What Are These Claims?
To understand a a new or an omitted medical condition claim, we need to first understand what a Notice of Acceptance is.
When an Oregon Workers' Compensation carrier accepts your claim, it issues a Notice of Acceptance. The Notice of Acceptance is important because in it, the insurance company is telling you what medical condition it will cover on your claim. This is known as the accepted condition. The insurance company's responsibility toward you and your claim begins and ends with the accepted condition.
Sometimes, the insurance company will fail to include all of the medical conditions your on the job injury caused in the Notice of Acceptance. This may be an innocent oversight, but often it is intentional. For example, a carrier may accept a "knee strain" when in fact you also suffered a torn knee ligament. This is critical because technically, you are only entitled to access medical care for the strain, and not the torn ligament. This is not the only benefit that may be underpaid or not provided at all. You may have a permanent partial disability, but only if your knee ligament tear is accepted does the carrier have to account for the permanent partial disability that condition causes.
What can you do? That is where New and Omitted Medical Condition claims come in.
Omitted Medical Condition Claims
These are the most common kinds of claims we make for our clients. The worker suffers an injury, files a claim, and it is accepted. However, there are medical conditions that are not included in the Notice of Acceptance. At any time, the injured worker can make a claim that one or more medical conditions were left out, or omitted from the Notice of Acceptance. This is done by making a written request to the insurance company to include the omitted medical conditions.
There are a few things to keep in mind. First, it has to be a medical condition, not a symptom. Also, when these claims are made, the insurer has sixty days to accept or deny the claim, and can have the injured worker attend another insurance compelled medical examination, often referred to as an "IME." If the claim is denied, the injured worker can appeal the denial by requesting a hearing. Finally, the injured worker must prove that the injury caused the specific medical condition, and this often requires a medical opinion.
New Medical Condition Claims
These claims are just like omitted medical condition claims. The only difference is that the medical condition is discovered after the claim is initially accepted. For example, you may have a knee injury, and the insurer initially accepts it as a knee strain. Then, an MRI shows that you actually tore a ligament. That is a newly discovered condition, so the claim is for a new medical condition. Just like the omitted medical condition claim, the insurer has sixty days to investigate the claim, and can send the injured worker out for an insurance compelled medical examination. If the claim is denied, the injured worker can appeal the denial, and at hearing, must prove a relationship between the injury event and the specific medical condition. This often requires a medical opinion to prove the claim.
Other Things to Keep In Mind
Many folks that contact us initially have no idea that the insurance company is not accepting all of the medical conditions the on the job injury caused. This is because the insurer will often pay for things that it has not formally included in the Notice of Acceptance. An insurer can do this because the workers' compensation rules say that just because an insurance company pays to treat a certain medical condition, it is not taking legal responsibility for that condition. This is misleading, because it would only make sense that if a workers' compensation carrier pays to fix a torn knee ligament, it is taking responsibility for that medical problem. Not so.
Why would an insurer do this? Sometimes, it is cheaper for the insurance company to pay for the knee surgery, and then at claim closure, pay no permanent partial disability benefits at all, or only for a knee strain. It's all about saving money. If the injured worker does not catch this, the insurance company escaped responsibility, and saved a lot of money.
We once saw a case where an insurer paid several thousand dollars for a back surgery, and only accepted a low back strain.
We also see lots of cases where the doctor will help the injured worker fill out a new medical condition claim form. Sometimes they get it right, and other times they do not. That kind of mistake can often be fixed, but it takes more time.
This is a tricky area of workers' compensation in Oregon, and if you are not sure if all your medical problems are covered, and you want to talk it over, contact us. We work with injured workers every day.