Brown v. SAIF: End of the Combined Condition?
A recent Court of Appeals decision changes the test for closing an accepted combined condition claim. What does Brown v. SAIF mean for employers and insurers?
In Brown v. SAIF, SAIF initially accepted a lumbar strain and was later ordered to accept a lumbar strain combined with lumbar disc disease and spondylolisthesis. A closing exam demonstrated the accepted condition was no longer the major contributing cause of the need for treatment or disability of the combined condition. SAIF then issued a current combined condition denial which claimant appealed. The ALJ and Board upheld the denial.
The Court of Appeals reversed finding the proper inquiry was whether the compensable injury, not the accepted condition, was no longer the major contributing cause of the need for treatment or disability. The Court determined the accepted condition was not the focus for determining whether a combined condition was still compensable. Instead, a carrier must prove the compensable injury was no longer the major contributing cause of the need for treatment of the combined condition. Only when the compensable injury is no longer the major contributing cause of the need for treatment of the combined condition can a current combined condition denial issue and the claim be closed. The Court stated there was no statutory link equating the compensable injury to the condition formally accepted in the notice of acceptance pursuant to ORS 656.262(6)(b)(A).
So what does this decision mean for insurers?
First, instead of focusing on the accepted condition, insurers must now focus on the “compensable injury” to issue a current combined condition denial and close a combined condition claim. Treating physicians must focus on the “compensable injury” rather than just the accepted conditions. This may create difficulties communicating with doctors. As is evident in other parts of workers’ compensation law, legal definitions and concepts do not always align with medical definitions.
Second, combined condition claims will be more difficult to close. The burden is on the employer to prove the compensable injury is no longer the major contributing cause of the need for treatment.
Third, it calls into question the difference between a combined condition and a worsening of a preexisting condition under ORS 656.225. Under ORS 656.225 a claimant can receive workers’ compensation benefits if a work injury constitutes the major contributing cause of a pathological or actual worsening of the preexisting condition. The ALJ in this matter, concluded claimant had a worsened condition, however, he had never claimed the condition. Since SAIF had proved that the accepted condition was no longer the major contributing cause of the need for treatment, the ALJ and Board upheld the current combined condition denial. The Court of Appeals did not discuss the difference between this new standard for a combined condition and a worsening of a preexisting condition under ORS 656.225.
Carriers will need to establish medical evidence that the injury as well as all formally accepted conditions are stationary and rated before issuing a current combined condition denial and closing combined condition claims.
If you have any questions regarding this case or other Oregon worker’s compensation issues, please contact me at: .
