation and rehabilitation process.
How do I contest an action by the Department or self-insured employer
if I feel it is wrong?
Any final order of the Department -- one which contains protest or
appeal language -- can be protested at the Department or appealed
to the Board of Industrial Insurance Appeals, a separate agency.
You may file a protest or appeal online or in writing, but it must be done
in writing - a phone call will not suffice.
Any protest or appeal must be supported by medical or vocational evidence,
and in the appeal process, the Department or self-insurer is represented
by counsel. In both actions, a worker is well advised to have legal
representation. More information concerning
the appeals process.
How long will it take to resolve my claim?
If an adverse decision is protested to the Department, the process of resolving
the issues presented can take from a few weeks to several months, depending
upon a variety of factors, including individual claim adjudicators and the complexity
of the claim. If an appeal is taken to the Board, the claim may be resolved
within a few months in the Board's "mediation" process, but if hearings
are necessary, the case will usually take a year or more before a final decision
is rendered. Even after such a decision, either party can appeal to the Superior
Court. Depending upon the county in which such an appeal is filed, another one
to two years may elapse before the case is tried and finally decided.
If my employer or co-workers were at fault for my injuries, can I sue
No. Under our workers' compensation system, employers and co-workers have what
is called "immunity" from legal action based on their fault or negligence.
On the other hand, your own fault or negligence, if any, will not affect your
right to recover workers' compensation benefits. This "no fault" system
is supposed to allow the worker to receive benefits quickly and without any
initial dispute over who was to blame for your accident.
If someone other than my employer or co-worker was responsible for
my injuries, can I sue them?
Quite possibly. If a party other than your employer or a co-worker
-- in other words, a "third party" -- causes your injuries,
you may be able to file a civil suit for damages in addition to recovering
workers' compensation benefits. Such a "third party" might
be, for example, the driver of the other vehicle in an on-the-job
auto accident, or the manufacturer or supplier of a defective product
or machine. More information concerning
personal injury claims.
What is the benefit of suing such a "third party"?
Your recovery of damages in a civil suit is potentially much greater than your
entitlement under the workers' compensation system, in which benefits are limited
by statute. You can continue to receive workers' compensation benefits while
pursing a third-party lawsuit. You will, however, have to repay a portion of
those benefits to the Department of Labor and Industries or self-insured employer
if a third-party recovery is obtained.
How can an experienced attorney assist in handling my claim?
There are literally hundreds of laws and thousands of cases interpreting those
laws which may impact your entitlement to benefits. An attorney knowledgeable
about those laws, and the system in general, can help to ensure your rights
are protected. Because of the complexity of the medical-legal issues in these
claims, an unrepresented worker may well fail to receive appropriate benefits
in times when the administration of the Industrial Insurance Act has become
increasingly conservative, and when so many employers are represented by legal
counsel in the process. Large agencies and employers can also simply make administrative
mistakes, resulting in the denial of benefits which may rightfully be yours.
Regrettably, if claims decisions are not challenged within the short time periods
prescribed by law, they are final and binding even if later shown to be based
on error of fact or law.
In some cases, such as those not involving serious injuries or extensive time loss from work, and with no employer intervention in the claim, legal representation may not be necessary. Our experience has shown, however, that the old adage -- "an ounce of prevention is worth a pound of cure" -- is increasingly applicable to a worker's legal rights under the Industrial Insurance Act. Having an experienced attorney or paralegal review your claim, even if only during an initial telephone call, may assist in identifying and attempting to eliminate future problems or, in the best case scenario, may at least confirm that you are, in fact, receiving all of the benefits to which you are entitled.
Personnel at Causey Law Firm have handled literally thousands of cases such
as yours, from initial administrative levels through the appellate courts of
the State of Washington. We have decades of combined experience in handling
the claims of injured workers.
We have been actively involved in major legislative battles involving the rights of injured workers for years. Mr. Causey has chaired the Workers' Compensation Section of the Washington State Trial Lawyers' Association, and has also chaired the Workers' Compensation and Workplace Injury Section of the Association of Trial Lawyers of America. In 1995 he was one of the founders of the Workplace Injury Law & Advocacy Group (WILG), a national network of prominent workers' compensation attorneys who meet regularly to address legislative attempts to limit or reduce workers' entitlements in all fifty states. Mr. Causey served a two-year term as President of WILG.
Additionally, we limit our practice to medical-legal matters -- in other words,
injury and disability claims. We are therefore in a position to coordinate an
industrial insurance claim with, for example, a Social Security disability claim,
a personal injury case, a "third-party" claim, or other insurance-related matter,
insuring that you receive all of the benefits to which you are entitled, from a
variety of potential sources.
Please feel free to contact our office
for more information.
It is easier to avoid any pitfalls in your claim than to try to unravel them
after the fact. Contact us now to discuss the details of your case.