An accepted Oregon Workers’ Compensation claim is a good thing, but there are still things to keep an eye on as the claim moves forward. In this article, we break down the Notice of Acceptance into smaller pieces, so you can know what to do to keep your claim moving forward with no problems. If problem should arise, this article will show you your options.
The Notice of Acceptance
The Notice of Acceptance is probably the most important part of your claims file. This is because the insurance carrier is notifying you of the medical condition it believes resulted from the on-the-job injury. This is often called the “accepted condition.” The insurer must provide benefits only for the medical conditions it accepts, and nothing more.
There are other issues in the Notice of Acceptance you should know about.
The Accepted Condition
This is usually one of the first issues addressed in the Notice of Acceptance. The insurer will tell you the medical conditions it is taking responsibility for and processing your claim. Often, the description of your accepted conditions is taken right out of your medical records, and can include complex medical diagnoses.
For example, a broken neck may be described as a “C6 bilateral lamina fracture,” or a “C7 vertebral body fracture.” In plain English, a C6 bilateral lamina fracture means you have broken one part of the sixth neck bone. A C7 vertebral body fracture means you have fractured the main part of the seventh neck bone.
What medical condition the insurer accepts is critical because it defines the insurance company’s responsibility to you in processing your claim. For example, you may have suffered a tear of a ligament in your knee. But if the insurer only accepts the knee strain, it provides benefits only for the knee strain. So, if the torn ligament is disabling you from work and the knee strain is not, the insurance company may choose not to pay temporary total disability (wage loss replacement), or it may decide not to pay permanent partial disability (compensation for lost work capacity) for the torn knee ligament.
Your “New” or “Omitted” Medical Condition Rights: This is Important!
Your right to make a claim to include medical conditions left out of the Notice of Acceptance, or new medical conditions that arise during your treatment are included in the Notice of Acceptance.
If you believe the insurer did not accept all the medical conditions that your on-the-job injury caused, you can make a claim in writing to include additional medical conditions as part of your claim. This is often called a “omitted” medical condition claim.
Let’s take our knee injury example. You suffer a torn knee ligament, but the insurer only accepted a knee strain. You can make a claim in writing to include a torn ligament. You should identify the specific medical condition when you make the claim. This sometimes becomes complicated, and an attorney can help you determine what claims you should make.
You can also make additional claims for new conditions that develop or are diagnosed after the initial injury. This is often called a “new” medical condition claim. Again, taking off from our example above, if you injure your knee, and the initial diagnosis is a knee strain, but then an MRI or other study finds you have a torn ligament, that condition is "new." This is because this medical condition was discovered after your initial claim acceptance. With the new condition diagnosed, you can make a claim to include the new diagnoses as part of your Notice of Acceptance.
Do not rely upon the insurer to amend your Notice of Acceptance to include conditions that were left out of the Notice of Acceptance, or newly discovered conditons. Even though the statutes require insurers to change the Notice of Acceptance with new evidence, they often ignore this requirement, sometimes on purpose, and it is up to you to make sure that all the medical problems from your on-the-job injury are included as part of your claim.
The good news is there is no time limit in making a “new” or “omitted” medical condition claim. However, these claims must be made in writing, and sent directly to your claims adjuster.
This is also part of the Notice of Acceptance. Claims in Oregon are classified as either disabling or nondisabling. A “nondisabling” claim is a claim where you return to work before the fourth calendar day after leaving the job for your injury, you miss no work after the initial injury, and there is no indication that you will have permanent disability because of the injury.
Often, a claim is initially classified as a non-disabling injury. Then, as the physicians determine the full extent of your injury, you may have to miss work, or new information indictaes that you will have some permanent impairment. If this happens, then the insurer will sometimes change the classification of your claim to a disabling claim.
You should not rely upon the insurer to change the classification of the claim, even if it should. You can ask that the claim classification be changed. You must do this in writing within one year from the date that the Notice of Acceptance was issued. The request is made directly to the insurer. If the insurer refuses to change the classification, then you can seek review with the State of Oregon
Why should you be concerned about claim classification? Only if your claim is classified as disabling must the insurer file a Notice of Closure and an updated Notice of Acceptance when your medical care is completed. The Notice of Closure will include a determination on whether you may qualify for permanent partial disability benefits. If you disagree with the permanent partial disability findings in the Notice of Closure, you can appeal the Notice of Closure. This is called a Request for Reconsideration.
The Notice of Closure also explains your right to “aggravation” benefits. An aggravation claim is a claim that your accepted condition has worsened and requires additional medical care. When you file an aggravation claim, you are asking the insurer to re-open your claim to get additional medical care. Only your attending physician can file the aggravation claim. The right to file an aggravation claim expires five years after the Notice of Closure. Even if after the aggravation claim rights expire, you still have some rights to get additional medical care.
If your claim is truly nondisabling, you still have aggravation benefits, but the time limits are different. If the injury is nondisabling for at least one year after the date your claim was accepted, the aggravation rights expire five years after the date of your injury.
The Notice of Acceptance also tells you about your right to be reinstated to your job after you recover from your injury. Most of the time, the Oregon Civil Rights Law requires companies with more than 20 employees to reinstate you to your position if your attending doctor approves a return to regular work. Even if you cannot return to your former job, the employer must provide you another existing job that is available, and suitable. A job is “suitable” if you can perform the job within your permanent limitations. The job must also pay a wage comparable to your wage when you were injured at work. The Notice includes a list of when you are or are not qualified for reinstatement.
Every Notice of Acceptance tells you about a Workers’ Compensation Division program that helps eligible injured workers stay at their job or return to work. This is The Employer-at-Injury Program. If you qualify, the program may help your employer assist you in returning to transitional work while your claim remains open.
Reimbursement for Claim Related Expenses
The Notice of Acceptance explains that you may be reimbursed for claim-related expenses. Examples include prescriptions, transportation costs (mileage or public transportation costs), meals, and lodging for mandatory medical appointments. There are maximum amounts set by rule and policy. You also must document your expenses by saving receipts and actual prescriptions.
You must submit the expenses within two years of the date you incurred the actual expense. The Workers’ Compensation Division provides a form called “Request for Reimbursement of Expenses.” Many insurers also provide their own forms.
Expedited Claims Service
Even with an accepted claim, you may disagree on claim decisions. In limited situations, you can request and go to hearing with the Workers’ Compensation Board within 30 days. The issues that qualify for an expedited hearing are:
A dispute that does not involve the compensability or the responsibility for claim, and the total amount in dispute is $1000.00 or less
The only dispute is the entitlement to penalties or related attorney fees
The dispute arose because your claim was denied for failing to cooperate with an investigation.
You Still May Have Issues with The Insurer
Even if the insurer takes responsibility for all the injuries you suffered on the job, there is potential for some disputes as the claim moves forward. For example, the insurer may refuse to pay for certain medical treatment, or there may be an issue with payment of temporary total disability. Keep in mind that if a benefit is denied, or underpaid, you have the right to request the State of Oregon review the claim dispute. In all cases, have the right to an attorney, and the attorney is entitled to a fee only if the attorney prevails. In most cases, the insurer pays the attorney fee. For disputes about permanent partial disability, the fee is a percentage of the increased benefit amount. In all cases, someone from the State of Oregon must approve the fee.
The Notice of Acceptance includes contact information for the Workers’ Compensation Division, and the Workers’ Compensation Board.
There is also contact information for the Ombudsman for Injured Workers. An “ombudsman” is an official appointed to investigate an individual’s complaints against a public agency. Oregon Workers’ Compensation is administered by private insurance companies, but there is government oversight. If you are having an issue with your claim, you can contact the ombudsman, and their office will help you navigate your options.
There is a lot to know about a workers’ compensation claim in Oregon, even if it’s been accepted. If you have questions about your claim, contact us, or check out our other helpful articles.