Navigating the maze of “combined condition” claim processing in Oregon
Last week, Evan Novotny provided analysis of numerous recent Board and Court of Appeals decisions, which highlight some of the multiple difficulties that employers/insurers/administrators face when processing “combined conditions,” as well as when defending combined condition denials in litigation. These rulings are cause for ongoing frustration, because they seem to emphasize a judicial disfavor for combined condition processing. That notwithstanding, combined condition processing remains a valuable, and sometimes necessary, tool at the employer/insurer/administrator’s disposal. Below are some guidelines to remember when processing “combined conditions” in Oregon:
- Claimant must sustain an “otherwise compensable” work injury, which results in “otherwise compensable” work injury condition(s). These are the accepted conditions of the claim, or the condition(s) that would otherwise be accepted, but for the work injury never constituting the major contributing cause of the combined condition’s disability or need for treatment.
- Claimant must have “legally-cognizable” preexisting condition(s). To qualify as a legally-cognizable preexisting condition, such condition must (1) contribute to disability or the need for treatment and (2a) be arthritis or (2b) be a condition previously treated or diagnosed. The Oregon Supreme Court defines arthritis as inflammation of one or more joints due to infectious, metabolic, or constitutional causes, and resulting in breakdown, degeneration, or structural change.
- There must be a pathological combination of the otherwise compensable work injury condition(s) with the legally-cognizable preexisting condition(s), to cause or prolong claimant’s disability and/or need for medical treatment.
- The otherwise compensable work injury must constitute the major contributing cause (greater than 50%) of the combined condition’s disability or need for treatment. If the preponderance of medical opinion supports that the otherwise compensable work injury never constituted the major contributing cause of the combined condition’s disability and need for treatment, then the claim should be denied. Conversely, if the preponderance of medical opinion supports that the otherwise compensable work injury was, at least at one point, the major contributing cause of the combined condition’s disability or need for treatment, then the claim may be accepted as a combined condition.
- Once the preponderance of medical opinion supports that the otherwise compensable work injury ceased constituting the major contributing cause of the combined condition’s disability and need for treatment, the employer/insurer/administrator may then issue a combined condition denial.
It is also important to remember that, when litigating an appealed combined condition denial, it is the employer/insurer/administrator’s burden of proof to establish that the otherwise compensable work injury ceased constituting the major contributing cause of the combined condition’s disability and need for treatment. So, it is paramount to generate a strong evidentiary record supporting each of the above elements.
Combined condition processing can be a complex and difficult maze to negotiate, and combined condition denial defense can be just as tricky. If you have any questions regarding combined condition processing and/or defense strategy, or you would like to discuss any other Oregon workers’ compensation issues, please contact me at 503-595-6109 or .
Posted by Andrew Evenson.
