New Administrative Rules Regarding Claim Closure effective March 1, 2015
By: Kevin Anderson
The WCD has published new administrative rules responding to two recent court cases (Brown v. SAIF, 262 Or App 640 (2014); Schleiss v. SAIF, 364 Or 637 (2013)). The WCD initially proposed a broad-sweeping change that would link all claim benefits to the “work injury” instead of “accepted conditions.” Based on the input received from many in the industry, the WCD approved these narrower changes.
While there are significant changes throughout the administrative rules, I highlighted the two major changes below. These new rules govern any claim closed on or after March 1, 2015.
- Closing Reports
In initial injury claims only, a closing report will need to “include objective findings of any permanent impairment that is caused in any part by an accepted condition, a direct medical sequela of an accepted condition, or a condition directly resulting from the work injury.” OAR 436-010-0280(6). Similarly medically stationary status and permanent impairment will be based broadly on accepted conditions, direct medical sequela, and any condition directly related to the work injury. OAR 436-030-0035(1); OAR 436-035-0006(1).
If the closing report does not contain sufficient information to determine whether a condition was “directly resulting from the work injury,” the WCD will rescind the closure. OAR 436-030-0135(3).
In new/omitted condition claims, aggravation claims, or occupational disease claims, the closing exam, medically stationary status, and permanent impairment are all still based on the accepted conditions and direct medical sequela only.
- Apportioning Impairment
These rules also affect the apportionment of permanent impairment for injury (not occupational disease) claims. As currently processed, when the impairment is entirely caused by the work injury, the worker receives the full impairment award. If the impairment is caused in no part by the work injury, the work receives no impairment award.
The changed rule affects those cases when impairment is partially work-related and partially unrelated. In such a case, a worker will receive impairment for the portion of the loss caused by the injury and for any loss caused by a condition that is not a legally preexisting condition. A worker will not receive an award for a denied, superimposed, or legally preexisting condition. If the preexisting condition is accepted as a combined condition and the work injury is still the major cause, the worker will receive an impairment award for the preexisting condition. OAR 436-035-0007.
The rules affect many divisions of the Workers’ Compensation OAR Chapter 436. To see the revised language, please follow the links below.
- Revisions to OAR 436-009 Medical Fee and Payment Rules, click here
- Revisions to OAR 436-010 Medical Services, click here
- Revisions to OAR 436-030 Claim Closure and Reconsideration, click here
- Revisions to OAR 436-035 Disability Rating Standards, click here
- Revisions to OAR 436-105 Employer-at-Injury Program, click here
- Revisions to OAR 436-110 Preferred Worker Program, click here
- Revisions to OAR 436-120 Vocational Assistance to Injured Workers, click here