A Reminder That Written Communications to Oregon Claimants to Resume Treatment Should Be Rule Compliant
Insurers and claim administrators often face a common problem when processing claims: the claimants stop treating for a significant amount of time for their accepted claim. Generally, claimants in Oregon must treat every 30 days for their accepted claim unless their attending physicians permit claimants to treat in longer intervals between their appointments.
Under OAR 436-030-034, when a claimant stops treating for a period greater than 30 days without an attending physician’s permission for longer intervals between appointments an insurer/claim administrators can send a letter to claimants informing them of their failure to treat, or a “bug letter.” This letter requires claimants to treat or respond with an explanation as to why they are not treating for their accepted claim within 14 days or face possible claim closure. If the claimant does not respond the insurer/claim administrator can administratively close the claim unless treatment has resumed, a new appointment has been scheduled, or claimant provides a reason for not treating beyond their control. Pushing an Oregon workers’ compensation claim towards administrative closure due to a claimant’s failure to treat and/or respond always begins with a bug letter.
A letter to claimant requesting resumption of treatment or an explanation for a failure to treat can be a useful tool for claim processing to get a claimant’s treatment back on track or move a claim to closure where the claimant is no longer treating. However, administrative closures have been set aside by the WCD’s Appellate Review Unit for failures to comply with relevant administrative rule, OAR 436-030-034. For this letter to set the stage for administrative closure it needs to be compliant with this rule’s requirements. OAR 436-030-034 requires this letter to be sent via certified and regular mail, with a copy sent to the claimant’s attorney if the worker is represented, informing the claimant of the following in writing:
- The worker’s responsibility to seek medical treatment in a timely manner;
- The consequences for failing to seek treatment in a timely manner which include, but are not limited to, claim closure and possible loss or reduction of a disability award; and
- The claim will be closed unless the worker establishes within 14 days from the date the letter was sent certified mail that:
a. Treatment has resumed by attending an existing appointment or scheduling a new appointment; or
b. The reasons for not treating were outside the worker’s control.
Failure to meet the mailing requirements and integrating the language provided in OAR 436-030-034 for a bug letter could be problematic if a claimant requests reconsideration of the administrative closure which the letter preceded. While reconsideration proceedings for administrative closures can be challenging to prevail on due to several factors beyond the contents of a letter to claimant, making sure these bug letters sent to claimants meet the requirements provided above can avoid these closures being set aside for noncompliance early on.
For any questions regarding these letters, administrative closures, and anything else related to Oregon workers’ compensation claim processing, I am more than happy to answer them! I can be reached at or (503) 595-2132.
Posted by Kieran MacIntyre.
