In Oregon, Medical Dispute Denials Are Now a Valid Basis for a WRME Request
In Cheri L. Goss, 77 Van Natta 159 (2025), the Oregon Workers’ Compensation Board reversed an Administrative Law Judge’s (ALJ) decision to uphold the Workers’ Compensation Division’s denial of a worker requested medical examination (WRME). The worker sought review of an ALJ’s Order.
On review, the Board considered whether a medical dispute denial qualified as a “compensability denial” relevant to the requirements for a WRME under ORS 656.325(1)(e). Generally, a WRME may be requested in conjunction with a Request for Hearing pertaining to a compensability denial based on one or more independent medical examination (IME) where their attending physician does not concur with the IME report. OAR 436-060-0147(1); ORS 656.325(1)(e). The requirements specify the denial must pertain to compensability under ORS 656.319(1)(a). ORS 656.325(1)(e). This subsection referred to a denial of a claim for compensation under ORS 656.262.
The Board found claimant made a timely request for hearing on a denial based on an IME report and her attending physician disagreed with the IME report. However, the determinative issue is whether the denial of medical services underlying claimant’s request qualified as a “denial of compensability as required by ORS 656.319(1)(a).” ORS 656.325(1)(e).
The Board initially found the statutory definition of “denial of a claim for compensation” refers to a denial of a written request for benefits, including medical services. ORS 656.003; ORS 656.005. To determine whether a denial of medical services also serves as a denial of compensability, the Board referred to the legislative intent underlying ORS 656.325(1)(e).
The legislature intended to provide an opportunity for workers to obtain a second opinion and access the medical arbiter panel with providers equivalent to the IME providers available to the employer/insurer with the costs paid by the employer/insurer. The Board reasoned the purpose of a WRME was to create a fair and just mechanism for the administration and delivery of workers’ compensation benefits. Since the medical dispute denial in this matter was based on the IME Report, it would necessarily be balanced to extend an opportunity to the worker to obtain a similar medical opinion.
This decision reversed the ALJ’s Order and the underlying Workers’ Compensation Division Order denying the WRME. The ruling expanded the workers’ access to WRME so that medical dispute denials and compensability denials issued under a claim may be serve as a basis for a WRME request, assuming all other qualifications are met.
At SBH Legal, we are ready and able to answer any questions or concerns pertaining to WRME requests, medical dispute denials, and/or compensability denials. If you would like to discuss an issue, please contact me at (503) 776-5434 or .
Posted by Hayley Porter.
