What evidence is necessary to support a ceases denial in Oregon?
ORS 656.262(6)(c) authorizes an administrator to deny an accepted combined condition if the compensable injury ceases to be the major contributing cause of the combined condition. In such situations, the administrator has the burden to show the compensable injury is no longer the major contributing cause of the workers’ disability or need for treatment of the combined condition. But what exactly does the administrator need to show to support such a position?
A recent Board case outlined what evidence is necessary to uphold a ceases denial. Philip Sappington, 75 Van Natta 321 (2023). In the Sappinton case, the administrator accepted a left knee strain and left knee medial meniscus tear combined with pre-existing left knee arthritis. The pre-existing left knee arthritis was not diagnosed or treated before the work injury and was asymptomatic prior to the work injury. The Board noted a change in claimant’s condition or circumstances after the effective date of the combined condition acceptance is a prerequisite for denial of an accepted combined condition. Additionally, the Board pointed out this is a complex medical issue so the ceases denial must be supported by expert medical opinions.
The medical experts in Sappington discussed in general that arthritis worsens over time and causes increased symptoms. The Board felt the medical experts did not sufficiently analyze claimant’s combined condition and what had changed. Additionally, the experts failed to explain why the current symptoms and need for treatment were now due in major part to the previously asymptomatic arthritis instead of the accepted conditions. The evidence presented was deemed insufficient to show the combined left knee condition had changed since the acceptance of the combined condition and the ceases denial was set aside.
If you have questions about a ceases denial or other claim issues, you can contact me at or (503) 412-3101.
Posted by Anna McFaul.
