Learn What You Need to Know About Your Injury and Disability Claim.
Answering the Most Frequently Asked Questions Is Good, Answering The Questions You Should Be Asking Is Even Better
We have been answering questions about Oregon and Washington personal injury and auto injury claims, Oregon Workers' Compensation claims, and Social Security Disability claims for more than a little while. People have a lot of the same concerns, so they ask the same questions. That's good. However, our job is not just to answer the most frequently asked questions, but also the ones you should be asking. That's better.
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Why did the insurance company discount my Permanent Partial Disability award in my Notice of Closure?
"Permanent Partial Disability" is a workers' compensatio cash benefit in Oregon that compensates injured workers for lost earning capacity. The amount of this award is based upon a "whole person impairment." The "whole person impairment" is determined in a closing medical exam. The physician will measure loss of range of motion, loss of strength, and determine whether the injured worker has suffered a loss of ability to use the injured body part. Also, if the injured worker can no longer return to the job that he or she was working on the date of the injury, there is a "work disability." The workers' compensation carrier supposed to look at your work background, your earnings, and your age to determine the amount of this part of the permanent partial disability "award." I put the word "award" in quotes because it's not really an award, but compensation for something that you have lost permanently.
Sometimes, insurance companies will accept a "combined condition" at the beginning of the case. This occurs when the work injury event (the fall or lifting injury) combined with some pre-existing medical issue (arthritis or an old injury) and the work injury event is the major cause for the need to treat the combined condition. Sometimes, the work injury event will no longer be the major cause of the combined condition. When this happens, an insurance company can issue a denial, claiming that because the work injury event is no longer the major cause of your need for treatment, the insurance company does not have to provide any more medical services. However, even though it issues that denial, the insurance company still must close the claim. When this kind of a claim goes to closure, the insurance company will pay permanent partial disability, but is allowed to discount the amount of permanent partial disability due by the percentage of disability that results from the pre-existing condition. We call this claim apportionment.
If you have a combined condition claim, and it was denied before the notice of closure was issued, then the insurance company is allowed to discount the permanent partial disability by the percentage that is due to the pre-existing condition. However, if you are combined condition claim is in accepted status when the claim goes to closure, then the insurance company is not allowed to discount any portion of the disability due the pre-existing condition part of the claim. This is because the pre-existing condition is part of the accepted claim. That's the way we see it anyway, and we think the Supreme Court of the State of Oregon sees at the same way.
Nonetheless, insurance companies continue to discount the permanent partial disability, leaving many injured workers underpaid. We think this is wrong, and are currently appealing many cases to argue our point.
If your claim has been closed, and you think that the insurance company incorrectly discounted your permanent partial disability rating, call us at 503-325-8600. We can look at your case, and let you know if you should appeal your Notice of Closure.
What is a Back Up Denial?
When a worker is injured on the job in Oregon, they can file a claim for workers's compensation benefits. The insurance company investigates the claim, and if it finds the claim valid, issues a Notice of Acceptance. Benefits are provided with the goal of getting the injured worker back on the job, or helping them find other work if they have some permanent work restrictions.
If, on the other hand, the insurance company does not feel the injury is work related, or that there was no injury at all, then the claim is denied. The injured worker can seek a hearing with the Oregon Workers' Compensation Board.
Accepting a Claim is Owning a Claim
When an Oregon Workers’ Compensation carrier or claims administrator accepts a claim, it owns that claim, and must provide benefits. It may later regret its decision to accept the claim, but nonetheless must carry through with its responsibility. The insurer cannot later change its mind, "back up," and deny the claim.
The Back Up Denial
There is an exception, however to this general rule. If the insurance company discovers “new and material” evidence that it did not have at the time the claim was accepted, it may be able to issue a “backup” denial. The evidence must be “new” and “material.” New evidence is pretty self-explanatory. For example, the insurance company may find evidence that the worker treated for the exact same injury a week before the on the job injury, or that the injured worker was actually injured when not at work.
However, whether the new evidence is “material” is another issue. Usually, newly discovered medical treatment prior to the date of injury is material evidence, and if an injured worker denies the existence of pre-injury medical care, there is a very good chance this will be considered “material” evidence, depending on the severity of the prior medical problem.
This is why it is so important for an injured worker to be honest and forthright when going through the claims process. In many cases, an injured worker may have a prior medical issue with the same area the body injured at work, but still as a valid claim
If you have a claim denial for an on-the-job injury in Oregon, contact us with your questions. We help injured workers every day.