Claims Adjudication Tune-Up (CAT-U)
April 2026 Edition
Welcome to Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter. This is where the Washington State Department of Labor & Industries (L&I) shares best practices and information, as well as highlight opportunities for improvement. The focus of this month’s edition of CAT-U is Accept/Deny Newly Contended Condition.
Legal Corner
Washington Administrative Code (WAC) 296-15-425: “Communicating to injured workers during the course of the claim.”
“(3)Within five days of a claims administrator taking action on a claim involving:
(c) Acceptance or denial of a condition contended under the claim;”
Take away: When a condition is newly contended under a claim, a template letter must be sent to the worker either accepting (F207-220-000) or denying (F207-221-000) the condition. Contention means that the worker or provider feels that an actual diagnosed condition is related to the industrial injury or exposure. If a medical opinion supports the diagnosis and relationship, the condition should be allowed. This includes pre-existing conditions that were aggravated by the injury or exposure. A contended condition that is not supported by medical findings would be denied. If there is no contention that the condition is being claimed, no template should be sent.
News You Can Use
Miller v. Dept. of L&I (1939, Washington State Supreme Court)
“We have held in an unbroken line of decisions that, if any injury, within the
statutory meaning, lights up or makes active a latent or quiescent infirmity or
weakened physical condition occasioned by disease, then the resulting disability
is to be attributed to the injury, and not to the preexisting physical condition.”
Summary: Clinton Miller’s claim for a low-back injury was closed without permanent partial disability (PPD). He appealed, contending his condition was not fixed. Miller had an extensive permanent disability due partly to a congenital weakness, and partly to the injury in the already weakened area. The combination resulted in a chronic strain at the lumbosacral area and the formation of localized traumatic arthritis. The court directed the department to accept the entire disability.
Claim impact: Workers whose prior conditions become symptomatic as a result of the industrial injury or exposure should have those conditions treated under the claim. An example might be a worker who has an impact to the knee, with the impact aggravating their pre-existing osteoarthritis. Since the worker has no history of treatment for this condition, the employer would be responsible for paying for treatment and associated time-loss and PPD.
Trainer Trivia
Question:
When was the first Earth Day?
Answer to last month’s trivia: The University of Oregon Webfoots won the 1939 inaugural “March Madness” championship over Ohio State, 46 to 33.
More reading/resources:
Self-Insurance Claim Adjudication Guidelines, Claim Validity (Pre-existing
Conditions), Medical Treatment (Newly Contended or Unrelated Medical
Conditions)
WAC 296-20-055:Limitation of treatment and temporary treatment of unrelated
conditions when retarding recovery.
WAC 296-20-03013:Will the department or self-insurer pay for a denied outpatient
in special circumstances?
Reminders/tips from the SI teams:
When a condition is determined to be aggravated by an industrial injury, the self-insurer must send the Accept Newly Contended Condition template to the worker advising that the condition has been accepted under the claim. The self-insurer should also advise that the condition is accepted as an aggravation.
Under WAC 296-15-425, L&I will not issue an order upon request. The department will only issue an order if the worker disputes the condition. Rather than asking for a department order regarding the determination on a contended condition, the claim manager should send out the Accept or Deny Newly Contended Condition template depending on their decision. This way, if the worker disagrees, there is a decision about which the Department can issue an order.
For more information, send an email to the SI Trainer Questions Box.
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