Introduction
The Oregon Workers’ Compensation system allows an injured worker to appeal the denials of benefits. How an injured worker files an appeal depends upon the type of benefit. This article discusses the basics on appealing a medical dispute.
Administrative Review
If your workers’ compensation carrier is denying medical benefits, or refusing to reimburse you for out-of-pocket expenses like prescription reimbursement for mileage, you can file a request for review with the Medical Resolution Team. There is a form called a Request for Dispute Resolution of Medical Issues and Medical Fees that you can fill out and send to the Workers’ Compensation Division. You should also send a copy to your insurance company as well.
You Need Not Be Represented
There is no requirement that you have an attorney represent you on this kind of an appeal. However, there are certain cases that may justify having an attorney involved. In many cases, the dispute is whether not the proposed or denied care is medically necessary. That often involves an issue of medical opinion, and an attorney experienced in workers’ compensation may be able to help you. If you do hire an attorney, there is no fee unless the attorney is instrumental in prevailing on the claim. If that occurs, then the insurance company will pay an assessed fee as determined by the State of Oregon.
Alternatives
The rules that set out the process for resolving these disputes does provide for alternative dispute resolution. "Alternative dispute resolution" means that the parties will get together, either directly, or through an intermediary, and resolve their differences. The Workers’ Compensation Division will then issue an order confirming the agreement.
Issues
As we mentioned above, one common issue with medical service disputes is whether the proposed care is necessary. There are other disputes that can come up, including the insurance company’s refusal to allow a change of attending physician beyond the number of allowable changes. Also, an insurance company may request an additional independent medical examination, again beyond what is allowed without an order from the State of Oregon..
Deferral and Transfer
The term “deferral and transfer” means that the Workers’ Compensation Division determined that the real issue is not so much whether the care is necessary, but instead, whether it is a result of the on-the-job injury. This is a “compensability” issue, and if that is the case, then the Workers’ Compensation Division will transfer the case to the Workers’ Compensation Board. The Board will then set a hearing in front of an Administrative Law Judge. When the issue involves “compensability,” it is often determined by expert medical opinion. Although an injured worker does not need to hire an attorney to go forward with the hearing, the Hearings Division of the Workers’ Compensation Board will encourage injured workers to seek legal counsel. As with medical disputes, there is no attorney fee unless the attorney prevails at hearing. If the attorney prevails, the fee is paid by the insurance company. In certain cases, the insurance company may also have to pay costs incurred in pursuing the claim.
Time Limits
The rules provide that an injured worker must file a request for review on a medical service dispute within 90 days of the date the injured worker learned about the dispute, or should have known about the dispute. Often times, there is no formal denial of the medical service, and an injured worker may not know that treatment was denied until he or she talks to the attending physician. However, if you have received some formal notice of a denial, you should file for review as soon as possible.
Medical Review
In the typical medical services dispute appeal, the insurance company is required to provide an organized copy of the claims file to Medical Resolution Team within fourteen days. The Medical Resolution Team may have a physician review the file, or may even schedule a medical examination to resolve the dispute.
Appeals
If you are not happy with the Medical Resolution Team order, you can file a request for hearing with the Workers’ Compensation Division. At the hearing, no new medical evidence is allowed, and the case is resolved by an Administrative Law Judge. There are strict time limits, depending upon the type of issue decided at the Medical Resolution Team level.
If you have an open Workers’ Compensation claim, and are facing issues regarding medical treatment, contact us. We have offices in Beaverton and Astoria, and can meet with you in person to discuss your case.
