The Anatomy Of A Workers’ Compensation Claim
A map of the area gives us the big picture and helps us to understand where we are. Likewise, an overview showing how a Workers’ Compensation claim unfolds in Oregon may be helpful to doctors – who play a very critical role in certain stages of the claim.
First, the work event occurs. This may be a discrete injury or an occupational disease that has developed over time and now has reached a critical stage, causing disability and/or a need for medical treatment.
• A compensable work injury is an accidental injury or accidental injury to prosthetic appliances which arises out of and in the course of employment and requires medical services or results in disability or death.
• An occupational disease means any disease or infection caused by substances or activities the worker is exposed to at work but not ordinarily exposed to anywhere else, which requires medical services or results in disability or death. Examples include the results of contact with or inhalation or absorption of dust, fumes, radiation, etc.; a series of traumatic events; and mental disorders of sudden or gradual onset.
The worker seeks medical treatment for his/her injury. (For simplicity, the word “injury” will be used in this article to mean injuries or occupational diseases unless specified otherwise.)
The worker reports the injury to the employer, usually by filing “Form 801.” Notice of an accident resulting in injury should be given to the employer as soon as possible, but not later than 90 days after the accident. It need not be in any particular form, but it must be in writing. This constitutes filing a claim. Therefore, if your patient’s injury may be work related, please encourage him/her to give written notice to the employer immediately. The deadline for occupational disease claims is one year after the worker discovers, or with reasonable care should have discovered, the occupational disease.
The treating doctor files Form 827, the “Doctor’s First Report” on an injury.
From the time a claim is filed, the Workers’ Compensation insurance company (the “carrier”) has 90 days to decide whether to accept or deny the claim. The carrier pays time loss (a percentage of income for time lost from work due to a disabling injury), but does not pay medical bills during this period.
During this 90-day “investigative” period, the carrier may:
• Take a statement from the injured worker (“claimant”);
• Consult with the treating physician; and/or
• Send the claimant for an Independent Medical Exam (“IME”)
The steps which follow depend on whether the carrier accepts or denies the claim.
If the carrier ACCEPTS the claim, the following occurs:
Carrier pays workers’ comp benefits:
• Time loss;
• Medical expenses.
• Vocational assistance, if needed.
• Permanent disability, if warranted.
Closure: The doctor declares when the worker needs no further medical treatment, or is “medically stationary.” After the claimant becomes medically stationary, the carrier closes the claim by issuing a “Notice of Closure.”
• If the injury resulted in a permanent loss of function, the Notice of Closure awards “Permanent Partial Disability” (PPD).
• PPD is based on medical findings and is stated in a percentage that equates to a specific dollar amount. If PPD is awarded, the injured worker may also be eligible for vocational assistance.
The injured worker also receives:
• “Aggravation rights” for 5 years following closure; and
• Medical benefits for life.
If the carrier DENIES the claim:
• The claimant has 60 days to request a hearing;
• At the hearing, an administrative law judge (ALJ) will hear testimonial evidence and will receive exhibits which may include, in addition to medical records and other relevant documentation, medical opinions in the form of written reports and transcripts of deposition testimony;
• If the ALJ rules in favor of the worker and finds the claim compensable, the claim will follow the above procedures for ACCEPTED claims;
• If the ALJ rules against the worker and affirms the carrier’s denial, the claimant may appeal, by requesting review by the Workers’ Compensation Board (“the Board”);
• Decisions of the Board may be appealed to the Oregon Court of Appeals;
• If the Court of Appeals rules against the worker, he/she may request review by the Supreme Court, but review is discretionary and only granted in a small percentage of the cases.
YOUR ROLE AS DOCTOR
Your chart notes of exams, treatment and diagnoses, as well as possibly special reports and deposition testimony or testimony at a hearing, will be requested and used in making claim decisions.
Your medical opinion is key to determining:
• Causation: whether a work incident or exposure caused (was a material factor or a major – 51% or more – cause of) the claimed injury, occupational disease condition or aggravation;
• Medically stationary status: when your patient becomes medically stationary;
• Disability: when your patient has recovered sufficiently to return to work and the extent of any permanent disability;
• Preexisting conditions: the extent to which “preexisting conditions,” as defined by Workers’ Compensation law, combined with and/or caused claimed injuries, conditions and aggravations.
Fuller explanations of the legal terms used in this article may be found in prior JOURNAL articles.
The article was prepared by Robert F. Webber.