Workers' Compensation Board Affirms Combined Condition Denials

Posted on Sep 29, 2014

The Workers’ Compensation Board ruled that an insurance company can still change its mind about what medical condition it is responsible for what it worker is injured on the job.

If somebody suffers an injury on the job, then the insurance company is responsible for the medical condition that results from that injury. However, if the on-the-job injury combines with a pre-existing condition, like arthritis, or a prior medical problem, then the insurance company can accept what is called a “combined condition.”

This is a big deal because the insurance company is only responsible to pay benefits for a combined condition for as long as the on-the-job injury is the major cause of this condition. In a typical injury claim, the Worker’s Compensation carrier must pay benefits for as long as the injury is a significant factor in causing the need for treatment, or disability from work. The bottom line is that an injured worker must show a stronger relationship between the work injury and the resulting combined condition in order to obtain benefits.

In May, we reported a Court of Appeals case that redefined the term “combined condition.” Essentially, a combined condition is a combining of the work injury event and the pre-existing condition. For more information about what a pre-existing condition is, read here.

The Workers’ Compensation Board is now dealing with how to interpret this new case law. In a recent decision, the Board found that even if an insurance company initially accepts an injury, and not a combined condition, it can change its mind and change the accepted condition to a combined condition. Of course, there must be some medical evidence to support this change of heart.

When insurance companies turn a basic injury claim into a combined condition claim, they will often deny the combined condition, and do it on the exact same day. So, it is not unusual for an injured worker to receive an amended notice of acceptance that changes an injury claim to a combined condition, and on the same day, receive the denial of that combined condition.

The lesson learned from this case is that combined conditions are still a real issue for injured workers in Oregon, and that even though a claim is initially accepted, there could be trouble in getting benefits in the future.

If you have an accepted workers’ compensation claim, and you are concerned about whether benefits will continue, call us at 503-325-8600. We can review your claims file, and help you know where you stand.