Denied Oregon Workers' Compensation Claim
Our experienced workers' compensation lawyer in Portland can help you with your denied workers' compensation claim
How to Fight a Denied Workers' Compensation Claim in Oregon
The insurance company will have 60 days to either accept or deny your claim. If your claim is accepted, you will receive an "Initial Notice of Acceptance." Importantly, the "Initial Notice of Acceptance" will specifically list which conditions were accepted. Insurance companies frequently accept the least severe condition they find in the medical record, which is typically a sprain, strain or contusion. See our injuries page for common injuries and conditions. As treatment progresses, it may be necessary to request acceptance of a more serious condition, such as a disc herniation, bulge, protrusion, rotator cuff tear, meniscus tear or SLAP tear. The insurance company will have an additional 60 days to accept or deny the new condition claim after it has been made. As with the initial injury, the insurance company will either issue a "Modified Notice of Acceptance" for the new condition or a denial.
If a condition is denied, the worker must file a Request for Hearing appealing the denial within 60 days. If they fail to file a timely Request for Hearing, the denial could become final.
Request a Hearing
The first step to appealing a denial is filing a written Request for Hearing. The Request for Hearing should be filed within the first 60 days of the claim denial. To file a Request for Hearing, the worker must either send a letter to the Workers' Compensation Board and insurer asking for a hearing or file a Request for Hearing Form with the Workers' Compensation Hearings Division. Copies of the Workers' Compensation Hearings Division's Request for Hearing form can be downloaded by clicking here. The Board is required to schedule a hearing within 90 days of the worker's Request for Hearing. The hearing will be conducted by an Administrative Law Judge that specializes in Oregon's Workers' Compensation Act. The hearing process can be seen in a flowchart created by the Workers' Compensation Board by clicking here.
Filing for a hearing may be difficult or confusing for many workers. Legal assistance is highly recommended to ensure that everything is filed properly. If the worker is represented, their attorney should handle all the paperwork necessary for appealing the denial and provide a copy to the worker once the Request for Hearing has been filed.
A hearing will be scheduled within 90 days of the worker's appeal of the denial. The hearing is similar to a bench trial and should not be confused with a small claims court proceeding or one of the "court" programs on daytime television. Legal representation is highly recommended. The workers' compensation laws are complex and the outcome of a worker's case will likely depend more upon the medical evidence than the worker's testimony. Most workers are simply unware of what medical evidence it will take to win their case and they are at a distinct disadvantage when facing a professional defense attorney and Independent Medical Examiner's findings.
If the worker is represented, their attorney will prepare them for the hearing and should discuss what it will be like before the hearing takes place. The worker's attorney will also gather any needed evidence, subpoena witnesses and prepare opening and closing arguments.
Following the hearing, the Administrative Law Judge will have 30 days to issue an Opinion and Order, which is a formal decision regarding the denial. The Administrative Law Judge may either affirm the insurer's denial or set it aside. Either party may appeal the Administrative Law Judge's Opinion and Order by filing a timely Request for Board Review.
Request Board Review
Either party may appeal the Administrative Law Judge's decision by filing a Request for Board Review within 30 days of the Opinion and Order issuing. If an appeal is not filed, the Opinion and Order will become final as a matter of law. This means that neither party will have the opportunity to appeal the decision later. Similarly, the judicial doctrine of res judicata prevents either party from litigating the same issues decided by the Administrative Law Judges Opinion and Order again in the future.
If an appeal is filed, the Board will provide a "briefing schedule" for written arguments. Once briefing is complete, the dispute will be resolved by at least two of the five Workers' Compensation Board members, who will issue an Order on Review affirming, modifying or reversing the Opinion and Order. Appeals may take from six months to over a year before an Order on Review is issued.
Request Judicial Review
If either party is dissatisfied with the Order on Review they may file an appeal with the Oregon Court of Appeals within 30 days of the Order. Appeal from the Oregon Court of Appeals to the Oregon Supreme Court is also possible, but highly uncommon. No additional appeals are available once a decision has been made by the Oregon Supreme Court.
Common Reasons Workers' Compensation Claims are Denied in Oregon
Many workers are shocked to receive a denial in the mail. Some assume they did something wrong or have a bad claim. Others believe the insurance company is mistaken or simply out to get them. The reality of the situation is usually much more complex.
Denials are issued for a variety of reasons, and many of those reasons have nothing to do with the strength of a worker's case. Claims adjusters are required to make a decision about a worker's claim within 60 days. Many adjusters fail to adequately investigate the claim to begin with and then issue a denial hoping the injured worker will not file an appeal. This is what we refer to as the "shoot first and ask questions later denial." Unfortunately, this tactic works. Not all workers file an appeal because they think something must be wrong with their claim if a denial issued. The truth, however, is that most adjusters would rather gamble on denying a claim they know nothing about than accept it.
As terrible as it may sound, some denials are issued simply because the claims adjuster was angry at the worker or frustrated with the claim. We would like to believe an insurer's processing decisions are completely logical and grounded in fact, but that is not always the case. In Oregon, insurer's rely heavily on combined condition denials to end ongoing benefits for difficult cases in an attempt to force settlement and resolution of the claim.
Other denials issue because the employer tells the insurance company the injury was faked. Insurance companies frequently depend on what the employer says about the injury and will often take the employer's word over the injured worker's. If the employer is angry or upset about the claim they may mislead the insurer about important facts surrounding the injury. Local supervisors may also feel pressured to cover up an injury if it would adversely impact their career.
Denials based upon an Independent Medical Examination (IME) are also common. Insurers usually turn to independent medical examiners when they want to deny or close a claim. While independent medical examiners are supposed to be neutral, these physicians typically perform examinations exclusively on behalf of insurance companies and are on a first name basis with many of the insurance company's defense attorneys. Some independent medical examiners are more creative in finding reasons for a denial than others, but most will conclude the worker's condition is either due to non-industrial arthritis or "idiopathic factors."
Prior injuries could also result in a claim denial. If you have a prior history of treatment for the injured body part, the insurance company will likely attempt to use your medical history against you. Insurance companies are always considering alternate explanations for a worker's condition. If they can point to a prior work injury, car accident or other non-industrial condition they likely will.
Workers should remember that if they receive a denial it does not mean they have a bad claim or did something wrong. There are many reasons why an insurer may issue a denial and just as many reasons why a denial may not be upheld by the Judge. Goin Law Group recommends consulting with an experienced Oregon workers' compensation attorney if your claim was denied.
Call our Experienced Workers’ Compensation Trial Attorney Today
Nathan Goin began his career as a claims examiner for one of the major workers' compensation insurers in Oregon. Through this experience, he learned firsthand how workers' compensation insurers view injured workers, manage their claims, value settlements and, ultimately, attempt to close claims while paying as little as possible. Nathan's legal career now focuses on fighting for the rights of injured workers to ensure that they receive the benefits they deserve.
We understand how difficult the workers' compensation process can be for an injured worker. Goin Law Group values every client and will work tirelessly to maximize your benefits. Schedule a free consultation with an experienced Oregon workers' compensation attorney today. Call now for assistance with your claim. You don't have to do this alone.