An Introduction
The best way to start this discussion is to think about an Oregon Workers' Compensation Claim as an insurance policy that covers your on the job injury. You are entitled to a menu of benefits for the on the job injury. However, there are limits.
The Oregon Workers' Compensation law requires the insurance company to accept a certain medical condition when it accepts your claim. The law also requires the insurance company to tell you what medical condition it is accepting by sending you a Notice of Acceptance.
Why Is The Notice of Acceptance So Important?
I often say that the Notice of Acceptance is the most important document in the claims file. This is because the insurance company decides what it will cover when providing benefits on your claim in the Notice of Acceptance.
For example, if you suffer a knee injury at work, and the insurance company accepts a knee strain, the insurer must cover medical care for the knee strain and nothing more. This can be a problem if you tore a ligament in your knee and need surgery.
We will use this example throughout the article: The injured worker tears their knee ligament at work, but the insurance company accepts only a knee strain.
How Paying Medical Bills Misleads Injured Workers in Oregon
Even though an Oregon Workers' Comp. carrier only accepts a knee strain, it may still pay for a knee surgery even though it does not have to. And when this happens, an injured worker may think that by paying the bill to fix the torn knee ligament, the workers' compensation carrier is including the torn knee ligament in the claim. But that is not the case.
This is because the Oregon Workers' Compensation law allows a comp. carrier to cover medical bills for medical problems it is not accepting. So, even though the knee surgery is covered to fix the torn ligament, the knee strain remains the only accepted condition.
So why would an Oregon Workers' Comp. carrier accept a knee strain, and pay all that extra money for a knee ligament repair when it does not have to?
On theory is that by paying for the surgery, the injured worker will assume that the ligament tear is now part of the claim, and there is no need to get a lawyer involved or ask any questions. This helps the insurance company a lot, because although it is spending a little to pay for a surgery, it will save money when it comes to other benefits.
For example, when the injured worker completes treatment, she may be entitled to permanent partial disability benefits to compensate her for permanent lost earning capacity. But remember, this benefit is only available for the accepted condition. The workers' comp. carrier will likely pay a whole lot less permanent partial disability for a knee strain than a torn ligament.
A serious injury may prevent an injured worker from returning to the job held when the injury occurred, and may qualify for vocational benefits. But, again, this only happens if the accepted condition knocks the injured worker from their job. So, if the knee strain is the only accepted condition, the insurer could avoid providing vocational rehabilitation.
A workers' comp. carrier may want to resolve the case, and in doing so, sneak in a provision where the injured worker agrees that the torn ligament is not work related. That cuts off any possibility of getting further treatment for the torn ligament, or any other problems that may develop as a result of the torn ligament.
The bottom line is that paying a medical bill early in the claim misleads the injured worker about what is covered, and allows the insurance carrier to potentially save a lot of money in the long run.
What You Can Do: The New or Omitted Condition Claim
Oregon workers' compensation law does give you an option. You can make a written request asking the Oregon Workers' Compensation carrier to add conditions to your notice of acceptance that were left out, or were discovered after the initial acceptance of your claim.Omitted Medical Condition Claims
These are the most common kinds of claims we make for our clients. The worker suffers an injury, files a claim, and it is accepted. However, there are medical conditions not included in the Notice of Acceptance. At any time, the injured worker can make a claim that one or more medical conditions were left out or omitted from the Notice of Acceptance. After making your claim in writing, the insurance company has sixty days to decide the claim.
There are a few things to keep in mind. First, it has to be a medical condition, not a symptom. Also, when these claims are made, the insurer may be able to require that you attend another insurance compelled medical examination, often referred to as an "IME." If the claim is denied, the injured worker can appeal the denial by requesting a hearing. Finally, the injured worker must prove that the injury caused the specific medical condition, and this often requires a medical opinion.
New Medical Condition Claims
These claims are just like omitted medical condition claims. The only difference is that the medical condition is discovered after the claim is initially accepted. For example, you may have a knee injury, and the insurer initially accepts it as a knee strain. When things do not heal up like they should, the doctor orders an MRI that shows you actually tore a ligament. That is a newly discovered condition, so the claim is for a new medical condition. Just like the omitted medical condition claim, the insurer has sixty days to investigate the claim, and may be able to send the injured worker out for an insurance compelled medical examination. If the claim is denied, the injured worker can appeal the denial, and at hearing, must prove a relationship between the injury event and the specific medical condition. This often requires a medical opinion to prove the claim.
Questions?
This is a tricky area of workers' compensation in Oregon, and if you are not sure if all your medical problems are covered, and you want to talk it over, contact us. We work with injured workers every day.
