Board Sorts Out Treatment From Actual Medical Opinion

Posted on Nov 21, 2015

In this recent Oregon Workers' Compensation Board case, the Board addressed how a claim should be evaluated, and whether the actual medical problem the injured worker claimed was indeed a medical problem.

Workers' compensation has its own language, and when explaining a case, we are almost always getting the definitions out ahead of time. In this case, the injured worker made a "new medical condition claim." This is a claim for a medical problem that requires treatment. Sometimes, it is not clear whether the condition that is being claimed is actually a medical condition in the first place.

This case involve the knee injury. The injured worker suffered an on-the-job injury, and the insurance company accepted a knee strain. An insurance company accepts a claim by issuing a notice of acceptance. The medical condition in that notice of acceptance governs the insurance company's responsibility to provide benefits. 

The injured worker's condition was much worse than a knee strain. As result, the injured worker made a claim for a knee microfracture, and articular damage. The insurance company denied these claims, contending that the microfracture was not a "condition" and, that the articular damage was not due to the on-the-job injury.  "Articular damage" refers to damage to the joint surface of the knee. If somebody suffers this kind of injury, it can lead to significant arthritis, and the possible need for a knee replacement down the road. Only if this condition was accepted with the insurance company be responsible for further treatment if the knee condition worsened.

The Board agreed with the insurance company on the articular damage claim.  this is because the term referred to a motive treatment rather than a medical condition.

However, when addressing the articular damage claim, the Board first decided on how it should evaluate the claim. The Board concluded that this was a "combined condition" claim. This means that the injury event combined with a pre-existing knee problems the caused the need for medical care, or disability. When these two things combined, then the injury event must be the main cause of the need for treatment or disability.

This is a tougher standard than an injury that does not involve or combined with a pre-existing condition. However, when these claims arise, it is the insurance company, not the injured worker that most prove that the two conditions combined. In addition to that, the insurance company as to show that the pre-existing condition is the main cause of this combined condition.

In this case, the Board found that the insurance company failed to prove that the pre-existing condition was the main cause of the need for treatment. As result, the Board ordered the claim accepted.