Oregon Workers' Comp.Board Decides New Medical Condition Claim

Posted on May 13, 2015

In this case, the Oregon Workers' Compensation Board upheld the denial of a new/omitted medical condition claim for "sacroiliac joint dysfunction with radiculopathy."

The Board, in arriving at its decision, reviewed the medical records, finding there was no evidence that this condition existed for the injured worker.

In this case, the insurance company initially accepted a lumbar strain. This is important because the benefits an injured worker is entitled to are limited to the accepted condition. The injured worker then made a claim for sacroiliac joint dysfunction. That claim was denied, and the injured worker argued that medical opinions supported the claim.

The Board acknowledged that other physicians had made the diagnosis, but reasoned that because these physicians do not refer to "radiculopathy," the diagnosis was different than that claimed. The Board also dismissed the opinion of a nurse practitioner who initially diagnosed sacroiliac joint dysfunction with radiculopathy. However, the Board dismissed this opinion because it thought that the nurse practitioner had made different diagnoses, and did not explain the change of opinion.

One Board member dissented. A "dissent" occurs when one of the board members disagrees with the majority of the board members writing the opinion. This Board Member asserted that because the nurse practitioner had examined the injured worker shortly after the injury, the nurse practitioner was in a better position to make an accurate diagnosis. In addition,  the dissenting Board Member reasoned that the other examining physicians bolstered the strength of the nurse practitioner's opinion because they also diagnosed a sacroiliac joint condition.

The dissenting Board Member made another valid observation. She explained that the physician who denied existence of the sacroiliac condition had not examined the injured worker until a year and a half after the injury. This dampened the strength of the opinion.

Medical opinions are central and establishing a new medical condition claim, or any type of claim. If you have a denied claim, call us at 503-325-8600. We can review your file, and if feasible, we will obtain the medical opinions needed to support your case.