Introduction: What is Covered for Medical Care
Oregon Workers’ Compensation covers medical services for accepted claims. A claim is accepted when the insurer issues a “notice of acceptance.” This document describes the medical conditions the insurer decided were work-related. An injured worker who disagrees with the Notice of Acceptance can request that the insurer add additional medical conditions to the Notice of Acceptance. This is important because insurers will only provide benefits that cover the accepted condition. This recent Oregon Workers' Compensation Court decision changes things, and for the better.
Court Tackles Diagnostic Testing
The Oregon Supreme Court recently ruled on whether a workers’ compensation carrier must cover diagnostic testing to determine whether a medical problem is related to the work injury.
The Facts
In this case, the injured worker suffered several fractures to her face and a laceration to her skull when a wind storm through a tent pole into the worker while she was working as a food server.
However, the injured worker was struggling with anxiety and panic with “triggers.” Her physician referred her to a psychologist to see if the injured worker suffered posttraumatic stress syndrome or some other psychological injury. However, because the anxiety condition was not part of the accepted condition, the insurer refused to authorize the psychological examination. The Claimant’s attorney appealed this decision all the way up to the Oregon Supreme Court.
The issue before the Oregon Supreme Court was the meaning of the phrase “compensable injury.” This is a term used in the statute. If it means the conditions the insurer accepted, then diagnostic testing, like an MRI or psychological exam could be denied. Insurers would love this because they could cut off an injured worker's ability to find out the extent of their on the job injury, and escape responsibility for treating on the job injuries. If this phrase means the injury event (in this case, being struck in the face and skull with a tent pole), then the injured worker could seek diagnostic testing to find out the full extent of the on the job injury, which would provide for treatment, recovery, and a return to work.
The Ruling
When the Court reviewed the case, it determined that the term “compensable injury” means different things in different parts of the statute. Reading other provisions in the statute alongside of the definition of “compensable injury,” the Court found that the psychological evaluation was a diagnostic service related to finding out what medical conditions the injured worker suffered as a result of the injury event. As a result, the court found that these medical services are covered, even if the specific condition they seek to diagnose have not yet been accepted.
Other online articles that survey case decisions across the country found that it is often difficult for an insurer to deny diagnostic testing, mainly because the request for testing or examination is made to determine whether the injured worker suffered a specific treatable medical problem as a result of the injury event.
How This Helps Injured Workers
This decision is significant for injured workers because often, injuries are diagnosed with little data. For example, an injured worker’s first medical treatment is at an urgent care clinic or emergency room. These facilities are set up to rule out more significant injury. There may be some diagnostic testing, but often not. It is only after the injured worker attempts to return to work or everyday activities that symptoms flare or worsen. Injured workers also may experience different symptoms, and it only makes sense to perform other diagnostic testing to make sure that the injured worker’s getting the medical services they need to get back to work.
Questions
If you are in the middle of an Oregon workers’ compensation claim, and have questions about your right to medical services, including diagnostic testing, contact us. We can meet with you to discuss your options and decide whether you need legal help in the first place.
The nice thing about Oregon Workers’ compensation fee agreements is that the attorney is not paid unless they are instrumental in getting you a benefit that was denied or underpaid. All fees must be approved by the State of Oregon.
