The Oregon Workers' Compensation Board provides this form to request a hearing with the Oregon Workers' Compensation Board Hearings Division.
The best way to check this out is to download and print out the form, and then review the remainder of this article to find out which issues you should raise when requesting a hearing.
The First Part of The Form
The first part of the form is fairly straightforward.the Workers Comp. Board is looking for your contact information, the date of your injury, and the claim number. You also must provide information about the insurance company handling the claim.
Things get a bit more complicated when identifying the issues that you wish to pursue at the hearing. Most of the cases we handle involved denied claims. However, there are several different kinds of denial. Here is a summary of the different denials that you may want to appeal:
The "compensability-complete claim denial" refers to a total denial of the claim. You may receive a letter indicating that your injury is not "compensable." There could be many reasons for this, but if the claim has been denied completely, this is the correct box to check.
Sometimes, an employer or insurance company will agree that the on-the-job injury event caused one kind of medical condition, but not another. In this kind of case, you will receive both a notice of acceptance, as well as a denial letter. If only part of the claim has been denied, then you would want to check the box next to "partial denial after a claim acceptance."
Challenging A Notice of Acceptance
The "challenge to a notice of acceptance" selection involves cases where your claim was accepted, but the insurance company did not take full responsibility for all of the medical conditions you suffered as a result of your on-the-job injury. For example, you may have suffered a rotator cuff tear of your shoulder, but the insurance company only accepts a shoulder strain. This is important, because your benefits are defined by the medical condition the insurance company takes responsibility for in its notice of acceptance.
You are able to make a "new medical condition claim" if you feel that there are medical conditions that were not made part of the claim. If you make this claim, you must do so in writing. The insurance company has 60 days to respond, and if it denies your request, you would make this selection when filing a request for hearing.
The "worker noncooperation" denial involves claim denials where the worker refused to cooperate with the insurance company's investigation. Insurance companies can investigate the claim, and you must cooperate with the investigation. For example, the insurance carrier can require that you attend and "independent medical examination." The insurance company can require that you provide a sworn statement. If you fail to provide the statement, or an attend an examination, the insurance company may be able to deny your claim. The insurance company should state in its denial letter that it is denying your claim for lack of cooperation. If you disagree, this is the box he should check when filing a request for hearing.
The "aggravation" selection refers to claims for aggravation benefits. This is a special benefit that is available after a claim is accepted and closed. Under the law, only your attending physician can make a claim for aggravation benefits. This is a claim that your condition has actually worsened since the date it was closed. This must be proven with objective medical evidence. If the aggravation claim is denied, then you should check this box if you would like an administrative law judge to review the evidence.
"Responsibility" claims occur where your on-the-job injury or condition may have happened over time while working for more than one employer. The most common example I have seen our mill workers who suffer a hearing loss in a lumber mill that has had several owners over several years. In these kinds of cases, there is usually no dispute that your hearing losses due to excessive noise at work. However, there is a disagreement as to which employer should be responsible for paying your benefits.
"Medical services" denials involved the denial of a specific medical treatment, like a surgery or a diagnostic procedure. Sometimes, disputes over medical services are heard by another part of the workers' compensation bureaucracy, but if the insurance company is denying medical care because it claims the treatment is not aimed at an accepted medical condition, this is the selection you make to appeal a medical services denial.
Temporary Disability issues involve the entitlement or the amount of temporary total disability or temporary partial disability. This is a benefit for wage replacement, and in order to qualify, you must show that your doctor has authorized you, in writing, to be off work, or to at least be working modified duty.
Order on Reconsideration
An injured worker can also appeal and Order on Reconsideration. This is an order that the Workers' Compensation Division issues when a Notice of Closure is appealed. Because and Order on Reconsideration can decide many issues, there are other selections available to further specify what issue you are seeking review of when you request a hearing.
For example, "classification" refers to the nature of the accepted claim. A claim is "disabling" when it is anticipated to cause permanent disability, or record results in a temporary disability.
"Premature closure" simply means that you are alleging the claim was closed to quickly. This happens when the insurance company closes your claim without your physician agreeing that your medically stable.
"Substantive temporary disability" refers to wage replacement or time loss benefits. The term "substantive" means that your physician has actually authorize you to be off work, but that the insurance company did not pay for a specific period of time that you were off work.
"Permanent partial disability" refers to a benefit that is designed to compensate you for any permanent loss of earning capacity as a result of your accepted condition. There are two kinds of permanent partial disability: "whole person disability" and "work disability." Many times, the argument over permanent partial disability is whether or not the insurance company properly accounted for all of your physical limitations when closing or claim.
The last group of potential issues are somewhat miscellaneous. The reference to the "Director's Order" refers to an order issued by the Workers' Compensation Division. This could be any kind of order.
"Penalties" refer to just that. An employer or insurance company can be penalized if they unreasonably delay payment of compensation, or fail to follow in order to pay compensation.
Attorney fees are available if the claimant's attorney is successful in prevailing on the claim. If an attorney represent you on a claim, he or she must specify the specific statute that authorizes payment of fees. These are only paid if the attorney is successful, and the fee is either paid directly by the insurance company, or out of any increased compensation obtained as result of the appeal.
"Costs" are available if the injured worker prevails on a denied claim. Costs are those items that an injured worker or her attorney may spend money on in order to prove the claim, and over, denial. Typical costs include the cost of conferring with medical experts, travel, and the cost of obtaining medical records.
An "offset" may occur when an insurance company pays temporary total or temporary partial disability benefits after the date an injured worker becomes medically stationary. Any payments during this point in time and up to the date of the Notice of Closure can be considered an overpayment, and either side can challenge whether or not permanent partial disability benefits can be offset by temporary disability benefits paid after the injured worker becomes medically stationary.
There are a lot of issues that can come up with a request for hearing. Our website covers many of the benefits discussed in this article. You can also check out our free e- book, which also covers many of these issues.