Workers’ Comp Claims Must Be Accepted or Denied Even if They Involve Only Symptoms

Workers’ Comp Claims Must Be Accepted or Denied Even if They Involve Only Symptoms

Workers’ Comp Claims Must Be Accepted or Denied Even if They Involve Only Symptoms

A new Oregon Court of Appeals opinion upholds an injured employee’s right to a clear decision accepting or denying his or her workers’ compensation claim in a timely manner. The court rejected the comp insurer’s argument that a letter announcing that a claimant’s requested “new or omitted medical condition” did not “qualify” as a claim was reasonable.1

The case arose out of the claimant’s 2007 injury while operating a floor buffer. The insurer “initially accepted a right shoulder strain, and later added right-shoulder tendonitis and a partial rotator cuff tear. The claim was closed in December 2008 but was reopened in July 2009 to address worsening tendonitis, which required two shoulder surgeries.” After the surgeries, the claimant began experiencing worsening shoulder pain. She requested acceptance of a “new or omitted condition” under ORS 656.267, which allows an injured worker to bring additional conditions related to a work injury into their compensable claims.2

The workers’ comp insurer’s letter informed the claimant that her request for acceptance of “right shoulder arthralgia” sought acceptance only of a “symptom, which is not a new or omitted medical condition.”3 But the letter neither accepted nor denied the new condition claim. The claimant then asked for a hearing, at which the administrative law judge (“ALJ”) treated the letter as a claim denial. The claimant appealed to the Oregon Workers’ Compensation Board.4

The Board disagreed with the ALJ. It concluded that the insurer’s failure to actually accept or deny the claimant’s request within 60 days, the time permitted by statute, was a de facto denial.5

Before the Oregon Court of Appeals, the insurer argued that there since the claimant had requested acceptance only of a symptom, not a medical condition, it was not obligated under ORS 656.262(7)(a) to formally accept or deny the request within 60 days. Thus, the insurer contended, it could not have acted unreasonably in informing the claimant that her request did not qualify as a claim.6 But the court disagreed. It held that a letter “seeking clarification or telling a claimant that [she] has not perfected a claim, is not an adequate statutory response.”7

The court went on to uphold an award of attorney fees in the case. An attorney who prevails in having an insurer’s claim denial set aside after a hearing is entitled to an assessed fee even if the denial is only de facto, meaning that the insurer fails to process the claim before the statutory time limit for doing so expires.8 It’s easy to see the benefit to the injured worker whose claim denial is overturned. In Traner, however, “right shoulder arthralgia” was still only a symptom. So what benefit did the claimant receive? The Court of Appeals explained that “a claimant achieves a better result than an insurer’s neglect when forcing a definitive response and creating an opportunity to present a claim at a hearing. The claimant achieves a procedural benefit to remedy an insurer’s procedural mistake.”9 A procedural benefit that could well help a worker get the benefits to which they are entitled sooner rather than later.

If you’ve been hurt on the job, notify your employer immediately. If your claim is denied, as a rule of thumb an Oregon workers’ comp lawyer can help at no cost to you.

1. SAIF Corp. v. Traner, 270 Or. App. 67 (2015).
2. Id. at 68.
3. Id. at 70.
4. Id. at 69.
5. Id.
6. Id. at 70.
7. Id. at 71 (internal quotations omitted).
8. Annalisa Pike, 56 Van Natta 870, 874 (2004).
9. Traner, 270 Or. App. at 74.