Workers' Compensation Board Slashes Injured Workers' Benefits

Posted on Jun 29, 2015

This case illustrates an issue that is currently undecided, and will probably be resolved at the Oregon Court of Appeals or even the Oregon Supreme Court.  There are some links to get an understanding of the underlying issues, but let's walk through the issues before summarizing the case.

There are different kinds of claims that exist in the Oregon Workers' Compensation system. One claim is known as a "combined condition" claim. This occurs when the work injury event, which could be a fall or back strain, combined with some pre-existing condition. A "pre-existing condition" is a medical problem that the injured worker may have treated for the past, or meets the legal definition of "arthritis." These claims  are accepted as long as the work injury event is the major cause of the need for medical treatment or disability from work. If there is some change in circumstances that causes a pre-existing condition to become the main reason for disability or need for medical care, the insurance company or its employer can issue a denial, claiming that the current combined condition is no longer compensable. Of course, the denial can be appealed.

Another kind of claim is commonly referred to as an "injury claim." Instead of saying there was a combination of the work injury event and some pre-existing condition, the insurance company or its employer will instead acknowledge an actual physical injury like a torn rotator cuff, a back strain, or a broken bone. This claim remains open as long as there is a need to provide medical care for the accepted condition. This is why the Notice of Acceptance, which tells you what conditions accepted is so important.

There is currently some disagreement about how combined condition claim should be handled at closure. A recent Supreme Court decision found that a "combined condition" is a combining of the injury event and the pre-existing condition. When explaining this ruling, the Supreme Court also discussed how these claims are processed at closure.

When a claim is closed, an injured worker  is entitled to a cash benefit for his or her permanent partial disability. This is based upon a closing examination. The results of the examination are applied to a set of rules, and from that, a money benefit is calculated which is known as a "whole person" permanent partial disability.

In the recent Supreme Court case, the Court found that an insurance company could discount the amount of permanent partial disability that is due to pre-existing condition, but only with combined condition claims where there was a finding that the pre-existing condition was more than 50% responsible for any medical care or need for treatment. The Workers' Compensation Board is not interpreting this recent case law in this way.

In this case, an injured worker with an accepted injury claim appealed a Notice of Closure that discounted pre-existing conditions, even though they were not part of the accepted conditions. The injured worker appealed this matter, where it eventually reached the Workers' Compensation Board. The Board still feels that the insurance company is allowed to get a discount for any pre-existing conditions, even if those conditions were not accepted as part of the claim. Two of the Board members disagreed with this decision, and in all likelihood, this case is on appeal.

This is an important issue, because many injured workers may suffer significant reductions in their permanent partial disability awards. This award is intended to compensate an injured worker for lost earning capacity, although in reality, it does not reflect that true value if used talk to many economists. If you have a case that was closed where permanent partial disability was discounted, contact us at 503-325-8600. We will review your file to see whether makes sense to appeal this determination.