How it Works: The Insurer Decides Whether to Pay
The Oregon Workers' Compensation statute is a private insurance system. When a worker is injured on the job, he or she files a claim with the employer. The employer typically turns the claim over to its workers' compensation insurance carrier. That insurance company makes a decision on the claim. There are several ways an insurance company can deny claim. This article gives some examples of the different kinds of claims denials with an Oregon Workers' Compensation claim.
Course and Scope Denials
An injured worker must show that he or she was injured on the job in order to enjoy workers' compensation benefits. In Oregon, the injury must occur in the course and scope of employment, and arise out of the work activity. There is a lot of case law about what this means, but here the basics.
The first part of the test deals with "course and scope" This means that the injured worker has to be on the clock, and performing some kind of work activity when the injury event occurs.
The second part of this is the "arising out of" test. This means that there has to be a relationship between the resulting injury and the work activity. One example that comes to mind is a worker having some kind of a health event like a stroke or a heart attack while at work. A stroke or heart attack while at work may have no connection to the work activity, and in that case, the incident would not be covered. However, there are cases where the type of work has a lot to do with the onset of the heart attack or stroke. This is often a question for a medical expert.
Compensability or "Medical" Denials
"Compensability" is a broad term, but for the purposes of this article, we are limiting it to denials based on medical opinion evidence. In some cases, the insurance company may retain a doctor to examine the injured worker. The insurance retained physician may then provide an opinion that the work activity was not enough of a cause of the resulting health issue to be covered under the Workers' Compensation system. The physician may point to some other, unrelated, medical condition to explain the onset of symptoms. This happens in cases where an injured worker is claiming an occupational disease, or where the injured worker has a pre-existing condition and the same areas the body that was injured on the job.
Current "Combined Condition" Denials
This is a mouthful. If the employer proves that an otherwise compensable injury combined with a "pre-existing condition," then the accepted medical condition is called a "combined condition." The insurance company is responsible for the combined condition only as long as the injury is the major cause of the combined condition.
An insurance company may find that a change in circumstances has caused the on-the-job injury to no longer be the major cause of the combined condition. In this case, the insurance company can issue a current combined condition denial. There must be some medical opinion evidence supporting the finding that an on-the-job injury is no longer the major cause of a "combined condition."
What You Can Do
If you receive a denial, you can file a request for hearing to appeal the denial. You have sixty days from the date of the denial letter to file your request for hearing. If you have any doubt about the denial, consider filing the request for hearing. It does not cost anything to request a hearing, and you have the right to withdraw the request if you find out that there is no evidence to support the claim.
How We Help
There are many other types of claim denials, but these are the most common we deal with in helping injured workers. If you have a question about a denied Oregon Workers' Compensation claim, contact us. We help injured workers every day.
