Claim Denials
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
Questions?
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.
