Combined Conditions in Oregon Workers’ Compensation: Not always a Simple Open and Shut Case
Combined condition acceptances and denials can be a useful claim processing tool in Oregon for several reasons. They can be used as a defense against compensability. They can also be used to close a claim and allow for apportionment of permanent impairment at claim closure.
A combined condition exists when an “otherwise compensable injury” combines with a preexisting condition. This means the two merge or “exist harmoniously.” In establishing a combined condition in the record, the insurer needs to make sure medical evidence supports that the preexisting condition actively contributes to the worker’s disability or need for treatment and that the preexisting has actually merged with or coexists with the otherwise compensable injury.
Under ORS 656.262(6)(c), once an insurer has accepted a combined condition, it may later deny the condition when the otherwise compensable injury ceases to be the major contributing cause of the combined condition. This leads to the question of when can an insurer close a claim based on a major contributing cause denial.
Current case law permits claim closure after the issuance of a combined condition denial as long as there is sufficient information to determine permanent disability. Under OAR 436-030-0020, the insurer must issue a Notice of Closure on an accepted disabling claim within 14 days when “the accepted injury/condition is no longer the major contributing cause of the worker’s combined condition, a major contributing cause denial has been issued, and there is sufficient information to determine the extent of permanent disability. Of course, sufficient information means there is a statement clearly indicating there is no permanent impairment or limitations attributable to the accepted conditions or in the alternative, a closing report has been performed which outlines impairment due to the compensable conditions.
But, what happens when there is not sufficient information to determine permanent disability? More often than not, we are looking at situations where a worker has not been declared medically stationary and there is no permanent impairment information.
If the medical evidence supports a combined condition denial, issuing one will cut off the worker’s right to further medical treatment and disability benefits under the claim. However, the claim will remain open until the attending physician provides the necessary information to support claim closure.
Under OAR 436-010-0280(7), when an insurer issues a major contributing cause denial on an accepted claim, and the worker is not medically stationary, the attending physician must perform a closing exam or refer the worker to a consulting physician for all or part of the closing exam. The permanent disability that likely would have been due to the current accepted condition must be estimated to meet claim closure requirements.
There is a major sticking point on this. If the attending provider does not elect to perform a closing examination and does not concur with an arranged closing IME, the claim cannot be closed. The rules for claim closure are explicit that a claim cannot be closed without sufficient impairment information.
There are a few options on how to approach a situation where an attending provider will not close or concur with a closing exam. Those options can range from a simple telephone call to a request for sanctions from the Director, but the response strategy will depend heavily on the circumstances for each claim. Nonetheless, at the end of the day, without the necessary information to rate permanent impairment, the attending provider holds the key to claim closure.
If you have any questions about the combined condition approach and claim closure, or if you need assistance on other legal issues, you can contact me at or (503) 595-6108.
Posted by Evan Novotny.
