Oregon Supreme Court rules that medical services for conditions caused in material part by the work injury incident, not just accepted conditions, are compensable
In a much-awaited decision, the Oregon Supreme Court recently ruled in Garcia-Solis v. Farmers Ins. Co., 365 Or 26 (2019) that medical services for conditions caused in material part by the work injury incident, not just accepted conditions, are compensable under ORS 656.245(1)(a). In relevant part, ORS 656.245(1)(a) states that “For every compensable injury, the insurer or the self-insured employer shall cause to be provided medical services for conditions caused in material part by the injury for such period as the nature of the injury or the process of the recovery requires.”
This case involves a 2009 work injury, in which a food server sustained bodily injuries. Over the next two years, the insurer accepted numerous musculoskeletal conditions. In 2012, the attending physician referred claimant for a psychological evaluation “to address PTSD-like symptoms.” The attending physician later opined the need for the psychological referral was caused in material part by the work injury.
The insurer denied authorization of the referral because it was not causally-related to any accepted conditions. The refusal was upheld by an ALJ and the Board, because the attending physician’s opinion related the services to claimant’s “work injury of February 25, 2009,” and not to her accepted conditions. Relying upon the Oregon Supreme Court’s decision in Brown v. SAIF, 36 Or 241 (2017), the Oregon Court of Appeals also affirmed the medical services denial.
In a unanimous decision, the Supreme Court reversed the Court of Appeals’ decision and ruled that, in the context of medical services and ORS 656.245(1)(a), the term “compensable injury” refers to the work accident, event, or incident that caused medical conditions and resulted in the need for treatment, and it is not limited to just those medical conditions already accepted.
It is worth noting that this litigation involved a referral for diagnostic medical services, but the Supreme Court did not limit its interpretation to just diagnostic services. So, it is reasonable to anticipate future litigation regarding whether this ruling extends to other medical services as well. On its face, it appears that it does. Additionally, the Oregon legislature is currently considering House Bill 3022, which would amend the language of ORS 656.245 to include a subsection stating in part that diagnostic services are compensable if they “are reasonable and necessary to identify the nature or extent of a medical condition” that may be related to a compensable work injury or disease.
So, what does this mean for you? Depending on your approach to processing Oregon workers’ compensation claims, it may not mean much, or it may be cause for change. The Supreme Court’s ruling means that medical service requests for conditions caused in material part by the compensable work event are now compensable, even if the conditions at which the service is directed have not yet been accepted.
You may read the Supreme Court’s decision HERE. If you have any further questions regarding this decision and its effects on your claim processing, or you have questions regarding any other Oregon workers’ compensation matters, please do not hesitate to contact me at 503-595-6109 or firstname.lastname@example.org.