Oregon Workers' Comp Board Finds Carrier Must Cover Injections

Posted on Sep 30, 2014

The Oregon Workers’ Compensation Board recently decided a case involving whether or not diagnostic cervical spine injections should be covered under an accepted combined cervical condition. This case really has more to do about the timing of proposed medical treatment as opposed to whether the medical treatment was necessary to treat the condition.

To explain the importance of this case, we first must explain what a combined condition is. We have discussed this issue before, but essentially, when an on-the-job injury, like a fall or lifting injury combines with some pre-existing medical problem, then the insurance company can accept a “combined condition” claim. Insurance companies like to do this because there are only responsible to pay benefits for these conditions for as long as the combined condition is the dominant cause of the need for treatment, or resulting disability. If there is no pre-existing condition involved, then the insurance company has a greater responsibility for the claim because it must pay benefits for as long as the on-the-job injury is a material factor in causing the need for treatment or disability from work.

Another way to think of this is that with combined conditions, the on-the-job injury must be more than 50% of the reason an injured worker is disabled or needs medical care. With a typical injury claim not involving a pre-existing condition, the insurance company must provide benefits for as long as the on-the-job injury is a significant cause (30 to 40%) of the need for treatment or disability.

In this case, the insurance company accepted a combined cervical condition. Most likely, the injured worker had some degenerative disc and joint disease in his neck, but suffered some kind of injury at work. After accepting the combined condition, the insurance company then issued a denial of the combined condition. The injured worker had sought injections to figure out what was going on in the cervical spine. These injections are often called “diagnostic” injections. The insurance company denied the proposed injections, claiming that the condition was no longer compensable under Oregon law.

The Board disagreed. Using basic logic, the Board explained that the injured worker’s doctor performed these injections before the insurance company issued the combined condition denial. This case shows that the “effective date” of the denial of a combined condition is important, because treatment the effective denial date can be found related to the compensable injury.

If you have an on-the-job injury involving a combined condition, or are facing problems in obtaining medical care, contact her office at 503-325-8600. We will look at your case, and we can pursue your claim. Under Oregon law, we do not get paid unless we get results.