Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-14 - Industrial insurance › Section 296-14-400 - Reopenings for benefits

Current through Register Vol. 24-14, July 15, 2024
The director at any time may, upon the workers' application to
				reopen for aggravation or worsening of condition, provide proper and necessary
				medical and surgical services as authorized under
				RCW
				 51.36.010. This provision will not apply to
				total permanent disability cases, as provision of medical treatment in those
				cases is limited by
				RCW
				 51.36.010.
The seven-year reopening time limitation shall run from the
				date the first claim closure becomes final and shall apply to all claims
				regardless of the date of injury. In order for claim closure to become final on
				claims where closure occurred on or after July 1, 1981, the closure must
				include documentation of medical recommendation, advice or examination. Such
				documentation is not required for closing orders issued prior to July 1, 1981.
				First closing orders issued between July 1, 1981, and July 1, 1985, shall for
				the purposes of this section only, be deemed issued on July 1, 1985.
The director shall, in the exercise of his or her discretion,
				reopen a claim provided objective evidence of worsening is present and
				proximately caused by a previously accepted asbestos-related disease.
In order to support a final closure based on medical
				recommendation or advice the claim file must contain documented information
				from a doctor, or nurse consultant (departmental) or nurse practitioner. The
				doctor or nurse practitioner may be in private practice, acting as a member of
				a consultation group, employed by a firm, corporation, or state agency.
For the purpose of this section, a "doctor" is defined in WAC
				296-20-01002.
When a claim has been closed by the department or self-insurer
				for sixty days or longer, the worker must file a written application to reopen
				the claim. An informal written request filed without accompanying medical
				substantiation of worsening of the condition will constitute a request to
				reopen, but the time for taking action on the request shall not commence until
				a formal application is filed with the department or self-insurer as the case
				may be.
A formal application occurs when the worker and doctor complete
				and file the application for reopening provided by the department. Upon receipt
				of an informal request without accompanying medical substantiation of worsening
				of the worker's condition, the department or self-insurer shall promptly
				provide the necessary application to the worker for completion.
If, within seven years from the date the first closing order
				became final, a formal application to reopen is filed which shows by
				"sufficient medical verification of such disability related to the accepted
				condition(s)" that benefits are payable, the department, or the self-insurer,
				pursuant to
				RCW
				 51.32.210 and
				51.32.190,
				respectively shall mail the first payment within fourteen days of receiving the
				formal application to reopen. If the application does not contain sufficient
				medical verification of disability, the fourteen-day period will begin upon
				receipt of such verification. If the application to reopen is granted,
				compensation will be paid pursuant to
				RCW
				 51.28.040. If the application to reopen is
				denied, the worker shall repay such compensation pursuant to
				RCW
				 51.32.240.
Applications for reopenings filed on or after July 1, 1988,
				must be acted upon by the department within ninety days of receipt of the
				application by the department or the self-insurer. The ninety-day limitation
				shall not apply if the worker files an appeal or request for reconsideration of
				the department's denial of the reopening application.
The department may, for good cause, extend the period in which
				the department must act for an additional sixty days. "Good cause" for such an
				extension may include, but not be limited to, the following:
(1) Inability to schedule a necessary medical
			 examination within the ninety-day time period;
(2) Failure of the worker to appear for a
			 medical examination;
(3) Lack of
			 clear or convincing evidence to support reopening or denial of the claim
			 without an independent medical examination;
(4) Examination scheduled timely but cannot
			 be conducted and a report received in sufficient time to render a decision
			 prior to the end of the ninety-day time period.
The department shall make a determination regarding "good
				cause" in a final order as provided in
				RCW
				 51.52.050.
The ninety-day limitation will not apply in instances where the
				previous closing order has not become final.
Statutory Authority:
				  RCW
				   51.36.010,
				  51.04.020, and
				  51.04.030. 12-06-066, §
				  296-14-400, filed 3/6/12, effective 4/6/12. Statutory Authority: 2004 c 65 and
				  2004 c 163. 04-22-085, § 296-14-400, filed 11/2/04, effective 12/15/04.
				  Statutory Authority:
				  RCW
				   51.32.190 and
				  51.32.210. 90-22-054, §
				  296-14-400, filed 11/5/90, effective 12/6/90. Statutory Authority: Chapters
				  51.04, 51.32 and 51.36
				  RCW. 90-04-007, § 296-14-400, filed 1/26/90, effective 2/26/90. Statutory
				  Authority: Chapters 51.08 and
				  51.32 RCW. 88-14-011 (Order 88-13),
				  § 296-14-400, filed 6/24/88.