Denied PFML claim filed before surgery - need advice on appeal vs. refiling

You need to file a new claim after your surgery is complete. PFML requires documentation of a "qualifying event" which in your case is the surgery. You'll need a Certification of Serious Health Condition form completed by your healthcare provider. Don't appeal - that's for when you think the decision was wrong, but in this case, the decision was technically correct (you hadn't had surgery yet). Once your surgery is done, file a new claim and make sure your doctor completes the certification form. You should be able to backdate your claim to the date of surgery.

omg same thing happened 2 me! i filed early cuz the HR lady at work said to do it like a month b4 my procedure. got denied 2. so frustrating!!

As someone who processes PFML claims, I can clarify a few things: 1. You absolutely need to file a new claim AFTER your surgery takes place. The denial was correct because you hadn't experienced the qualifying medical event yet. 2. The document you need is called a "Certification of Serious Health Condition" form. Your healthcare provider must complete this, not just write a generic letter. 3. There is a 7-day waiting period before benefits begin. This means you won't be paid for the first week after your surgery. 4. You can file your new claim up to 30 days after your surgery without it being considered "late filing." 5. You'll need to provide your healthcare provider's contact information, dates of treatment, and estimated recovery time. Don't appeal the current denial - it will just waste time. Start fresh with a new claim after May 10th.

I went through this exact nightmare in January. The whole PFML system is DESIGNED to deny claims and make it as hard as possible to get benefits we've paid into!!! I applied before my surgery too, got denied, then had to reapply after. But then they said my documentation wasn't sufficient even though my doctor filled out their stupid form. Had to appeal THAT decision and wait another 6 weeks while bills piled up. The ESD is completely broken and nobody can ever get through to them on the phone to fix problems!!

just wondering did u check ur WA PFML account online? sometimes they list exactly what docs u need to send in. thats how i figured out what was wrong w/ my claim

To answer your follow-up question: Yes, there is a 7-day waiting period before PFML benefits begin. This means the first week after your surgery won't be paid. It's actually a good idea to use any available sick time for that first week if possible. Also, make sure when you file your new claim that you have these documents ready: 1. The Certification of Serious Health Condition form (completed by your doctor) 2. Your surgery records/discharge paperwork 3. Your estimated recovery timeline If you know you'll be out for 12 weeks, for example, have your doctor document that on the certification form. This helps prevent having to extend your claim later.

u might want to check if your employer offers supplemental benefits too besides the state PFML. my company has a policy that covers that 7 day waiting period the state doesn't pay for. also the PFML only pays like 90% of your salary up to some max amount ($1,427 per week I think?).

I had knee surgery last year and I had the same exact problem. I ended up waiting until 2 days after my surgery to file and it went through fine. Make sure you know your first day of missed work too because they'll ask for that exact date. Also my doctor's office was really familiar with the certification form and had it ready for me when I asked.