Oregon Injured Worker Not Cooperating? There’s a Denial for that.
Insurers or self-insured employers are required to conduct a reasonable investigation based on all available information” in order to decide whether to accept or deny a claim. See OAR 436-060-0140(1). Additionally, workers also have an obligation to cooperate with and assist the insurer’s or self-insured employer’s investigation into their claim. See ORS 656.262(14). A workers’ failure to reasonably cooperate with an investigation can result in suspension of benefits and denial of the claim.
Specifically, during an initial claim investigation to establish a compensable injury or an aggravation claim to reopen the claim for a worsened condition, a worker is required to reasonably cooperate with the investigation of their claim and if they do not, suspension of benefits and denial of the claim can occur. See ORS 656.262(15). Reasonable cooperation can include a worker attending an independent medical examination (IME), fully cooperating with personal/telephonic interviews, and other formal and informal information gathering techniques. See ORS 656.262(14)(a). If the director concluded that a worker failed to reasonably cooperate the director shall suspend all or part of the payment of compensation after notice to the worker pursuant to ORS 656.262(15).
To initiate this process, the insurer or self-insured employer must request that the director suspend the worker’s compensation and the reason for such suspension. If the director agrees, a Notice of Suspension will be issued, shortly after the notice, the order suspending claimant’s compensation will issue. If the worker continues to fail to cooperate for an additional thirty (30) days after the notice, the insurer or self-insured employer may deny the claim because of the worker’s failure to cooperate. ORS 656.262(15).
Normally, the insurer or self-insured employer has an obligation to accept or deny the claim within sixty (60) days from the employer’s notice or knowledge of the claim. See ORS 656.262(6). However, the obligation of the insurer or self-insured employer to accept or deny the claim within 60 days is suspended during the time of the worker’s noncooperation.
After issuing a noncooperation denial, the worker shall not be granted a hearing or other proceeding under this chapter on the merits of the claim unless the worker first requests and establishes at an expedited hearing under ORS 656.291 that the worker fully and completely cooperated with the investigation, that the worker failed to cooperate for reasons beyond the worker’s control or that the investigative demands were unreasonable. The Administrative Law Judge (ALJ) will then either find that the worker did or did not fully cooperate. If the ALJ finds that the worker has not fully cooperated the noncooperation denial shall be affirmed and the worker’s claim for injury shall remain denied. However, if the ALJ finds that the worker has cooperated, or that the investigative demands were unreasonable, the ALJ shall set aside the denial, order the reinstatement of interim compensation if appropriate, and remand the claim to the insurer or self-insured employer to accept or deny the claim.
The timeline to issue a noncooperation denial can be tricky and move quickly. If you have questions regarding the process or issuing a noncooperation denial, please do not hesitate to contact me at either or 503-776-5421.
Posted by Daisha Barnes.
