Investigations and Compensability Standards
Industrial Injury? Occupational Disease? Combined Condition? Under what theory of compensability should you investigate an initial claim for compensation? All of them!
Under Oregon Administrative Rule 436-060-0140, the insurer is obligated to conduct a “reasonable” investigation upon receipt of a worker’s claim for compensation. This may include a recorded statement or an independent medical evaluation (IME), among other investigative activities. But, that begs the question: Under what standard of compensability should the insurer investigate/analyze a claim for compensation, prior to rendering an acceptance or denial? The short answer is: All of them!
Just because the worker reports an acute onset of pain/symptoms at work, does not mean the claim should be analyzed as an acute industrial injury – which is subject to a material contributing cause standard. Rather, if the claim for compensation is directed at a condition/need for treatment which developed gradually over time, even if the worker experienced an acute onset of symptoms, the worker has not experienced an injury and the claim should be analyzed as an occupational disease – which is subject to a heightened major contributing cause standard. Similarly, just because a worker reports, or even has a documented history for, prior complaint and/or treatment, a combined condition analysis is not necessarily appropriate. Ultimately, if a claim is denied and litigated, it is the administrative law judge’s obligation to review the medical evidence and the record to determine the appropriate legal standard to evaluate the compensability of a claim, while the parties are left to argue why the standard of proof most favorable to their positions is appropriate.
So, when investigating an initial claim for compensation, it is vitally important to evaluate the claim under all legal theories, in order to obtain the most comprehensive set of information on which to provide an initial compensability determination. Doing so will assist your claim processing of an accepted claim, and it will undoubtedly assist your defense of a denied claim.
If you would like to discuss your initial claim investigation strategy and/or plans, or if you have any other Oregon workers’ compensation questions, please contact me at 503-595-6109 or .
Posted by Andrew Evenson.
